Momentous Health At Richfield

Based on observation, interview, and review of the facility menus, the facility failed to serve palatable meals at appetizing temperatures for residents' meals. This had the potential to affect all 51 residents residing in the facility. The facility indicated all residents received meals from the kitchen. The facility census was 51.
Findings include:
Review of the breakfast menu for 06/03/25 revealed the planned meal included a cheese omelet, two breakfast sausage links, cold or hot cereal, assorted juices, and milk of choice.
Observation on 06/03/24 at 6:45 A.M. with Dietary Manager #208 revealed initial food temperatures on the steam table as follows: egg cheese omelet 166 degrees Fahrenheit (F), sausage links 181 degrees F, pureed sausage 179 degrees F, pureed eggs 169 degrees F, oatmeal 172 degrees F, mechanical sausage 173 degrees F, white milk 31 degrees F, chocolate milk 32 degrees F, and apple juice 30 degrees F.
Continuous observation of the breakfast tray line on 06/03/25 beginning at 7:09 A.M. with Dietary Manager #208 revealed Dietary Manager #208 was preparing trays. Hand hygiene, proper sanitation and portions were observed during tray line. At 7:46 A.M. Dietary Manager #208 confirmed she ran out of oatmeal and needed to use cold cereal for the four remaining trays for Residents #18, #22, #23, and #25. Dietary Manager #208 also confirmed they ran out of spoons and had to use plastic spoons for the last four trays as well. Tray line finished at 7:52 A.M. A test tray was prepared and sent on the last food cart. The food cart arrived on the east unit at 7:55 A.M. and the tray pass was initiated. The last resident food tray was passed at 8:06 A.M.
Interview on 06/03/25 at 8:03 A.M. with Resident #33 revealed the food was cold and the kitchen does not always have enough for meals.
Interview on 06/03/25 at 8:05 A.M. with Resident #48 revealed the kitchen always runs out of food and meals are cold.
A test tray was completed with Dietary Manager #208 at 8:08 A.M. which revealed the following temperatures: Cheese Omelet 118 degrees F, Sausage 109 degrees F, Sausage 109 degrees F, Pureed Sausage 112.8 degrees F, pureed egg 106 degrees F and milk 65 degrees F. Taste test with Dietary Manger #208 at the time revealed Dietary Manager #208 confirmed the food was not warm enough for preference, and the pureed omelet was bland, tasteless, and did not have a desirable flavor.
Review of the Resident Council Meeting Minutes dated 05/27/25 revealed the residents reported food concerns. Residents noted the meals were repetitive at times and residents requested more fresh fruit.
Review of the facility policy Food Temperatures at Point of Service dated 07/14/23 revealed best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plate and thermal pellets as necessary. Food service will monitor the palatability of food at point of service by periodic test tray evaluation and review of resident council concerns.
This deficiency represents non-compliance investigated under Complaint Numbers OH00165087 and OH00164461.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure weights were obtained upon readmission from the hospital and refusals were consistently documented. This affected one resident (Resident #32) of four residents reviewed for weights. The facility census was 51.
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity.
Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) indicated Resident #32 was dependent upon staff for ADLs.
Review of the physician order dated 04/18/25 and discontinued on 05/22/25 for Resident #32 revealed an order for monthly weights every day shift starting on the 18th every month for screening.
Review of the most recent weight recorded in the medical record for Resident #32 revealed it was on 04/18/25 with a weight of 536 pounds.
Review of Resident #32's census revealed Resident #32 went to the hospital on [DATE] and returned on 05/23/25.
Review of the 05/23/25 nursing admission assessment with care plan revealed under section four: dietary/nutritional status section revealed the most recent weight was 536 pounds from 04/18/25. No indication was recorded of any resident refusal.
Review of the nursing progress notes dated 05/23/25 for readmission revealed no documentation of weight refusal for Resident #32.
Review of the physician orders following hospitalization on 05/20/25 and readmission on [DATE] revealed no physician orders for weight monitoring frequency.
Interview on 06/03/25 at 11:15 A.M. with the DON confirmed there was no readmission weight was obtained nor was a refusal documented for Resident #32 upon readmission from the hospital on [DATE] as required.
Review of the policy Weight Management dated 05/01/22 revealed the nursing assistant will weigh residents within 24 hours of admission to the facility, then weekly for four weeks and then monthly thereafter. Resident's weight information is recorded and trended in the medical record by the unit manager or charge nurse.
This deficiency represents non-compliance investigated under Complaint Number OH00165009.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the power of attorney (POA) was notified of a change in condition. This affected one resident (#32) of four residents reviewed for notification of change in condition. The facility census was 51.
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity. Review of the banner bar of Resident #32's electronic medical record revealed special instructions which stated: POA (power of attorney) would like to be notified of any behaviors or concerns.
Review of Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #32 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #32 was dependent upon staff for ADLs.
Review of the nursing progress note dated 04/17/25 timed 10:32 P.M. written by Registered Nurse (RN) #223 revealed upon entering Resident #32's room, Resident #32 was noted to be bleeding puddles of blood from bed onto floor. Emergency Medical Services (EMS) and Nurse Practitioner (NP) were called, and Resident #32 was sent to the hospital. No evidence was recorded that the POA was notified.
Review of the nursing progress note dated 04/18/25 timed at 5:37 A.M. written by RN #223 for Resident #32 returned from the hospital and noted the NP was aware. There was no evidence the POA was notified of the resident's return.
Review of the nursing progress noted dated 05/20/25 timed at 5:24 P.M. written by Licensed Practical Nurse (LPN) #215 revealed Resident #32 had worsening symptoms like shortness of breath (SOB), being extremely tired and groggy as the shift progressed. The NP was notified of Resident #32's change in condition and NP assessed Resident #32. LPN #215 was notified to have Resident #32 use his continuous positive airway pressure (CPAP) machine (a device used to treat sleep apnea and other breathing disorders. It delivers a constant stream of pressurized air through a mask to keep the airway open and prevent pauses or shallow breaths) which Resident #32 refused. Resident #32 was noted to be sent out to the hospital at approximately 4:00 P.M. for SOB and change in condition. There was no evidence the resident's POA had been notified.
Review of the nursing progress note dated 05/23/25 written by LPN #204 revealed Resident #32 returned to the facility and the physician and NP were notified. No evidence was found of the POA being notified of the resident's return.
Interview on 06/02/25 at 11:24 A.M. with Resident #32 revealed concerns related to his POA not being notified of changes in his condition and when he has gone to the hospital in the past few months.
Interview on 06/03/25 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #32's chart had special instructions which listed the POA would like to be notified of concerns. The DON confirmed there was no evidence of the POA being notified when Resident #32 went to the hospital on [DATE], returned on 04/18/25, went to the hospital on [DATE], or when he returned on 05/23/25.
Review of the policy Change in Condition Monitoring dated 05/01/22 revealed our facility shall promptly notify the resident, his or her attending physician, and family/Power of Attorney (POA)/guardian of changes in the resident's medical status.
This deficiency represents non-compliance investigated under Complaint Number OH00165009.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring general cleanliness was maintained, water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, and door frames were without the need for repair. This affected all residents residing in the facility. The facility census was 51.
Findings include:
During the onsite survey an interview on 06/04/25 at 11:07 A.M. with Chief Operating Officer (COO) revealed she was aware of physical environmental concerns that resulted in citations during the previous annual survey. She verified the physical environmental issues currently in the building, including water temperatures not reaching the appropriate and homelike temperatures, and concerns regarding the general repair and cleanliness of the room were ongoing. The COO confirmed the broken blinds, discolored and bulging ceiling tiles, gouges, and missing paint on walls and door frames, furniture in disrepair, and general housekeeping tasks were not completed by the facility's allegation of compliance date of 04/20/25 as planned in the facility's plan of correction.
An interview on 06/09/25 at 1:06 P.M. with the Chief Executive Officer (CEO) confirmed the facility's physical environmental needs were not met by the deadline of 04/20/25 as stated in the facility's previous plan of correction.
A follow up interview with the Administrator on 06/11/25 at 11:03 A.M. revealed the new Director of Maintenance who was due to begin employment on 06/09/25 fell through. The Administrator reported she is still in need of a new Director of Maintenance and has refreshed the advertisement for the position. The Administrator stated she had been working with the CEO to develop a revised corrective action plan. The Administrator reported the CEO will be bringing in a contractor and the goal was to go room-to-room to identify the environmental needs of each room.
Review of the policy Homelike Environment dated 05/01/22 revealed residents are to be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary environment, adequate lighting, clean bed and bath linens that are in good condition, and pleasant and neutral scents.
The following environmental concerns were identified at the time of the onsite investigation:
1. Interview on 06/02/25 at 1:47 P.M. with Resident #53 revealed her room was not being cleaned consistently and had not been cleaned for the past five days. Observation at the time of the interview revealed the floor appeared soiled with dried stains.
Interview on 06/02/25 at 1:56 P.M. with Resident #49 revealed had previously requested a new mattress due to sinking in the middle several months ago but had not been addressed. Resident #49 also stated the blinds had missing pieces and the bathroom ceiling tile was bulging.
Interview on 06/02/25 at 3:48 P.M. with Resident #34 stated sometimes there are no washcloths available for bathing and towels are used.
Observation on 06/03/25 from 3:00 P.M. to 4:35 P.M. of a facility tour with the Administrator and Maintenance Director #218 revealed the following concerns
- Resident #30's room was missing a light bulb above the sink in the resident's room. Saturated paper towels with a strong urine odor were noted on the floor at the entrance to the resident's bathroom near the bed. Resident #30's call light indicator cover was hanging and was not fully attached outside of the resident's room.
- Resident #35's room was missing a bottom drawer in front of a three-drawer built-in cabinet. The floor of Resident #35's room was heavily soiled.
- The flooring around the 100-hall nurse's station had a trail of various dried brown spots of an unknown substance on the floor.
- Resident #49 and Resident #50's shared room had broken blinds covering the window. Ceiling tiles in the bathroom were cracked and bulging. The privacy curtain dividing the room was visibly soiled.
- Resident #51's room had two stained ceiling tiles near the entrance door.
- The exit door at the end of the 100-hall outside Resident #53's room revealed various loose trash debris including used gloves, napkins, condiment wrappers, lids, etc. outside of the exit door and visibly blowing around the parking lot.
- Resident #53's room had multiple holes in the wall and ceiling tiles near the door. There were two stained ceiling tiles, and dried stains on the floor. The toilet paper holder in Resident #53's bathroom was empty, with two rolls of toilet paper on the back of the toilet and a partially used roll of toilet paper not easily reached on the bathroom counter. An interview at the time of observation with Resident #53 stated it was hard to reach the toilet paper, and she wished staff would replace the toilet paper on the older for her and wished staff would clean her floors.
- A used glucometer test strip was on the floor outside the rooms of Residents #49, #50, #51, and #52.
- Resident #40's floor was visibly soiled. Resident #40's toilet was visibly soiled with dried brown stains around the whole base of the commode. The bathroom had a strong pervasive odor, and the bathroom light was missing a cover.
- The [NAME] shower room had cracked tiles to the floor and edges.
- Resident #41's room contained a sink, above which were dirty dishes with the present of gnats. Resident #41's baseboards near the bathroom were loose.
- Resident #42's electrical outlet between the bathroom and the bed had visible white rough spackling and dried white powder on the floor below. There were large stains on the ceiling tiles and the bathroom floor and fixtures were visibly soiled.
- Resident #43 and Resident #44's shared room had a visibly dirty floor with dried brown spots around and behind the toilet. The bathroom had a strong pervasive odor. The bathroom doorframe was visible eroded from a prior leak, and dried stains were visible on the window blinds.
- Resident #45's room contained two missing tiles near the sink base and the floor of the room was visibly soiled.
- Resident #1 and Resident #2's shared room had two missing light bulbs in the room and no cover over the bathroom light.
- Resident #3 and Resident #4's shared room floor was visibly soiled with various debris. The bathroom was wet with what appeared to be a leak.
- Resident #5's bathroom had stains splattered on the blinds and walls surrounding the window.
- There was a partially missing floor tile on the [NAME] hall entrance to the dining room.
- There was missing wood trim pieces above the handrail outside room [ROOM NUMBER] which was vacant at the time of the survey.
- Resident #6's room had a soiled privacy curtain. There were bulging ceiling tiles above the sink in Resident #6's room. The bathroom floor had wet, soiled paper towels in a pile on the floor.
- Resident #7 had a stained ceiling tile above the bed and the room contained broken window blinds.
- Resident #8's room had a hole in the wall next to the bed. There was a stained ceiling tile near the air conditioning unit.
- Resident #9's room had peeling paint on the bathroom door, stained and bulging ceiling tiles above the bed, and a missing trim piece near the entrance door to the room.
- Resident #10's room had three missing light bulbs, seven stained ceiling tiles, and six missing drawers on the bathroom cabinet. The clock in the room was non-functional. There were no paper towels in the room and the entrance door was missing the mechanism/latch for the door handle.
- Resident #11's room had gouges on the wall and a visibly soiled floor.
- The dining room floor in the memory care unit was peeling up. The peeling floor had previously been taped down but the tape had worn off and was not secured.
- Resident #14 and Resident #15's shared room contained visibly soiled floors to the room. The bathroom contained a visibly soiled toilet seat.
- Resident #17's room had a dirty privacy curtain and a bathroom with surfaces which were visibly soiled.
- The East shower room had a stained ceiling tile near the vent near the entry door.
- Resident #18's room contained various stains on the floor. Resident #18 was missing a drawer in the room vanity.
- Resident #19's room had a stained privacy curtain that would not slide on the track. There was a brown stained sheet on the bed. The wall underneath the window had missing paint. There was a broken drawer in the dresser cabinet. The resident's bathroom was visibly soiled and had a strong pervasive odor.
- Resident #21's room had a visibly dirty fan with a soiled and sticky floor.
- Resident #22's room had a heavily soiled floor.
- Resident #25 and Resident #26's room contained no privacy curtain.
The Administrator confirmed the above findings at the time of observation during the facility environmental tour.
2. Review of the facility water temperature logs dated 04/21/25, 04/28/25, 05/05/25, 05/12/25, 05/20/25 and 05/27/25 revealed on 04/28/25 the East one shower room was recorded as 103.2 degrees Fahrenheit (F), on 05/12/25 the East two shower rooms were recorded as 103.4 degrees F and on 05/27/25 the East one shower room was recorded as 103.1 degrees F.
Observation and interview on 06/02/25 at 12:00 P.M. with the Administrator conducting water temperatures revealed the shared bathroom for Resident #34 and #35's faucet was 103.1 degrees F after running the hot water for a few minutes and the hot water in the East shower room was 100.7 degrees F. The Administrator confirmed the above findings at the time of observation and confirmed the water temperatures did not meet the required minimum of 105 degrees F.
Review of the 05/01/22 facility policy called Water Temperature revealed maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Water temperatures would not be more than 120 degrees.
3. An observation on 06/04/25 at 9:15 A.M. with Maintenance Director #218 of the shower rooms revealed the rooms contained no washcloths in the East shower room and approximately 10 washcloths in the [NAME] shower room. Maintenance Director #218 confirmed the lack of washcloths in the shower room.
Observation on 06/04/25 at 9:15 A.M. with Maintenance Director #218 of the shower rooms revealed no washcloths in the east shower room and approximately 10 washcloths in the west shower room. Maintenance Director #218 confirmed the above observations.
Observation on 06/04/25 at 9:22 A.M. of the laundry area with Maintenance Director #218 and Laundry Staff #229 revealed no washcloths in the clean laundry area. Laundry Staff #229 confirmed staff frequently run out of washcloths and reported more were on order but had not arrived and he was waiting for the dirty washcloths to come back to laundry to wash them for resident use.
This deficiency represents non-compliance investigated under Master Complaint Number OH00165391 and Complaint Number OH00165087.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel files, interviews, and review of the nursing job description, the facility failed to ensure nurses providing direct care to residents maintained current cardiopulmonary resuscitation (CPR) certification. This had the potential to affect all 37 residents whose advanced directives were listed as full code (term used to signify all measures which should be taken to resuscitate, including CPR). The facility census was 51.
Findings include:
Review of the personnel files for three licensed practical nurses (LPNs) and the Director of Nursing (DON) revealed one LPN (LPN #215) had a hire date of [DATE] with proof of CPR certification from [DATE] through [DATE] and from [DATE] through [DATE]. There was no evidence LPN #215 had active CPR certification from [DATE] through [DATE].
Interview on [DATE] at 3:30 P.M. with Business Office Manager (BOM) #207 confirmed there was no evidence of active CPR certification for LPN #215 in the personnel file. During the interview, it was revealed that BOM #207 just started the Human Resources position the end of [DATE] and began performing personnel file audits, at which time she notified any staff whose file was noted to have missing necessary items, such as documentation of active CPR certification during their course of employment, and she had received the CPR documentation with the issue date of [DATE].
During a follow-up interview on [DATE] at 5:00 P.M., BOM #207 provided proof of ongoing, valid CPR for LPN #223 and LPN #228, whose files previously showed a gap in certification, but confirmed there was no further documentation of CPR certification from the time of the lapsed certification (expired [DATE]) and the new certification (issued [DATE]).
Interview on [DATE] at 10:54 A.M. with LPN #215 confirmed there was a gap in her CPR certification and that LPN #215 was not certified in CPR from the end of [DATE] until [DATE].
Interview on [DATE] at 11:00 A.M. with the DON confirmed all facility nurses should maintain current CPR certification. A follow-up interview on [DATE] at 12:28 P.M. with the DON confirmed LPN #215 was assigned to work units per facility need and could work on any unit.
Review of the job description for Licensed Practical Nurse last updated [DATE] revealed the LPN must be certified in CPR.
This deficiency represents non-compliance investigated under Complaint Number OH00165087.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility immunization report, facility policy review, review of facility census, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to ensure residents were offered, screened, educated and received influenza and pneumococcal vaccinations as required. This affected nine residents (#23, #24, #25, #26, #31, #38, #43, #55 and #204) reviewed/interviewed as part of the survey and the lack of an effective system to manage vaccinations and prevent incidents of influenza/pneumonia had the potential to affect all 54 residents residing in the facility. The facility census was 54.
Findings include:
1.Review of the facility census on 12/04/24 revealed there were 45 residents, Resident #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #27, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #45, #46, #50, #51, #55, #56, #57, and #58 who resided in the facility on this date.
Review of the facility Immunization Report from 01/01/24 to 03/13/25 revealed there was no documented evidence of any pneumococcal vaccinations completed for any residents during this time period of 01/01/24 to 03/31/25. In addition, record review revealed there was no documented evidence of consent/declination, screenings, or education regarding pneumococcal vaccinations for any facility residents during this time period.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any evidence of pneumococcal vaccinations being completed as required for any residents between 01/01/24 and 03/13/25.
Review of a facility Immunizations Report from 01/01/24 to 03/13/25 revealed 23 residents (#4, #5, #7, #8, #11, #12, #15, #18, #20, #21, #24, #25, #27, #29, #32, #33, #36, #40, #41, #44, #45, #46, #51) were included on the report as having received an influenza vaccination on 12/04/24 and 12 residents (#2, #9, #10, #16, #19, #22, #23, #30, #35, #37, #38, #42) who refused the influenza vaccination. However, there was no documented evidence of consent/declination, screenings, or education regarding influenza vaccinations for any facility residents during this time period.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate evidence of education or any of the 23 consents for influenza vaccinations that were completed on 12/04/24.
A follow-up interview on 03/17/25 at 11:27 A.M. with the Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. They were unaware of how the previous DON, DON #313 and Assistant DON (ADON) #368 had been handling vaccinations and acknowledged there was a lot of missing vaccination forms. COO #300 indicated she was unsure why the annual influenza vaccinations were not administered until 12/04/24. COO #300 indicated that was the responsibility of Former DON #313 and she likely did not place her order for vaccinations in a timely manner.
A follow-up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate any additional information on pneumococcal or influenza vaccinations for any residents.
A follow-up interview on 03/19/25 at 3:37 P.M. with the DON confirmed she was unable to provide any additional information on pneumococcal or influenza vaccinations for any residents.
Interview on 03/27/25 at 11:09 A.M. with Resident #26 revealed she was admitted right before Christmas, on 12/20/24. She stated she was never educated about or asked if she wanted the influenza or pneumococcal vaccines. She stated she would have taken the influenza vaccine.
Interview on 03/27/25 at 11:13 A.M. with Resident #43 revealed he arrived in December 2024 (12/16/24) and he was never offered or educated on the influenza or pneumococcal vaccines. He stated he did not receive any vaccines while he was at the facility and he would have liked to have had them.
Review of the facility policy Pneumococcal (Pneumonia) Vaccine dated 10/27/21 revealed administration of pneumococcal vaccines or revaccinations would be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at time of vaccination. Residents would be assessed for eligibility as indicated and offered within 30 days of admission to facility unless medically contraindicated or already up to date on vaccination status. The resident or legal representative would receive information and education on benefits and potential side effects. Administration and refusal would be documented in the resident's medical record.
Review of the facility policy Influenza Vaccine dated 07/01/23 revealed all residents should receive influenza vaccinations annually unless there was a documented contraindication. Influenza vaccinations should be offered from October 1st through March 31st of each year. Consent and declination shall be documented in resident's medical record.
2. Review of the medical record for Resident #23 revealed an admission date of 06/27/24 with diagnoses including asthma and pulmonary embolism. The medical record revealed Resident #23 was her own responsible party and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident #23 for pneumococcal vaccinations. The record indicated Resident #23 refused the influenza vaccination at an unspecified time; however, there was no evidence of a consent/declination, education, or rationale for it being declined.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #23 did not receive the influenza vaccine as the resident was not in the facility. The assessment also noted Resident #23 was not up to date on the pneumococcal vaccination as the resident was not assessed.
On 03/13/25 at 7:30 A.M. interview with the Director of Nursing (DON) revealed she was unable to find any evidence of pneumococcal vaccination being completed as required for Resident #23.
On 03/13/25 at 12:10 P.M. a follow-up interview with the DON confirmed she was unable to locate any consents or declination for the influenza vaccination for Resident #23.
On 03/27/25 at 10:05 A.M. an interview with Resident #23 revealed the last vaccine she received was prior to coming to the facility. The resident denied being offered any vaccines or education while she was in the facility. During the interview, the resident indicated it was likely she would not want to receive an influenza or pneumococcal vaccination based on the preservatives in them because of her low white blood cell count.
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses including dementia, hypertension, lymphedema, psychosis, Parkinson's disease, and atherosclerotic heart disease. The medical record revealed Resident #24 had a guardian and the residents was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident #24's guardian about pneumococcal vaccinations. The record indicated Resident #24 received the influenza vaccination on 12/04/24; however, there was no evidence of a consent, screening, or education for the vaccination.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #24 did not receive the influenza vaccine as the resident was not in the facility. The assessment also noted Resident #24 was not up to date on pneumococcal vaccinations as the resident was not assessed.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any evidence of pneumococcal vaccination being completed as required for Resident #24.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or declinations for the influenza vaccination for Resident #24.
Interview on 03/27/25 at 9:38 A.M. with Resident #24's guardian revealed she had been the resident's guardian since admission on [DATE] and the facility had never educated or offered immunizations, including influenza and pneumonia.
A follow-up interview on 03/27/25 at 11:44 A.M. with Resident #24's guardian the guardian revealed the resident would have taken the vaccines as she usually did get an influenza vaccine every year. It was unclear during the interview if the guardian was aware that the facility immunization log identified Resident #24 as a resident who had received the influenza vaccine.
4. Review of the medical record for Resident #25 revealed and admission date of 09/16/24 with diagnoses including focal traumatic brain injury, vascular dementia, diabetes mellitus, end stage renal disease, dependence on renal dialysis, and bradycardia. The medical record revealed Resident #25 had an appointed guardian and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident #25's guardian about pneumococcal vaccinations. The record indicated Resident #25 received the influenza vaccination on 12/04/24; however, there was no evidence of a consent, screening, or education for the vaccination.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #25 received the influenza vaccination on 12/04/24. The assessment also noted that Resident #25 was not up to date on pneumococcal vaccinations as the resident was not assessed.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any evidence of pneumococcal vaccinations being completed as required for Resident #25.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or declinations for the influenza vaccination for Resident #25.
Interview on 03/27/25 at 10:16 A.M. with the Administrator revealed Resident #25 was younger than [AGE] years old and she did not think the resident fit the criteria for pneumococcal vaccination.
Interview on 03/27/25 at 10:20 A.M. with MDS Nurse #365 revealed it had been a year or two since he reviewed the guidance on the MDS section O for vaccines. However, he was educated through American Association of Nurse Assessment Coordinators (AANAC) that on the question for pneumococcal vaccines, you would answer yes if the resident had it, and he would look in the medical record to see if they refused it, then he would mark that, and if they were under 65 he would mark that the resident was not eligible. He stated that criteria (ineligibility) would apply to Resident #25.
5. Review of the medical record for Resident #38 revealed an admission date of 06/22/24 with diagnoses including traumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), hypertension, alcohol dependence, and COVID-19 on 12/28/24. The medical record revealed Resident #38 had an appointed guardian and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a pneumococcal vaccination received. There was no evidence of the facility offering, screening, or educating Resident #38's guardian about pneumococcal vaccinations. The record indicated Resident #38 refused the influenza vaccination at an unspecified time; however, there was no evidence of a consent/declination, education, or rationale for it being declined.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #38 did not receive the influenza vaccine as the resident was offered and declined it. The assessment also noted that Resident #38 was not up to date on pneumococcal vaccinations as the resident was not eligible.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any evidence of pneumococcal vaccinations being completed for Resident #38.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or declinations for the influenza vaccination for Resident #38.
Interview on 03/27/25 at 9:19 A.M. with the Administrator and DON revealed that, per the MDS nurse, Resident #35 was younger than [AGE] years old and did not fit the criteria for pneumococcal vaccines during the MDS assessment, based on advice from education at American Association of Nurse Assessment Coordinators (AANAC).
Interview on 03/27/25 at 10:20 A.M. with MDS Nurse #365 revealed it had been a year or two since he reviewed the guidance on the MDS section O for vaccines. However, he was educated through American Association of Nurse Assessment Coordinators (AANAC) that on the question for pneumococcal vaccines, you would answer yes if the resident had it, and he would look in the medical record to see if they refused it, then he would mark that, and if they were under 65 he would mark that the resident was not eligible. He stated that criteria (ineligibility) would apply to Resident #38.
6. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, Alzheimer's disease, and hypothyroidism. The medical record revealed Resident #204 was their own responsible party and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of influenza or pneumococcal vaccinations being received by the resident. There was no evidence of the facility offering, screening, or educating Resident #204 for the influenza or pneumococcal vaccinations.
Review of the Medicare Minimum Data Set (MDS) admission assessment revealed it had not yet been completed for Resident #204.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) confirmed she had not been able to locate any historical vaccination information for Resident #204 and confirmed Resident #204 had not been offered any vaccinations since admission.
Interview on 03/27/25 at 9:19 A.M. with the Administrator and DON confirmed they should offer the vaccines upon admission.
Interview on 03/27/25 at 11:05 A.M. with Resident #204's family revealed the facility never offered the vaccines (influenza or pneumococcal) for the resident or provided education related to them.
7. Review of the closed medical record for Resident #55 revealed an admission date of 01/27/23 and discharge date of 01/09/25. Resident #55 had diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage. The medical record revealed Resident #55 had an appointed guardian and was [AGE] years old.
Review of the immunizations record revealed Resident #55 was not up to date with pneumococcal vaccinations as pneumococcal Polysaccharide Vaccine (PPSV) 23 was administered before the age of 65.
Review of the Nurse Practitioner (NP) progress note dated 01/09/25 revealed Resident #55 had complaints of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP ordered to send Resident #55 to the emergency room for evaluation.
Review of the nurse's note dated 01/09/25 revealed Resident #55 was transported to hospital for complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood thinner.
Review of the nurse's note dated 01/10/25 revealed Resident #55 was admitted to hospital for pneumonia. Further review of the medical record for Resident #55 revealed no additional hospital documentation was available for review.
Interview on 03/17/25 at 8:03 A.M. with the guardian of Resident #55 revealed Resident #55 had passed away at the hospital. The resident's death certificate was not available as of this date.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #55 had been hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a change in condition since testing positive for COVID-19 on 12/27/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident #55.
8. Review of the medical record for Resident #31 revealed an admission date of 08/13/24 with diagnoses including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual disabilities. Resident #31 was hospitalized from [DATE] to 01/08/25. The medical record revealed Resident #31 was his own responsible party and he was [AGE] years old.
Review of immunizations record revealed no evidence of Resident #31's pneumococcal vaccinations status.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was independent for activities of daily living. The assessment revealed Resident #31 had not received pneumococcal vaccinations.
Review of a Nurse Practitioner (NP) progress note dated 12/26/24 revealed Resident #31 continued to have cough and congestion. On 12/23/24 Resident #31 had a chest x-ray with no findings. On 12/24/24 Resident #31 had four to five watery stools and was ordered Loperamide two milligrams (mg) every six hours as needed for diarrhea. Resident #31 also complained of nausea and emesis. Laboratory services were ordered on 12/24/24 and were not obtained. Resident #31's pulse ox was 92 percent on room air and the resident's heart rate was 109 (tachycardic). While the NP was visiting, she was alerted Resident #31 had fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated 12/27/24 revealed Resident #31 had been admitted to the hospital with acute hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19.
Review of a hospital note revealed Resident #31 was admitted to the step-down unit on 12/26/24 for acute hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis. Resident #31 continued to have intermittent coughing while hospitalized .
Review of a NP progress note dated 01/09/25 revealed Resident #31 had re-admitted to the facility from the hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #31 had been hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since 12/06/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident #31.
Interview on 03/27/25 at 9:52 A.M. with Resident #31 revealed he was educated regarding the influenza and pneumococcal vaccines by the facility and he did consent to and received the vaccines, but he could not remember when he had them or when the education was. Resident #31 stated he knew he had to go to the hospital because he was sick, but he could not remember when it was, and he also could not remember any treatments or medications he was given prior to the hospitalization. He stated he had poor memory.
Review of online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination, dated 10/26/24 revealed the following
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CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older.
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CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease.
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Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need.
The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility immunization report, review of staff vaccination reports, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed ensure residents and staff were educated, screened, and offered COVID-19 vaccinations as required. This affected seven residents (#23, #24, #25, #31, #38, #55 and #204) of seven reviewed for immunizations and the lack of an effective program to manage vaccinations affected all residents in the facility. The facility census was 54.
Findings include:
1. Review of the Immunizations Report from 01/01/24 to 03/13/25 for COVID-19 vaccinations revealed there was no evidence of any COVID-19 vaccinations being completed from 01/01/24 to 03/13/25. In addition, record review revealed there was no documented evidence of consent/declination, screenings, or education regarding COVID-19 vaccinations for any facility residents during this time period.
Interview on 03/13/25 at 7:30 A.M. with Director of Nursing (DON) revealed she was unable to find any evidence of COVID-19 vaccinations being completed as required for any residents between 01/01/24 and 03/13/25.
Follow up interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility, but had been assisting the facility with infection control in interim between IPs. They were unaware of how the previous DON #313 and assistant DON (ADON) #368 had been handling vaccinations and acknowledged there were a lot of missing vaccination forms.
Follow up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate any additional information on COVID-19 vaccinations for any residents.
Follow up interview on 03/19/25 at 3:37 P.M. with the DON confirmed she was unable to provide any additional information on COVID-19 vaccinations for any residents.
Review of facility policy Resident COVID-19 Vaccine dated 05/01/22 revealed all residents and employees who had no medical contraindications will be offered the COVID-19 vaccine. The facility shall provide education on risks and benefits of vaccine. Administration or declination shall be documented in the resident medical record and employee personnel record. Vaccines shall be administered in accordance with current Centers for Disease Control and Prevention (CDC) recommendations.
Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating strains.
Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes.
2. Review of the medical record for Resident #23 revealed an admission date of 06/27/24 and diagnoses including asthma and pulmonary embolism. The medical record revealed Resident #23 was her own responsible party.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19 vaccinations. There was no evidence of the facility offering, screening, or educating Resident #23 for COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #23 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate any consents or declinations for COVID-19 vaccinations for Resident #23.
On 03/27/25 at 10:05 A.M. an interview with Resident #23 revealed the last vaccine she received was prior to coming to the facility. The resident denied being offered any vaccines or education while she was in the facility.
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 and diagnoses including dementia, hypertension, lymphedema, psychosis, Parkinson's disease, and atherosclerotic heart disease. The medical record revealed Resident #24 had a guardian.
Review of the immunizations record revealed Resident #24 had received doses of COVID-19 vaccinations prior to admission on [DATE], 08/12/21, and 11/02/22. There was no evidence of the facility offering, screening, or educating Resident #24's guardian about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #24 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate any consents or declinations for COVID-19 vaccinations for Resident #24.
Interview on 03/27/25 at 9:38 A.M. with Resident #24's guardian revealed she had been the resident's guardian since admission on [DATE] and the facility had never educated or offered immunizations.
4. Review of the medical record for Resident #25 revealed and admission date of 09/16/24 and diagnoses including focal traumatic brain injury, vascular dementia, diabetes mellitus, end stage renal disease, dependence on renal dialysis, and bradycardia. The medical record revealed Resident #25 had an appointed guardian.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19 vaccinations. There was no evidence of the facility offering, screening, or educating Resident #25's guardian about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #25 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate any consents or declinations for COVID-19 vaccinations for Resident #25.
5. Review of the medical record for Resident #38 revealed an admission date of 06/22/24 and diagnoses including traumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), hypertension, and COVID-19 on 12/28/24. The medical record revealed Resident #38 had an appointed guardian.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19 vaccinations. There was no evidence of facility offering, screening, or educating Resident #38's guardian about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #38 was not up to date on COVID-19 vaccination.
Interview on 03/13/25 at 12:10 P.M. with DON confirmed she was unable to locate any consents or declinations for COVID-19 vaccinations for Resident #38.
6. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 and diagnoses including paranoid schizophrenia, hypertension, Alzheimer's disease, and hypothyroidism. The medical record revealed Resident #204 was their own responsible party.
Review of the immunizations record revealed no historical records of COVID-19 vaccinations being received by the resident. There was no evidence of the facility offering, screening, or educating Resident #204 for COVID-19 vaccinations.
Review revealed the Medicare Minimum Data Set (MDS) admission assessment had not yet been completed for Resident #204.
Interview on 03/13/25 at 7:30 A.M. with Director of Nursing (DON) confirmed she had not been able to locate any historical vaccination information for Resident #204 and confirmed Resident #204 had not been offered any vaccinations since admission.
Interview on 03/27/25 at 11:05 A.M. with Resident #204's family revealed the facility never offered vaccines to the resident or provided education related to them.
7. Review of the closed medical record for Resident #55 revealed an admission date of 01/27/23 and discharge date of 01/09/25. Resident #55 had diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage. The medical record revealed Resident #55 had an appointed guardian and was [AGE] years old.
Review of the immunizations record revealed Resident #55 was not up to date with the COVID-19 vaccinations, with the last dose administered 06/02/22.
Review of the nurse's note dated 12/27/24 revealed Resident #55 tested positive for COVID-19.
Review of the Nurse Practitioner (NP) progress note dated 12/30/24 revealed Resident #55 had nasal congestion. The NP ordered oxygen via nasal cannula to keep oxygen saturation above 92 percent, Dexamethasone six mg daily for seven days, and monitor temperature, pulse oximetry (ox), and respirations every shift for 10 days. The NP noted to continue Eliquis five mg twice per day, Acetaminophen 650 mg every six hours as needed, and Albuterol nebulizer every four hours as needed.
Review of the Nurse Practitioner (NP) progress note dated 01/09/25 revealed Resident #55 had complaints of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP ordered to send Resident #55 to the emergency room for evaluation.
Review of the nurse's note dated 01/09/25 revealed Resident #55 was transported to hospital for complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood thinner.
Review of the nurse's note dated 01/10/25 revealed Resident #55 was admitted to hospital for pneumonia. Further review of the medical record for Resident #55 revealed no additional hospital documentation was available for review.
Review of the Ohio Department of Medicaid Facility Communication dated 01/16/25 revealed Resident #55 had passed away at the hospital on [DATE].
Interview on 03/17/25 at 8:03 A.M. with the guardian of Resident #55 revealed Resident #55 had passed away at the hospital. The resident's death certificate was not available as of this date.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #55 had been hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a change in condition since testing positive for COVID-19 on 12/27/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident #55.
8. Review of the medical record for Resident #31 revealed an admission date of 08/13/24 with diagnoses including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual disabilities. Resident #31 was hospitalized from [DATE] to 01/08/25. The medical record revealed Resident #31 was his own responsible party.
Review of the immunizations record revealed no evidence of Resident #31's COVID-19 vaccinations status.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was independent for activities of daily living. The assessment revealed Resident #31 was not up to date on COVID-19 vaccinations.
Review of a Nurse Practitioner (NP) progress note dated 12/26/24 revealed Resident #31 continued to have cough and congestion. On 12/23/24 Resident #31 had a chest x-ray with no findings. On 12/24/24 Resident #31 had four to five watery stools and was ordered Loperamide two milligrams (mg) every six hours as needed for diarrhea. Resident #31 also complained of nausea and emesis. Laboratory services were ordered on 12/24/24 and were not obtained. Resident #31's pulse ox was 92 percent on room air and the resident's heart rate was 109 (tachycardic). While the NP was visiting, she was alerted Resident #31 had fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated 12/27/24 revealed Resident #31 had been admitted to the hospital with acute hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19.
Review of a hospital note revealed Resident #31 was admitted to the step-down unit on 12/26/24 for acute hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis. Resident #31 continued to have intermittent coughing while hospitalized .
Review of a NP progress note dated 01/09/25 revealed Resident #31 had re-admitted to the facility from the hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #31 had been hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since 12/06/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident #31.
9. Review of the COVID-19 Vaccination Record Card for Nurse Aid #339 revealed doses of COVID-19 vaccinations were received on 12/23/20, 01/13/21, 02/06/23, and 04/24/23. There was no evidence of facility offering, screening, or education to Nurse Aid #339 for additional doses of COVID-19 vaccination.
Interview on 03/20/25 at 8:50 A.M. with the Administrator confirmed she was unable to provide any additional offerings of COVID-19 boosters to Nurse Aid #339 or evidence of any education provided on COVID-19 vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the personnel files, review of the facility assessment and interviews, the facility failed to ensure Certified Nursing Assistants (CNA) #305 and #329 received annual performance reviews. This affected two CNAs of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility.
Findings include:
Review of the personnel file for CNA #305 revealed a hire date of 06/03/21. There was no documented evidence that CNA #305 had an annual performance review.
Review of the personnel file for CNA #329 revealed a hire date of 06/03/21. There was no documented evidence that CNA #329 had an annual performance review.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNAs #305 and #329 did not have an annual performance reviews in their personnel files.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services.

Based on record review, observations and interviews, the facility failed to ensure medical records were complete and accurate. This affected four (Residents #11, #18, #22 and #43) of 28 records reviewed. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 01/25/17 with diagnoses including dementia with behavioral disturbance and Coronavirus Disease 2019 (COVID-19).
Review of the physician's orders for Resident #11 revealed an order dated 12/27/24 to maintain contact and droplet precautions every shift.
Review of the Treatment Administration Record (TAR) for March 2025 for Resident #11 revealed nursing staff were still signing that Resident #11 was on contact and droplet precautions for COVID-19.
Observation and interview on 03/10/25 at 11:46 A.M. with Certified Nursing Assistant (CNA) #305 verified Resident #11 was on enhanced barrier precautions related to having a wound. She stated staff wore gowns and gloves when providing care.
Interview on 03/18/24 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #11 should not have the physician's order for contact/droplet precautions as he no longer had COVID-19. She stated the order should have been discontinued in January 2025.
2. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the physician's orders for Resident #22 revealed an order dated 12/28/24 to maintain contact and droplet precautions every shift for 5 to 10 days if symptomatic.
Review of the Treatment Administration Record (TAR) for March 2025 for Resident #22 revealed nursing staff were still signing that Resident #22 was on contact and droplet precautions for COVID-19.
Interview on 03/13/25 at 12:25 P.M. with Resident #22 verified he had COVID-19 in December of 2024. He verified he was not on isolation for COVID-19.
Interview on 03/18/24 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #22 should not have the physician's order for contact/droplet precautions as he no longer had COVID-19. She stated the order should have been discontinued in January 2025.
3. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, oropharyngeal phase dysphagia, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of nurses note dated 12/27/24 revealed Resident #18 had tested positive for COVID-19.
Review of physician's order dated 12/30/24 revealed an order to maintain contact and droplet precautions. There was no noted duration on the order.
Review of the Treatment Administration Records (TAR) from January 2025 to March 2025 revealed nursing staff continued to signed off on confirmation of contact and droplet precautions through 03/17/25.
Observations from 03/10/25 to 03/20/25 revealed no evidence Resident #18 was on any kind of transmission based precautions.
Interview on 03/18/25 10:09 A.M. with Director of Nursing (DON) confirmed Resident #18 still had an order for contact/droplet precautions that needed discontinued due to resolved symptoms. The DON indicated she noticed the orders in place that were no longer applicable when she was doing medication pass.
4. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses including COVID-19 (12/28/24), sepsis, anemia, diabetes mellitus, paranoid schizophrenia, and chronic obstructive pulmonary disease.
Review of nurses note dated 12/27/24 revealed Resident #43 had tested positive for COVID-19.
Review of physician's order dated 12/30/24 revealed an order to maintain contact and droplet precautions. There was no noted duration on the order.
Review of Treatment Administration Records (TAR) from January 2025 to March 2025 revealed nursing staff continued to sign off on confirmation of contact and droplet precautions through 03/17/25.
Observations from 03/10/25 to 03/20/25 revealed Resident #43 was on enhanced barrier precautions for a wound.
Interview on 03/18/25 10:09 A.M. with the Director of Nursing (DON) confirmed Resident #43 still had an order for contact/droplet precautions that needed discontinued due to resolved symptoms. The DON indicated she noticed the orders in place that were no longer applicable when she was doing medication pass.

Based on record review, interview and review of the facility policy, the facility failed to ensure all required members of the quality assurance performance improvement (QAPI) committee met quarterly as required. This affected all 54 residents residing in the facility.
Findings include:
Review of the QAPI meeting minutes and sign-in sheets from January 2024 through February 2025 revealed QAPI met on 03/19/24, 04/16/24, 05/21/24, 06/18/24, 07/16/24, 08/16/24, 09/17/24, 10/15/24, January 2025 and February 2025. There was no evidence the facility's previous Medical Director, Physician #367, attended the QAPI meetings on 03/19/24, 04/16/24, 05/21/24, 06/18/24 and 07/16/24. There was no evidence a member of the facility's governing body attended the QAPI meetings until the January 2025 meeting. Additionally, there was no identification of the facility's Infection Preventionist (IP) on the sign-in sheets provided to ensure the IP was involved as required.
On 03/17/25 at 12:05 P.M. telephone interview with Physician #366 revealed he had been the Medical Director at the facility since 07/01/24. Physician #366 stated the facility had QAPI meetings monthly which he strove to attend and denied any concerns with the facility at this time.
On 03/17/25 starting at 3:02 P.M. interview with Chief Operating Officer (COO) #300 revealed if the medical director attended by phone or in person, their attendance should have been reflected on the QAPI signature sheets. COO #300 was made aware during the interview there was no evidence Physician #367 had attended any of the QAPI meetings before Physician #366 took over the Medical Director role in July 2024. COO #300 verified there were no QAPI meeting minutes or sign-in sheets for November 2024 and December 2024 available for review.
Follow-up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to provide IP certificates for the former Assistant Director of Nursing (ADON) or the night nurse (not identified) that helped to cover the IP 'role for a time.' COO #300 confirmed she only covered the facility's infection control program for January 2025 and February 2025 and attended the facility's QAPI meetings those months and verified there was no evidence the IP routinely attended QAPI meetings as required.
Review of the facility policy, QAPI Committee Meetings, dated 05/01/22 revealed the facility's Quality Assurance (QA)/Quality Improvement (QI) committee members include but are not limited to: Director of Nursing, Medical Director/Physician, Administrator, Director of Housekeeping/Laundry, Director of Therapeutic Recreation, Director of Social Work, Director of Food Services, Director of Rehabilitation, QA Nurse, Director of Maintenance and Other designated facility staff. The policy did not identify the IP role as a required component of its QA/QI meetings. The QA/QI committee will meet at least quarterly to identify QA/QI issues and to develop appropriate plans of action needed to correct the issues. The Committee monitors the effect of the implemented changes and makes any revisions necessary to the plan of action.
Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2025 revealed the facility implemented a comprehensive QAPI program which addresses all the care and unique services that the facility provides .the IP shall report to the facility's governing body on the facility's infection prevention and control program and on incidents such as healthcare associated infections on a regular basis; the IP shall attend each QAPI meeting in order to be considered an active participant and if the IP cannot attend a QAPI meeting, then another staff member of the facility may attend in lieu of the IP but that does not change or absolve the IP's responsibility to fulfill the role of a QAA committee member or reporting on the facility's infection control and prevention program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Review of the physician's orders for Resident #49 revealed a treatment order for Triad Hydrophilic Wound Dress External Paste (debriding paste utilized as a wound dressing), apply to buttock topically two times a day dated 02/26/25. There were no orders for Resident #49 to be on EBP (gown and gloves) during care.
Observation on 03/12/25 at 2:33 P.M. of wound care to Resident #49 with NP #364 (wound nurse) and the DON revealed he had a Stage III pressure ulcer to Resident #49's right buttock. NP #364 and DON washed their hands prior to wound care and donned gloves. There were no gowns available in the room, and there was no sign on the door revealing Resident #49 was on EBP.
Interview on 03/12/25 at 3:40 P.M. with the DON verified Resident #49 did not have an order for EBP, but he should have had one due to the Stage III pressure ulcer to his right medial buttock.
Review of the facility policy titled, Transmission Based Precautions dated 05/01/22 revealed EBP should be implemented for high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and or clothing. The use of gown and gloves for high contract resident care activities was indicated when contact precautions would not apply otherwise for nursing homes residents with wound and/or indwelling medical devices regardless of MDRO colonization as well as residents with MDRO infection or colonization. Examples of high contact resident care activities requiring gown and gloves are providing hygiene, device care such as urinary catheter and wound care.
7. Review of the medical record for Resident #11 revealed an admission date of 01/25/17 with diagnoses including dementia with behavioral disturbance and non-compliance.
Review of the physician's orders for March 2025 revealed an order initiated on 11/26/24 for hospice was to change Resident #11's wound dressings on Tuesdays and Thursdays on night shift. On 02/26/25 an order was initiated for staff to apply Skin Prep (forms a film to protect the skin by reducing friction) daily to the right side of the foot and then leave the foot in the boot at bedtime for wound care.
Observation on 03/12/25 at 2:33 P.M. of wound care with the DON and NP #364 (wound nurse) to Resident #11's right lateral foot. During the dressing change and assessment, NP #364 removed Resident #11's dressing, removed the scab to the wound, measured the wound and then applied Skin Prep via wipe. NP #364 then placed a dry dressing over the wound. NP #364 was asked if the Skin Prep was a cleansing agent, and she verified it was not a cleansing agent but was like a liquid band-aid. NP #364 stated the wound had been cleaned during the last dressing change earlier in the night or day shift.
Interview on 03/12/24 at 3:40 P.M. with the DON verified NP #364 did not cleanse Resident #11's right lateral foot wound during the dressing change.
Review of the facility policy titled, Wound Care dated 05/01/22 revealed the facility would ensure all residents skin conditions were properly tracked and cared for.
8. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's disease and dementia.
Review of Resident #204's nursing admission assessment dated [DATE] revealed he had an indwelling Foley catheter in place. There was no documentation related to Resident #204 needing to be placed on EBP.
Observation on 03/12/25 at 10:40 A.M. of care to Resident #204 by CNA #305 and CNA #353 revealed he had an indwelling Foley catheter. CNA #305 and CNA #353 washed their hands, donned gloves and then provided Foley catheter care to Resident #204. There were no gowns available in the room and there was no sign on the door revealing Resident #204 was on EBP. Both CNA #305 and CNA #353 verified Resident #204 was not on EBP
Interview on 03/12/25 at 11:30 A.M. with the Administrator verified Resident #204 was not on EBP but he should have been due to having an indwelling Foley catheter.
Review of the facility policy titled, Transmission Based Precautions dated 05/01/22 revealed EBP should be implemented for high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and/or clothing. The use of gown and gloves for high contract resident care activities was indicated when contact precautions would not apply otherwise for nursing homes residents with wound and/or indwelling medical devices regardless of MDRO colonization as well as residents with MDRO infection or colonization. Examples of high contact resident care activities requiring gown and gloves are providing hygiene, device care such as urinary catheter and wound care.
9. Review of four out of six new employee personnel files revealed the facility was not ensuring staff were given a purified protein derivative (PPD) test (test for tuberculosis) on hire. The Administrator, Housekeeping Supervisor #306, Activities Director #330 and Receptionist #335 tuberculosis screenings were blank or not in their files.
Interview on 03/18/25 at 1:04 P.M. with COO #300 verified the Administrator, Housekeeping Supervisor #306, Activities Director #330 and Receptionist #335 did not have tuberculosis screening on hire.
The facility was unable to provide a tuberculosis screening policy for staff.
This deficiency represents noncompliance investigated under Master Complaint Number OH00163232 and Complaint Number OH00162361.
Based on record review, observations, interviews, review of hospital discharge summaries, review of the Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS), review of the Summit County Public Health (SCPH) Public Health Nurse (PHN) communications, and facility policy review, the facility failed to develop, maintain, and implement an effective infection control program. This had the potential to affect all 54 residents residing in the facility.
The failed to follow the local health department's directives for Resident #24 with a MDRO. This affected one resident (#24) of one resident reviewed for a MDRO and had the potential to affect all residents.
The facility failed to ensure infection control tracking was not complete or accurate. This had the potential to affect all residents.
The facility failed to have effective COVID-19 outbreak testing, or infection surveillance for staff and residents. The affected 20 residents (#2, #9, #11, #16, #18, #21, #22, #31, #35, #36, #37, #38, #40, #41, #42, #43, #44, #46, #47, and #55) and had the potential to affect all residents.
The facility failed to have an effective legionella water management program. This had the potential to affect all residents.
The facility failed to ensure EBP, transmission-based precautions (TBP) and/or contact precautions were in place for Residents #10, #14, #25, #30, #38, #49, and #204. This affected seven residents (#10, #14, #25, #30, #38, #49, and #204) of 12 residents reviewed for infection control and had the potential to affect all residents.
The facility failed to ensure maintain proper infection control practices while providing wound care for Resident #11. This affected one resident (#11) of two residents reviewed for wound care.
The facility failed to ensure tuberculosis screening upon hire for four employees (Administrator, Housekeeping Supervisor #306, Activities Director #330 and Receptionist #335) of ten employee personnel files reviewed. This had the potential to affect all residents.
Findings include:
1. Review of the medical record for Resident #24 revealed admission date of 06/04/24 with diagnoses including dementia with psychotic disturbance, hypertension, hyperlipidemia, lymphedema, Parkinson's disease, anxiety disorder, and atherosclerotic heart disease.
Review of a nurses note dated 11/05/24 revealed Resident #24 stated he was not feeling well. Resident #24 had a temperature of 101.4 degrees Fahrenheit (F), blood pressure of 132/87, oxygen saturation of 93 percent, and heart rate of 117. Resident #24 was sent to hospital for evaluation.
Review of the hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital from [DATE] to 11/11/24 for sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). It was noted blood and respiratory cultures had no growth.
Review of a nurses note dated 11/20/24 timed 7:30 A.M. revealed Resident #24 complained of being cold and not feeling well.
Review of a nurse's note dated 11/20/24 timed 1:58 P.M. revealed Resident #24 had a temperature of 99.8 degrees F and symptoms had not improved. Resident #24 was sent to hospital for evaluation.
Review of the hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital from [DATE] to 11/24/24 for cellulitis (an acute bacterial infection of the skin and underlying tissues) of the left lower extremity. Resident #24 admitted for recurrent left lower extremity cellulitis and had previously been admitted from 11/05/24 to 11/11/24. Resident #24 was noted to have Methicillin-resistant Staphylococcus aureus (MRSA) growth on the sputum culture, so doxycycline (antibiotic) was added. The sputum culture appeared consistent with colonization (the presence and multiplication of microorganisms on or within a host organism without causing any apparent symptoms or disease).
Review of a Nurse Practitioner (NP) progress note dated 11/25/24 revealed Resident #24 returned from hospital on [DATE] with a diagnosis of cellulitis. The NP noted Resident #24 was discharged on an antibiotic for cellulitis and MRSA in the sputum culture.
Review of a NP progress note dated 12/16/24 revealed Resident #24 completed an oral antibiotic treatment of cephalexin for cellulitis and doxycycline for MRSA of sputum on 12/02/24.
Review of a nurses note dated 02/24/25 revealed Director of Nursing (DON) spoke with Resident #24's daughter regarding concerns about testing. The DON assured Resident #24's daughter the test would be completed, and she would be notified when the sample was sent to the lab. There was no specification regarding what the test was for.
Review of the current physician's orders for March 2025 revealed no evidence Resident #24 had order for enhanced barrier precautions (EBP) related to MDRO status.
Review of the plan of care for March 2025 revealed no care plan related to infections or MDRO status.
Further review of the medical record for Resident #24 revealed no additional information on Resident #24's MDRO status of colonization.
Review of the undated ODH ODRS report revealed Resident #24 had sputum culture collected on 11/10/24 while at hospital. Results of sputum culture returned on 11/27/24 and were positive for Citrobacter koseri and Klebsiella aerogenes. Klebsiella pneumoniae carbapenemase (KPC) was detected.
Review of the facility infection control logs from November 2024 to February 2025 revealed no evidence Resident #24's MDRO infection was logged, tracked, or monitored.
Review of documented notes from SCPH PHN #370 revealed:
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On 12/04/24 PHN #370 contacted the hospital requesting labs and provider notes with information on Resident #24's location of residence.
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On 12/10/24 PHN #370 attempted phone contact to facility without success.
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On 12/18/24 PHN #370 attempted phone contact to facility without success.
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On 12/27/24 PHN #370 attempted phone contact to facility. PHN #370 was able to obtain DON's email address and email communication was sent.
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On 01/07/25 PHN #370 had not received response to email to DON. A follow-up call was placed to facility and voicemail was left for Admissions/Social Service Designee (SSD) #355. SSD #355 returned phone call and confirmed Resident #24 had not been in EBP. PHN #370 provided education on colonization screening and would send follow up email with more information. DON returned call to PHN #370 and was also educated on EBP and screening needs.
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On 01/15/25 PHN #370 had not received follow up from facility on initiating colonization screening. PHN #370 left voicemail for SSD #355.
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On 01/17/25 PHN #370 was contacted by Chief Operating Officer (COO) #300. PHN #370 forwarded email with screening recommendations, swab request form, and education.
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On 01/27/25 PHN #370 had not received screening request forms and placed follow up call to COO #300 without successful contact.
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On 02/04/25 PHN #370 had not received follow up for screening from facility. SCPH Medical Director called facility and spoke with the Administrator. The Administrator indicated the facility was having turnover and requested email be forwarded to her.
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On 02/12/25 PHN #370 received a request for testing kits from DON.
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On 02/28/25 PHN #370 noted the facility was scheduled to perform screening on 02/17/25; however. No results had returned. PHN #370 followed up with lab and discovered no specimens were received from facility.
Review of email communication dated 12/27/24 at 3:01 P.M. from SCPH PHN #370 addressed to Registered Nurse (RN)/Former DON #313 revealed PHN #370 notified facility of Resident #24 was reported to SCPH for a carbapenemase producing organism (CPO) and PHN #370 requested more information. It was noted Resident #24 should be on EBP.
Review of email communication dated 01/07/25 at 2:56 P.M. from SCPH PHN #370 addressed to Former DON #313 and SSD #355 revealed PHN #370 provided educational materials and instructions for Carbapenemase Producing Carbapenem Resistant Enterobacteriaceae (CP-CRE) screening. PHN #370 indicated Point-Prevalence Screening (PPS) should be completed on Resident #24's unit. Resident #24 was identified as the index case and should be on EBP. Screenings were by rectal swab and must be completed on an agreed collection date.
Review of email communication dated 01/17/25 at 11:55 A.M. from SCPH PHN #370 addressed to COO #300 revealed PHN #370 forwarded email sent to Former DON #313 and SSD #355.
Review of email communication dated 02/04/25 at 1:41 P.M. from SCPH PHN #370 addressed to the Administrator revealed PHN #370 re-sent email sent to Former DON #313, SSD #355, and COO #300.
Review of email communication dated 02/10/25 at 11:23 A.M. from COO #300 addressed to SCPH PHN #370 revealed COO #300 attached order form for rectal swab test kits with no specification of number of kits needed.
Review of email communication dated 02/12/25 at 10:09 A.M. from Former DON #313 addressed to SCPH PHN #370 revealed Former DON #313 attached consent forms for five swab culture kits.
Review of Laboratory Report dated 03/05/25 revealed a rectal swab was obtained on 02/28/25 for Resident #24 and KPC gene deoxyribonucleic acid (DNA) was detected.
Review of Laboratory Report dated 03/05/25 revealed rectal swabs were obtained on 02/28/25 for Residents #34 and #46. Residents #34 and #46 were identified to share a bathroom with Resident #24. Residents #34 and #46's swabs were negative for any detectable genes.
Observation on 03/10/25 at 12:55 P.M. revealed Resident #24 was on EBP.
Observation on 03/11/25 at 5:55 A.M . revealed Resident #24 was changed to contact precautions.
Interview on 03/11/25 at 9:55 A.M. with PHN #370 revealed the facility had been difficult to contact and did not complete screening as scheduled. PHN #370 indicated Resident #24 was the index case and due to colonization status needed to be on EBP. PHN #370 indicated screening was necessary to determine if there had been any transmission.
Interview on 03/11/25 at 11:53 A.M. with the DON confirmed she had changed Resident #24 from EBP to contact precautions as she had noticed report of CRE in sputum. DON indicated she became aware of the issue in a care conference with Resident #24's daughter. The DON indicated in her investigation she realized the facility had been contacted by SCPH, and there were required screenings to be done. She collected the samples and got the swabs sent out for testing.
Interview on 03/11/25 at 1:59 P.M. with SSD #355 revealed she became involved with SCPH via phone. SSD #355 indicated the DON was on vacation and she took a message. SSD #355 indicated she relayed all information to COO #300.
Interview on 03/11/25 at 2:13 P.M. with the Administrator and COO #300 confirmed SCPH had reached out about Resident #24. COO #300 indicated SCPH was working with RN/Former DON #313.
Interview on 03/11/25 at 4:20 P.M. with RN/Former DON #313 revealed she was contacted sometime in January 2025 by SCPH. DON #313 indicated SCPH PHN #370 had emailed her information on EBP and screening that needed done. DON #313 indicated the screening specimens were collected mid-February 2025 and she had left the specimens for the new DON to send out. DON #313 indicated she was unaware of a 02/17/25 testing date with the lab. DON #313 indicated she was on vacation during this time.
Interview on 03/12/25 8:23 A.M. with the DON revealed there had not been any information left for her on swabs or documentation on Resident #24's MDRO status left by Former DON #313. When she became aware, she took action to get test swabs sent to lab to comply with SCPH recommendations. The DON confirmed there was no documentation in Resident #24's medical record on MDRO status or order for EBP.
Review of undated SCPH provided educational document Enhanced Barrier Precautions revealed EBP was recommended for life for diagnosed clinical cases and colonized positive residents of CPOs due to increased risk for transmission. EBP required use of gowns and gloves during high contact patient care activities including dressing, bathing, transfers, hygiene, changing linens, care of or use of medical devices, and wound care.
Review of SCPH provided educational document Facility Guidance for Control of CRE dated November 2015 revealed CDC CRE tool kit was intended for all long-term care facilities. The effort to prevent transmission of resistant organisms could be coordinated by local public health.
Review of the facility policy Screening and Management of Residents with Infections dated 05/01/22 revealed the infection preventionist would maintain a log of residents with current evidence of infection or colonization due to MDRO. Room placement should be considered to prevent placing a resident with MDRO with a resident at high risk for infection. A resident admitted with colonization of MDRO should be reviewed prior to return for details of the status and any possible infection control risks the situation presents.
Review of the facility policy Infection Surveillance dated 10/27/21 revealed cultures may be sent for infections or colonization with epidemiologically important organisms. All MDRO reports required immediate attention to ensure appropriate precautions were in place and notifications were made. The infection control committee would communicate important surveillance data to state and local health departments.
2. Review of infection control logs from January 2024 to December 2024 revealed that starting in June 2024 logs were not completed appropriately to adequately track and trend infections. Identified infections did not include dates of onset, culture or testing results, symptoms, if resident was placed on isolation, or if organisms were sensitive to medications. The Infection Preventionist (IP) had only recorded the residents' name, room number, general infection type and antibiotic ordered. There was no evidence of ongoing analysis of infection data.
Review of the Antibiotic Use Audit Tool for January 2025 and February 2025 revealed COO #300 had audited use of antibiotics for infections. There was no evidence of complete and accurate infection control tracking or trends.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed she was unsure if there was a full 12 months of infection control logs. COO #300 indicated she had started an infection control book for January 2025 and February 2025.
Interview on 03/12/25 at 8:23 A.M. with the DON confirmed infection control tracking was not complete or accurate. There was not much available to review for the past 12 months. The facility should be tracking infections on a log and using mapping to identify patterns.
Review of the facility policy Infection Surveillance dated 10/27/21 revealed the infection preventionist was responsible for gathering and interpreting surveillance data. Surveillance data should include identifying information of resident, diagnoses, admission date, date of onset of infection, site of infection, pathogens, risk factors, pertinent remarks on signs and symptoms, if resident was admitted to hospital or other outcomes, and treatment measures and precautions. Monthly data should be collected and entered onto a line listing report then data should be summarized for each nursing unit by site and pathogen. Predominant pathogens or sites should be identified for trending.
3. Observation on 03/10/25 at revealed there were no current residents on isolation for COVID-19.
Interview on 03/11/25 at 11:25 A.M. with COO #300 revealed she was aware there were a few cases of COVID-19 in December 2024 but was trying to get a list from the Former DON #313.
Interview on 03/12/25 at 4:50 P.M. with COO #300 confirmed there was no COVID-19 infection tracking. COO #300 indicated the last outbreak was handled by the Former DON #313 and Former Assistant DON (ADON) #368.
Interview on 03/13/25 at 8:22 A.M. with SCPH Staff #371 revealed she was responsible for COVID-19 tracking in the community. SCPH #371 indicated there was an online form that facilities could fill out weekly for reporting purposes. SCPH #371 indicated they asked facilities to fill out the form even if there were no cases of COVID-19. SCPH #371 indicated the last data submitted for the facility was for 12/04/24. SCPH #371 indicated there had been no data submitted about a COVID-19 outbreak in December 2024. SCPH #371 indicated the facility needed to report COVID-19 cases or outbreaks to be considered compliant.
Interview on 03/13/25 at 12:25 P.M. with Resident #22 confirmed he had COVID-19 in December 2024. Resident #22 stated staff wore appropriate personal protective equipment (PPE) while in his room and they moved his roommate to another room.
Despite multiple requests on 03/10/25, 3/11/25, 03/12/25, and 03/13/25 the facility was unable to provide any COVID-19 infection tracking.
On 03/13/25 the surveyor completed a record review of residents residing in the facility. It was discovered that Residents #2, #11, #16, #18, #21, #22, #31, #37, #42, #43, #44, #47, and #55 tested positive for COVID-19 on 12/27/24. Resident #31 tested positive for COVID-19 while in the hospital. It was discovered that Resident #38 tested positive for COVID-19 on 12/30/24. It was discovered that Resident #35 tested positive for COVID-19 on 01/01/25. It was discovered that Residents #9, #40, #41, #46 tested positive for COVID-19 on 01/03/25. There was no evidence able to be obtained on staff positives for COVID-19, and no staff identified themselves as having COVID-19. Residents #9, #16, #35, #40, #41, and #46 had no identified orders for transmission-based precautions (TBP) related to COVID-19 positive status. Residents #21, #22, #37, #42, #47, and #55 TBP orders were added on 12/28/24. Residents #2, #11, #18, #34, #38, #43, and #44 TBP orders were added on 12/30/24. It was discovered that there was no evidence COVID-19 positive Resident #22's roommate COVID-19 negative Resident #36 was moved until 12/30/24.
Attempts on 03/13/25 and 03/17/25 to reach Former DON #313 and Former ADON #368 via phone were unsuccessful.
Interview on 03/17/25 at 8:00 A.M. with Certified Nurse Aide (CNA) #305 and CNA #353 revealed they had not been on the schedule when the COVID-19 outbreak started in December 2024. Both nurse aides recalled there being plenty of PPE and isolation in place for COVID-19 positive residents. Neither CNA #305 or CNA #353 could recall the testing procedures followed during the outbreak.
Interview on 03/17/25 at 9:06 A.M. with Central Supply/Scheduler #338 confirmed there were cases of COVID-19 in December 2024 among staff and residents. Central Supply/Scheduler #338 indicated she knew there was a whole facility round of testing done. Central Supply/Scheduler #338 indicated Former DON #313 and Former ADON #368 were completing the testing. Central Supply/Scheduler #338 indicated she was not sure who the staff were that had COVID-19, and there was no method for monitoring staff illness.
Interview on 03/17/25 at 11:27 A.M. with COO #300, Administrator, and RN/IP #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. RN/IP #374 indicated she knew there was a COVID-19 outbreak in December 2024. Surveyor identified COVID-19 cases were reviewed with COO #300, Administrator, and RN/IP #374, and COO #300 indicated she did not know there were so many cases. COO #300, Administrator, and RN/IP #374 were unable to provide additional information related to the COVID-19 outbreak, outbreak testing, or infection surveillance.
Interview on 03/17/25 at 2:26 P.M. with NP #363 revealed Resident #31 was sent to the hospital after a fall on 12/26/24. NP #363 indicated they were made aware Resident #31 tested positive for COVID-19 at the hospital and the facility did whole house testing on 12/27/24. NP #363 reported no concerns with COVID-19 management at the facility.
Review of the facility policy COVID-19 Precautions and Prevention dated 10/05/22 revealed the IP should maintain communication and collaboration with state and local health authorities including notification. IP should conduct frequent monitoring and surveillance for new respiratory illnesses. An outbreak would be declared when one case had suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or more than three residents or staff display new-onset respiratory symptoms within 72 hours of each other. IP should follow the local health department's recommendations for the next steps on managing a COVID-19 outbreak.
4. Interview on 03/11/25 at 11:25 A.M. with COO #300 revealed she was unable to find the legionella water management program binder.
Interview on 03/11/25 at 1:08 P.M. with Administrator confirmed she was unable to locate any evidence of water management program or evidence of water temperature logs.
The facility provided documents Water Management Plan for Potable Water and policies on Legionella Water Management on 03/12/25.
Interview on 03/17/25 at 11:27 A.M. with Administrator, COO #300, and RN/IP #374 confirmed they were unable to locate any additional information on legionella water management program. COO #300 confirmed provided Water Management Plan for Potable Water and policy for Legionella Water Management did not meet requirements for assessing risk, measures to prevent growth of Legionella in building water systems based on nationally accepted standards, or method for monitoring measures in place.
Review of the undated facility Water Management Plan for Potable Water revealed a section indicating water system was fed bottom-up, potable water system had two loops, there were no holding tanks for potable water, there were two water mains from public water supply with one for potable water and one for sprinkler system, and water mains were equipped with backflow preventers. The plan went on to indicate an environmental assessment would be updated annually and as needed. There was no evidence of an environmental assessment being completed. From the environmental assessment water testing would be completed. There was no evidence of water testing or sampling completed. There was no evidence of lab testing samples.
Review of the facility policy Legionella dated 07/01/23 revealed the facility would establish protocols for prevention and control of transmission of Legionnaire's disease including conducting sampling of potable water per facility's water management plan, disinfecting water distribution system using a high temperature flush, and keeping a log reflecting flushes.
Review of the facility policy Legionella Water Management dated 05/01/22 revealed as part of the facility's infection control program there would be a water management team to oversee water management program. The team would include an infection preventionist, administrator, medical director, director of maintenance, and director of environmental services. The water management program would be based on Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHREA) recommendations. The water management program would include a detailed description and diagram of water system in the facility, identification of areas in water system that could encourage growth and spread, identification of situations that could lead to growth, specific measures used to control, control limits or acceptable parameters, diagram of where control measures are applied, a system to monitor control limits and effectiveness, a plan for when control limits are not met, and documentation of program.
5. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed Residents #11, #20, #24, #30, #39, and #43 were identified as on EBP. There was signage for EBP instructions and to see nurse before entering and PPE was available at the entrance to the room. It was not clear which resident in the shared room for Resident #11 and #39 was on EBP. Resident #25 was identified as on contact precautions. There was signage for contact precautions instructions and a door hanger with PPE on the back of the door that contained gloves and red biohazard bags. There were no gowns readily available for Resident #25.
Interview on 03/10/25 at 12:43 P.M. with Licensed Practical Nurse (LPN) #369 revealed she worked for an agency and it was only her second time working at this facility. LPN #369 indicated she was unsure why Resident #25 was on contact precautions.
Follow up tour on 03/10/25 from 4:10 P.M. to 4:18 P.M. the DON revealed that she had been working at the facility for approximately three weeks and verified that she had not yet provided the survey team with the requested list of residents on precautions. She observed Residents #11, #20, #24, #30 and #43 and confirmed the residents were on EBP. The DON observed Resident #25 and confirmed the resident was on contact precautions for a Clostridium difficile (C. diff) infection, but it was cleared now. She indicated the signage needed changed to EBP. The DON confirmed there were no gowns readily available for Resident #25, and she verified Residents #11, #20, #24, #25, #30, and #43 all required EBP or TBP.
Observations on 03/11/25 from 5:45 A.M. to 5:55 A.M. revealed Residents #10, #14, #38, and #204 were newly placed on EBP, and Resident #24 was changed to contact precautions.
Int[TRUNCATED]

Based on interview, record review, review of infection control logs, and review of facility policy, the facility failed to ensure implementation of appropriate antibiotic stewardship measures. This affected one Resident (#9) of three reviewed for urinary tract infections and 15 residents (#2, #9, #19, #23, #24, #25, #29, #32, #33, #35, #37, #42, #43, #50, and #55) of 15 residents reviewed in the infection control log. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #9 revealed an admission date of 04/12/24 and diagnoses including bell's palsy, systemic lupus erythematosus, congestive heart failure, hypertension, dementia, metabolic encephalopathy, malignant neoplasm of bronchus and lung, and chronic kidney disease.
Review of the nurses note dated 01/11/25 revealed Resident #9 was agitated and adamant she was going home. Resident #9's son came to the facility to try to calm her down and he reported that Resident #9 was exhibiting symptoms of a urinary tract infection (UTI) as she had in the past. Hospice and the residents physician were notified. The physician gave an order for Ciprofloxacin (Cipro) for seven days and to collect a urine sample.
Review of Resident #9's physician's orders for January 2025 revealed no documented evidence of an order for a urine sample.
Review of Resident #9's laboratory results for January 2025 revealed no documented evidence of a urinalysis or culture completed to support the antibiotic treatment for UTI symptoms.
Review of the Antibiotic Use Audit Tools for January 2025 revealed on 01/11/25 Resident #9 received Cipro with an indication for use of a UTI. The tool indicated Resident #9 did not meet McGeer's Criteria, indicating that the resident did not exhibit the necessary signs, symptoms, and/or laboratory findings to be definitively diagnosed with a UTI.
Review of Resident #9's physician's order dated 01/12/25 revealed an order for Ciprofloxacin 500 milligrams (mg) two times per day for seven days.
Review of Resident #9's physician's order dated 01/21/25 revealed order for Macrobid (Nitrofurantoin) 100 mg two times per day for an unspecified number of days. The order was discontinued on 02/04/25.
Review of the Antibiotic Use Audit Tools for January 2025 revealed on 01/21/25, Resident #9 received Nitrofurantoin with an indication for use of a UTI. The tool indicated Resident #9 did not meet McGeer's Criteria, indicating that the resident did not exhibit the necessary signs, symptoms, and/or laboratory findings to be definitively diagnosed with a UTI.
Interview on 03/17/25 at 10:32 A.M. with Chief Operating Officer (COO) #300 confirmed she was unable to find a urinalysis completed for Resident #9 in January 2025 when Resident #9 was treated with an antibiotic for UTI symptoms.
Interview on 03/17/25 at 2:26 P.M. with Nurse Practitioner (NP) #363 indicated Resident #9's family reported she had history of UTI's and she was on hospice. NP #363 indicated she did not find it unusual for hospice to treat symptoms.
2. Review of the infection control logs from January 2024 to December 2024 revealed starting in June 2024, logs were not completed appropriately to adequately track and trend infections. Identified infections did not include the date of onset, culture or testing results, symptoms, if the resident was placed on isolation, or if organisms were sensitive to medications. The log had only recorded the residents' name, room number, general infection type and antibiotic ordered. Fifteen residents (#2, #9, #19, #23, #24, #25, #29, #32, #33, #35, #37, #42, #43, #50, and #55) were identified in the incomplete infection control log from June 2024 to December 2024.
Review of the Antibiotic Use Audit Tool for January 2025 and February 2025 revealed Chief Operating Officer (COO) #300 had audited the use of antibiotics for infections. COO #300 had indicated none of the residents with infections that were treated with antibiotics had met McGeer's Criteria, indicating that the resident did not exhibit the necessary signs, symptoms, and/or laboratory findings to be definitively diagnosed with an infection.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed she was unsure if there was a full 12 months of infection control logs. COO #300 indicated she had started an infection control book for January 2025 and February 2025.
Interview on 03/12/25 at 8:23 A.M. with Director of Nursing (DON) confirmed she was unable to locate any information on the facility's antibiotic stewardship program. DON indicated there was limited information available left for her regarding infection control in general. The DON indicated she would expect to see the use of McGeer's criteria and would have the nurse practitioner evaluate if the resident did not meet criteria for treatment with antibiotic.
Interview on 03/13/25 at 11:29 A.M. with COO #300 revealed she had created logs for January and February 2025 by reviewing progress notes. COO #300 indicated a lot of the residents on the log came in from the hospital already on antibiotics. COO #300 indicated residents did not always meet McGeer's criteria, but the physician did not want to change or discontinue the antibiotic. COO #300 indicated they just followed what the physician said.
Interview on 03/13/25 at 12:01 P.M. with COO #300 confirmed she did not have McGeer's criteria filled out on each infection with an antibiotic ordered, however she had cross referenced it when she created her logs.
Review of facility policy Antibiotic Stewardship Program dated 07/01/23 revealed lab results would be reported to prescriber to determine if antibiotic therapy should be started, continued, modified, or discontinued. The infection preventionist would continue infection line listing and review antibiotic utilization on a monthly basis to ensure appropriate prescribing and use of antibiotics.

Based on review of Quality Assurance and Performance Improvement (QAPI) meetings, staff interview, review of staff certificates and personnel files, the facility failed to ensure there was a qualified infection preventionist (IP) working on at least a part time basis. This had the potential to affect all residents residing in the facility. The facility census was 54.
Findings include:
Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets from March 2024 to February 2025 revealed no designation of an IP or evidence of an IP participation in meetings, except for in January 2025 and February 2025 when Chief Operating Officer (COO) #300 was present.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed there was not currently an infection preventionist (IP) employed at the facility. COO #300 indicated she held an IP certificate and Registered Nurse (RN) #374 was a Director of Nursing and IP for another facility, who was assisting with the changeover in staff. COO #300 indicated former Assistant Director of Nursing (ADON) #368 was the IP from May 2024 through December 2024.
Interview on 03/11/25 at 8:00 A.M. with the Director of Nursing (DON) revealed she had an IP certificate, but was unable to provide evidence of the certificate.
Interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate an IP certificate for the former ADON #368 and confirmed there had not been consistent participation from an IP on QAPI meetings as required. She stated she was only at the facility from January 2025 to current and was only present one day per week and RN #374 worked mostly offsite.
Review of the certificate dated 06/05/20 revealed RN #374 completed IP training course with Centers for Disease Control and Prevention (CDC) via web-based training.
Review of certificate dated 01/09/25 revealed COO #300 completed IP training course with CDC via web-based training.
Review of the personnel file of former ADON #368 revealed no evidence of an IP certificate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy, the facility failed to act upon pharmacy reviews in a timely manner. This affected five (Residents #5, #7, #18, #24 and #37) of five residents reviewed for unnecessary medications. Facility census was 54.
Findings include:
1. Review of Resident #5's medical record revealed an admission date of 07/26/17 and diagnoses including heart failure, schizophrenia, anxiety, constipation, type two diabetes, depression and unspecified psychosis.
Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she received insulin, antipsychotic's, antianxiety medications, antidepressants, anticoagulants, diuretics and opioids.
Review of Resident #5's discontinued orders revealed an order dated 07/21/24 for hydroxyzine pamoate oral capsule 25 milligrams (mg) give by mouth every six hours as needed (PRN) for itching. The order was discontinued on 02/04/25.
Continued review of Resident #5's discontinued orders revealed an order dated 10/11/24 for Ativan oral tablet 0.5 mg give by mouth every four hours as needed (PRN) for anxiety. The order was discontinued on 02/04/25.
Review of Resident #5's assessments revealed the last Abnormal Involuntary Movement Test (AIMS) completed was on 05/24/24.
Review of a pharmacy recommendation dated 09/24/24 revealed the pharmacist recommended adding a stop date to Resident #5's PRN Ativan. The recommendation was left blank and was not signed and not dated.
Review of a pharmacy recommendation dated 10/23/24 revealed the pharmacist recommended adding a stop date to Resident #5's PRN Ativan and PRN hydroxyzine. The recommendation was left blank and was not signed and not dated.
Review of a pharmacy recommendation dated 11/21/24 revealed the pharmacist recommended for an AIMS to be added now and every six months thereafter. The recommendation was left blank and was not signed and not dated.
Nurses' notes from September 2024 through November 2024 did not indicate the pharmacy recommendations were addressed.
Interview on 03/17/25 at 2:46 P.M. with the Director of Nursing (DON) revealed the pharmacy recommendations had not been available in the residents' medical records so she had called the pharmacy to obtain them. The DON verified Resident #5's PRN Ativan and PRN hydroxyzine medication reviews were not timely addressed as they continued without stop dates until 02/04/25. The DON also confirmed there were no additional AIMS assessments for Resident #5 to review since the one completed on 05/24/24.
2. Review of Resident #7's medical record revealed an admission date of 05/07/15 and diagnoses including schizoaffective disorder-bipolar type, depression, generalized anxiety disorder, dementia with agitation and legal blindness.
Review of Resident #7's quarterly MDS 3.0 assessment date 12/05/24 revealed Resident #7 was moderately cognitively impaired and received insulin, antianxiety medications, antidepressant medications, anticoagulants and opioids.
Review of Resident #7's physician's orders revealed an order dated 09/05/24 for Xarelto 20 mg and an order dated 09/05/24 for cetirizine hydrochloride oral tablet 10 mg.
Review of a pharmacy recommendation dated 05/29/24 revealed the pharmacist recommended to reduce the dose of Xarelto 20 mg to 10 mg daily. The recommendation was left blank and was not signed and not dated.
Review of a pharmacy recommendation dated 05/29/24 revealed the pharmacist recommended to reduce the dose of Zyrtec 10 mg to 5 mg daily. The recommendation was left blank and was not signed and not dated.
Nurses' notes from May 2024 and June 2024 did not indicate the pharmacy recommendations were addressed.
Interview on 03/17/25 at 2:46 P.M. with the DON revealed the pharmacy recommendations had not been available in the residents' medical records so she had called the pharmacy to obtain them. The DON verified Resident #7's pharmacy recommendations for reducing Xarelto and Zyrtec were blank as of the time of the interview and should have been addressed timely as required.
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses including dementia with psychotic disturbance, hypertension, insomnia and anxiety.
Review of the Note To Attending Physician/Prescriber, dated 09/24/24 from the pharmacist revealed Resident #24 was on Seroquel and Zyprexa (antipsychotic medications used to treat symptoms of psychosis such as delusion, hallucination, paranoia and confused thoughts) and requested the facility either document the use for two antipsychotics or adjust therapy as appropriate. The form was not addressed by the facility or the physician.
Review of the Note To Attending Physician/Prescriber, dated 11/21/24 from the pharmacist revealed Resident #24 was on Seroquel, Risperdal and Zyprexa (antipsychotic medications used to treat symptoms of psychosis such as delusion, hallucination, paranoia and confused thoughts) and requested the facility evaluate the use of the three medications from the same drug class and adjust therapy or give clinical rationale for continued use. The form was not addressed by the facility or the physician.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24's cognition and depression were not assessed. He was noted to be on anti-psychotics and anti-depressants. There was no gradual dose reduction attempted for the anti-psychotic medications.
Review of the physician's orders for March 2025 for Resident #24 revealed he was medications including blood pressure medications, medications for insomnia, three anti-psychotic medications and an anti-depressant.
Review of the care plan dated 03/10/25 for Resident #24 revealed he was on psychotropic medications (drugs that affect behavior, mood, thoughts or perceptions) related to behavior management and psychotic disturbance. Interventions included to consult with the pharmacy and his doctor to consider dosage reduction if clinically appropriate when indicated.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) verified the pharmacy recommendations for Resident #24 were not addressed by the staff or the physician for the past year.
Interview on 03/17/25 at 2:46 P.M. with the DON verified the pharmacy recommendations she provided were printed off the pharmacy's website during the survey.
4. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression, heart failure and bipolar disorder (mental illness that causes mood shifts between mania and depression).
Review of the care plan dated 08/21/24 for Resident #37 revealed he was on psychotropic medications (drugs that affect behavior, mood, thoughts or perceptions) related to depression and bipolar disorder. Interventions included to consult with the pharmacy and his doctor to consider dosage reduction if clinically appropriate when indicated.
Review of the Note To Attending Physician/Prescriber, dated 01/13/25 from the pharmacist revealed Resident #37 was on Trazadone (medication for depression) and the facility should attempt to taper the medication. If the reduction in dose was contraindicated, the physician was to document why the reduction was not indicated. The form was not addressed by the facility or the physician.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition and was depressed. He was noted to be on anti-psychotics, anti-depressants, insulin and hypnotic medications. There was no gradual dose reduction listed for the anti-psychotic medication.
Review of the physician's orders for March 2025 for Resident #37 revealed he was on medications including insulin, blood pressure medications, medications for insomnia, anti-psychotics and anti-depressants.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) verified the pharmacy recommendations for Resident #37 were not addressed by the staff or the physician for the past year.
Interview on 03/17/25 at 2:46 P.M. with the DON verified the pharmacy recommendations she provided were printed off the pharmacy's website during the survey.
5. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 09/24/24 revealed pharmacist recommended to add duration and provide supporting clinical documentation for continued use of as needed Ativan. There was no evidence of physician/prescriber response or action. The pharmacist recommended as Resident #18 was receiving Sinemet four times per day to increase Comtan from two times per day to four times per day to allow for more active Levodopa. There was no evidence of physician/prescriber response or action.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 10/24/24 revealed pharmacist recommended to attempt a dose reduction of Zoloft 50 milligrams (mg) once daily. There was no evidence of physician/prescriber response or action.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 11/22/24 revealed pharmacist recommended to add duration and provide supporting clinical documentation for continued use of as needed Ativan. There was no evidence of physician/prescriber response or action. The pharmacist recommended to evaluate 12-hour frequency on as needed Melatonin and consider change to once daily as needed. There was no evidence of physician/prescriber response or action.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 01/13/25 revealed pharmacist recommended to attempt a dose reduction of Ativan 0.5 milligrams (mg) twice daily. There was no evidence of physician/prescriber response or action.
Further review of Resident #18's medical record revealed pharmacy recommendations were not addressed in a timely manner.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed there had not been any evidence of physician/prescriber follow up to pharmacy recommendations.
Review of facility policy Pharmacy Services Policy and Procedure dated 2025 revealed each resident shall have a drug regimen review at least monthly by a licensed pharmacist. The attending physician shall document in the resident's medical record that any medication irregularities had been reviewed and what actions were taken to address. If there were no changes to the medication the attending physician shall document rationale in the resident's medical record. Further review revealed, the facility would ensure residents who used psychotropic drugs received gradual dose reductions unless clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's medical record revealed an admission date of 07/26/17 and diagnoses including heart failure, schizophrenia, anxiety, constipation, type two diabetes, depression and unspecified psychosis.
Review of Resident #5's physician's orders revealed an order for Lorazepam 0.5 milligrams (mg) every four hours as needed for anxiety for 14 days (03/13/25); an order for buspirone hydrochloride oral tablet 10 mg twice a day for anxiety (02/04/25); an order for bupropion hydrochloride extended release oral tablet 150 mg give two tablets once a day for depression (02/04/25); an order for abilify oral tablet 10 mg daily for anxiety (07/22/24); and an order for Zoloft tablet 100 mg daily for depression (07/22/24). Further review of the physician's orders revealed no psychotropic medication monitoring was currently in place. Review of discontinued orders revealed antipsychotic, antidepressant and antianxiety medication monitoring was last in place on 07/09/24.
Review of Resident #5's quarterly MDS 3.0 assessment dated [DATE] revealed she received insulin, antipsychotics, antianxiety medications, antidepressants, anticoagulants, diuretics and opioids.
Review of Resident #5's plans of care revealed an anxiety care plan dated 10/04/17 and revised 02/24/22 with an intervention including administer medications as ordered, see medication record. Monitor for effectiveness and side effects (10/04/17). An additional plan of care dated 07/27/17 and revised 02/14/23 revealed Resident #5 utilized psychotropic medications (antipsychotic, antianxiety, antidepressant) related to anxiety, depression, schizophrenia, behavioral disturbance and insomnia. Listed interventions included lists of side effects for antidepressants, antipsychotics and antianxiety medications; monitor for side effects and effectiveness; monitor AIMS test for extrapyramidal symptoms and report abnormal findings (07/27/17).
Review of Resident #5's assessments revealed the last AIMS completed was on 05/24/24.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #5's AIMS testing had not been done again since 05/24/24 and verified although Resident #5 was on hospice services, her psychotropic medications were still to be monitored for side effects. The DON could not state why Resident #5's previous orders for psychotropic medication monitoring were discontinued as she had only been working at the facility since 02/17/25.
3. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Review of Resident #37's electronic medical record and paper chart revealed facility staff had not assessed the side effects of medications with the Abnormal Involuntary Movement Scale (AIMS) since he was admitted .
Review of the physician's orders for March 2025 for Resident #24 revealed he had psychotropic medications (drugs that affect behavior, mood, thoughts or perception) including Trazodone HCl 150 milligrams (anti-depressant) once daily for insomnia dated 09/03/24 and Quetiapine Fumarate 400 milligrams (mg) (antipsychotic medication) for bipolar disorder daily dated 03/03/25. There were no orders for monitoring of these medications or his behaviors.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #37 did not have an AIMS assessment in his medical record or monitored the psychotropic medications or behaviors of Resident #37. The DON also verified the facility did not have a policy on psychotropic monitoring.
Based on interview and record review, the facility failed to ensure residents were monitored for the use of psychotropic medications. This affected three residents (#5, #18, and #37) of five residents reviewed for unnecessary medications. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar (an antipsychotic medication).
Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam (a medication used for anxiety).
Review of physician's order dated 07/17/24 revealed order for 150 mg Clozaril (an antipsychotic medication).
Review of Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] revealed Resident #18 was not observed to have any abnormal movements.
Review of physician's order dated 10/26/24 revealed order for 75 mg Zoloft (an antidepressant medication).
Review of plan of care dated 02/14/25 revealed Resident #18 received psychoactive medications to treat mental illness. Interventions included to monitor AIMS test for extrapyramidal symptoms (EPS) and report any abnormal findings.
Review of physician's order dated 03/13/25 revealed order for 0.5 mg Lorazepam every four hours as needed for 14 days.
Further review of the medical record revealed there were no additional assessments to monitor AIMS test for EPS.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed there had not been any evidence of additional monitoring for EPS with AIMS testing.

Based on interview, record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one resident (#18) of 28 residents reviewed for medications. The facility census was 54.
Findings include:
Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, oropharyngeal phase dysphagia, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar one time per day. The medication was scheduled for 9:00 A.M.
Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam two times per day. The medication was scheduled for 9:00 A.M. and 9:00 P.M.
Review of physician's order dated 03/20/24 revealed order to ensure Carbidopa-Levodopa was administered one hour prior to a meal to assist with swallowing and to hold meal tray until at least 60 minutes have passed since medication administration.
Review of physician's order dated 07/17/24 revealed order for 150 mg Clozaril two times per day. The medication was scheduled for 9:00 A.M. and 9:00 P.M.
Review of physician's order dated 07/23/24 revealed an order for one tablet of Carbidopa-Levodopa 25-100 mg in the evening. It was noted to give medication 60 minutes prior to eating.
Review of physician's order dated 08/17/24 revealed an order for two tablets of Carbidopa-Levodopa 25-100 mg before meals (three times per day). It was noted to give medication one hour prior to meals.
Review of physician's order dated 10/26/24 revealed order for 75 mg Zoloft one time per day. The medication was scheduled for 9:00 A.M.
Review of Medication Administration Record (MAR) for January 2025 revealed no evidence Carbidopa-Levodopa was administered at 6:00 P.M. dose on 01/04/25 and 6:00 P.M. dose on 01/14/25.
Review of Medication Administration Record (MAR) for February 2025 revealed no evidence Carbidopa-Levodopa was administered at 6:30 A.M. dose on 02/04/25, 6:00 P.M. dose on 02/12/25, 6:30 A.M. dose on 02/13/25, and 6:00 P.M. dose on 02/27/25.
Review of Medication Administration Record (MAR) for March 2025 revealed no evidence Carbidopa-Levodopa was administered at 6:30 A.M. dose on 03/13/25 and 6:00 P.M. dose on 03/14/25.
Review of Administration History Report from February 2025 to March 2025 revealed the report indicated medication administration of Carbidopa-Levodopa had delays in treatment as follows:
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4:00 P.M. dose on 2/15/25 was not administered until 5:30 P.M.
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6:30 A.M. dose on 02/18/25 was not administered until 7:25 A.M.
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11:00 A.M. dose on 02/22/25 was not administered until 12:27 P.M.
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11:00 A.M. dose on 02/25/25 was not administered until 12:23 P.M.
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4:00 P.M. dose on 02/25/25 was not administered until 5:53 P.M.
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11:00 A.M. dose on 03/10/25 was not administered until 12:34 P.M.
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4:00 P.M. dose on 03/10/25 was not administered until 5:22 P.M.
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11:00 A.M. dose on 03/12/25 was not administered until 12:08 P.M.
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11:00 A.M. dose on 03/15/25 was not administered until 12:59 P.M.
The report indicated medication administration of Clozaril, Lorazepam, Vraylar, and Zoloft had delays in treatment as follows:
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9:00 A.M. dose on 02/19/25 was not administered until 11:03 A.M.
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9:00 A.M. dose on 03/02/25 was not administered until 11:04 A.M.
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9:00 A.M. dose on 03/05/25 was not administered until 11:15 A.M.
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9:00 A.M. dose on 03/07/25 was not administered until 10:58 A.M.
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9:00 A.M. dose on 03/10/25 was not administered until 12:02 P.M.
Interview on 03/10/25 at 4:19 P.M. with Resident #18's sister revealed concerns regarding timely medication pass particularly for Carbidopa Levodopa and her morning psych medications. Resident #18's sister indicated when the medications were not passed timely Resident #18 had difficulty with meals.
Observation on 03/18/25 at 8:00 A.M. of Resident #18 for breakfast meal revealed Resident #18's sister had visited for breakfast and was assisting with feeding. Resident #18 was noted to have the correct diet order of puree texture with thickened liquids however Resident #18 was still noted to cough at times. Resident #18's sister indicated this was what she meant by how Resident #18 was affected by timeliness of medications. Resident #18 made few attempts to self-feed but was able to hold glass when put in hands.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed Resident #18 did not receive medications as ordered or in a timely manner for Carbidopa-Levodopa, Clozaril, Lorazepam, Vraylar, or Zoloft.
Review of facility policy Medication Administration dated 05/01/22 revealed medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered within one hour prior and after their prescribed time.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to follow the menu spreadsheets as written to ensure proper portion sizes were served to the residents. This affected 53 residents receiving food from the kitchen as Resident #10 was ordered nothing by mouth (NPO). Facility census was 54.
Findings include:
Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop (one each), seasoned rice (four ounces), Price [NAME] vegetable blend (four ounces), yellow cake with frosting (one slice) and beverage of choice (four ounces).
Review of the facility production sheet for lunch on 03/11/25 revealed those receiving a mechanical-soft diet received a #10-scoop (three ounces) of ground pork and those on a low-concentrated sweets (LCS) diet were to have a half-portion of yellow cake with frosting.
Review of the facility's diet list as of 03/10/25 revealed Resident #10 was NPO, eight residents were ordered mechanical soft diets (Residents #7, #8, #16, #28, #32, #33, #35 and #204) and eight residents were ordered LCS diets (Residents #5, #20, #21, #29, #31, #36, #37 and #44).
Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in each pan on the steam table. The rice was noted to have a green #12-scoop (serving 2.66 ounces) and the ground pork had a blue #16-scoop (serving two ounces). Trayline began at 11:34 A.M. Clear plastic and colored plastic bowls with cake in them were noted on the individual trays and all of the portions of cake appeared to be the same size.
Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and he bought his own food because it is so bad.
Interview on 03/11/25 at 11:43 P.M. with Dietary Manager (DM) #361 verified all the portions of cake for this meal were the same size.
Interview on 03/11/25 at 12:09 P.M. with [NAME] #315 verified the mechanical soft pork had a #16-scoop which did not follow the spreadsheet as written.
Interview on 03/11/25 at 12:15 P.M. with DM #361 verified the rice had a #12-scoop which did not follow the spreadsheet as written.
During a follow-up interview on 03/11/25 at 12:40 P.M. DM #361 was made aware the facility did not follow the portion sizes for the LCS diets as a full piece of cake was provided, did not follow the portion sizes for the mechanical soft diets as too small of a scoop was used and did not follow the portion size for the rice as too small of a scoop was used and DM #361 did not disagree.
Review of the facility policy, Portion Control, no date, revealed a specific portion size shall be established for all menu items. A serving utensil that will yield the designated portion will be specified for each menu item.
Review of the facility policy, Portion Sizes, no date, revealed menu items shall be served according to pre-determined portion size. The standard portion is a level measure using the appropriate serving utensil, which is used to accurately serve the designated portion size.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the menu, the facility failed to serve palatable meals at appetizing temperatures. This had potential to affect all 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth. The facility census was 54.
Findings include:
Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop, seasoned rice, Prince [NAME] vegetable blend, yellow cake with frosting and beverage of choice.
Interview on 03/10/25 at 10:20 A.M. with Resident #48 revealed the hot food was served cold and terrible.
Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and he bought his own food because it is so bad and the hot food was really cold.
Interview on 03/10/25 at 1:23 P.M. with Resident #42 revealed the food at the facility was terrible as it was cold, tasted awful and was a low quality of food.
Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in each pan on the steam table. Temperatures of the foods to be served were as follows: pork chop, 173 degrees Fahrenheit (F); vegetable blend, 177 degrees F; rice, 172 degrees F and cake, room temperature (not taken). Trayline began at 11:34 A.M. The east cart began at 12:09 P.M. and a test tray was requested. The test tray was made at 12:21 P.M., on the cart at 12:22 P.M., and was on the unit at 12:23 P.M. Nursing staff began passing trays from the cart immediately after its arrival. The test tray was sampled at 12:40 P.M. with Dietary Manager (DM) #361 and temperatures obtained at that time with the facility's self-calibrating electronic thermometer were as follows: pork, 116 degrees F; rice, 112 degrees F; milk, 45 degrees F; vegetable, 115 degrees F. The foods sampled were lukewarm and not palatable at the current temperatures.
Interview on 03/11/25 at 12:40 P.M. with DM #361 confirmed the test tray was lukewarm and the hot foods were not at appropriate temperatures during the sampling of the test tray thus were not palatable. DM #361 stated hot foods were to be at 145 degrees F minimum at point of service.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.

Based on observation, interview, review of the facility policy and record review the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth (NPO). The facility census was 54.
Findings include:
Observation of the kitchen on 03/10/25 from 9:20 A.M. to 9:54 A.M. with Dietary Manager (DM) #361 revealed the following areas of concern:
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In the walk-in cooler, there were two expired cartons of cream dated 02/27/25 and 03/02/25, a package of bologna that did not have a date nor a label, two expired bags of salad lettuce dated 01/14/25 and expired coleslaw dated 01/28/25.
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In the dry stock room, there were nine expired cartons of thickened dairy beverage dated 02/13/25 that were in between rows of thickened beverages that still had appropriate dates.
Interviews with DM #361 verified the above findings at the time of observation. DM #361 stated the first shift cook was responsible for checking for expired food and this was documented on the cleaning sheets. DM #361 confirmed foods were to be labeled and dated.
Review of the supplied cleaning schedules revealed the morning cook was responsible for removing out-of-date items from the refrigerator at the beginning of their shift. This was not documented as completed on 03/09/25 and 03/10/25, with 03/08/25 being the last day this task was marked as completed.
Review of the facility policy, Labeling and Dating Foods, dated 07/30/23 revealed to decrease the risk of foodborne illness and to provide the highest quality, foods are labeled with the date received. If the product does not have an expiration date, the product is labeled with a discard or use by date.
Review of the facility policy, First In, First Out (FIFO), no date, revealed food products are used by the expiration date, if not, food items are discarded. Do not use any item that for which the manufacturers' suggested use by date has passed.

Based on record review, review of facility job descriptions and interview the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental and psychosocial well being of all 54 residents residing in the facility.
Findings include:
1. Review of the Administrator's job description, dated May 2022 and signed by the Administrator on 01/20/25, revealed the Administrator would provide overall direction for all activities related to administration, personnel, physical structure, information systems, office management and marketing of the entire facility. The Administrator works closely with all members of the management team and others to ensure their responsibilities are effectively and consistently discharged . The Administrator will ensure all facility operations are in compliance with federal, state and local regulations. The essential functions included developing and implementing facility policies and procedures that comply with federal, state and local regulations; act as liaison with the governing body, outside medical professionals, nursing staff and other professional and supervisory staff through regular meetings and periodic reporting; reports all hazardous conditions, damaged equipment and supply issues to appropriate persons; assists appropriate department heads with development and implementation of infection control procedures; and maintains the comfort, privacy and dignity of residents.
Review of the Director of Nursing (DON) job description, dated May 2022 and signed by the DON on 02/14/25, revealed the DON played a critical role in providing superior customer service and nursing services to all residents in the facility. The DON works with the Administrator and the Medical Director in the planning, development and overall operation of the nursing department which ensures residents receive quality care 24 hours a day. The essential functions included assuring that established infection control and standard precaution practices are maintained at all times; and maintains the comfort, privacy and dignity of residents.
Interview on 03/19/25 at 4:32 P.M. with the Administrator, DON and Chief Operating Officer (COO) #300 revealed the Administrator had assumed her position on 01/27/25 and the DON had assumed her position on 02/17/25.
During the onsite investigation, the following concerns were identified related to a lack of comprehensive and effective administrative oversight:
2. Review of the QAPI meeting minutes and sign-in sheets from January 2024 through February 2025 revealed no evidence the facility's previous Medical Director, Physician #367, attended the QAPI meetings on 03/19/24, 04/16/24, 05/21/24, 06/18/24 and 07/16/24. There was no evidence a member of the facility's governing body attended the QAPI meetings until the January 2025 meeting. Additionally, there was no identification of the facility's Infection Preventionist (IP) on the sign-in sheets provided to ensure the IP was involved as required.
On 03/17/25 starting at 3:02 P.M. interview with Chief Operating Officer (COO) #300 revealed if the medical director attended by phone or in person, their attendance should have been reflected on the QAPI signature sheets. COO #300 was made aware during the interview there was no evidence Physician #367 had attended any of the QAPI meetings before Physician #366 took over the Medical Director role in July 2024. COO #300 verified there were no QAPI meeting minutes or sign-in sheets for November 2024 and December 2024 available for review.
3. Observations of the facility on 03/10/25 revealed loose hand-rails, broken blinds, discolored ceiling tiles, dented and chipped walls and a broken shower room.
Interview on 03/10/25 at 1:00 P.M. with the Administrator verified the observed findings and shared the facility did not have a maintenance director as of the time of the interview.
4. Continued observations of the facility on 03/12/25 revealed hot water temperatures across the facility ranged from 77 degrees Fahrenheit (F) to 102.6 degrees F which did not provide the residents with a comfortable, homelike environment.
Interview on 03/12/25 at 11:42 A.M. with Housekeeping Director (HD) #306 verified the observed findings, indicated this was the first time he had checked water temperatures and had no record of water temperatures being checked previously.
5. Review of the facility's infection control program documentation revealed a lack of a legionella water management program and an incomplete infection tracking and trending log including antibiotic use and COVID-19. There was no documentation to show there had been a routine and consistent infection preventionist at the facility in the time leading up to the survey. Documentation indicated concerns were identified with offering and providing influenza, COVID-19 and pneumonia vaccines as required. Additionally, the facility did not collaborate timely with the local health department regarding residents with suspected Carbapenem-Resistant Enterobacterales (CRE) infections and did not identify or place residents in Enhanced Barrier Precautions (EBP) as indicated per the Centers for Disease Prevention and Control (CDC).
Interviews with administrative staff, including the Administrator, DON and COO #300 during the survey period verified the infection control concerns identified during the survey.
6. Review of QAPI meeting minutes revealed for the month of April 2024 (date not specified) there was an action plan to a (unidentified date) state agency survey with citations for dignity, not providing private communication, quality of care, notification of condition change, homelike environment, reporting allegations of abuse, investigating allegations of abuse, assistance with activities of daily living, activities to meet the needs of the residents, accidents/hazards, nutrition, significant medication errors, medication storage, notification of laboratory results and infection control. The plan referenced to see the plan of correction and indicated the department responsible for the corrective action. The columns under completion date and follow-up were blank. There was no additional information provided to verify the correction plan was completed.
During the current annual survey, repeat deficiencies were identified related to privacy, homelike environment, reporting abuse to the state agency, investigating allegations of abuse, activities of daily living assistance, quality of care, falls, significant medication errors and infection control in addition to additional citations due to a lack of oversight and monitoring.
7. Review of the July 2024 QAPI meeting minutes included an action plan related to a survey (not identified) with citations for food storage and appropriate garbage disposal. Under tasks, the minutes directed to see plan of correction (POC). Departments were assigned, completion dates were indicated as ongoing and no follow-up was identified. There was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to expired and undated foods.
8. Review of the second set of July 2024 QAPI meeting minutes included an action plan to address missing copies of Do Not Resuscitate (DNR) forms, also known as advance directives. Tasks were listed and staff were assigned. The columns under completion date and follow up were blank and there was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to advance directives.
9. Review of the August 2024 QAPI meeting minutes included an action plan related to a survey (not identified) with citations related to dignity, reporting allegations of abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder concerns, nutrition, significant medication errors and safe, homelike environment. Under tasks, the minutes directed to see plan of correction (POC). Staff were assigned, completion dates were indicated as ongoing and no follow-up was identified. There was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified in some of the identified areas including reporting alleged abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder, significant medication errors and a safe, homelike environment.
10. Review of the November 2024 QAPI meeting minutes included an action plan to address an in-house acquired pressure ulcer, affecting Resident #11. Tasks were listed and staff were assigned. The columns under completion date and follow up were blank and there was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to pressure ulcers. Resident #11, the resident with the identified in-house acquired pressure ulcer found on 11/23/24, had a task including weekly measurements of all areas input into the Electronic Medical Record (EMR) no longer than seven days apart. Record review and interview indicated Resident #11's wound was not measured again until 02/26/25. A deficiency was issued regarding pressure ulcers during the annual survey.
11. The February 2025 QAPI meeting minutes revealed an environmental PIP was started on 02/02/25 with weekly updates on the program documented in the minutes.
During the annual survey, concerns were identified related to the environment and deficiencies were issued.
Interview on 03/19/25 at 4:32 P.M. with Chief Operating Officer (COO) #300 revealed she relied on the facility's DON and the Administrator to follow up with any QAPI-related concerns. The COO verified she was unaware the PIPs were not completed prior to the interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the facility assessment was accurately completed. The facility also did not implement their facility assessment in regard to staff training and education. This had the potential to affect all 54 residents residing at the facility.
Findings include:
1. Review of the letter dated 05/25/23 from the state survey agency to the facility revealed the facility had their request approved to decrease the capacity and licensed beds to 72 residents.
Review of the facility assessment dated [DATE] revealed the resident profile portion was incorrect. The number of residents the facility was licensed to care for stated 118. Their average daily census ranged from 35 to 85 residents (the capacity for the facility was 72 as of 05/25/23).
On 03/17/25 at 12:05 P.M. interview with the Administrator verified the facility assessment was inaccurate and did not reflect the correct capacity.
2. Review of in-services provided by the facility from 05/13/24 through 02/20/25 revealed staff had received eight trainings total and the topics included abuse, human resource issues, answering call lights, infection prevention, documentation, supplies, communication, resident smoking, harassment free working conditions, mechanical lift policy, transfers, therapy, dementia care, stepping stones program (drug and alcohol program), customer service, hydration and calling off to the facility. In-service sheets revealed not all employees were present at the eight trainings and had not received all the trainings listed above.
Review of the facility assessment dated [DATE] revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment stated training topics for staff would include communication, resident rights, abuse, infection control, culture change and dementia management.
Review of the personnel file for Certified Nursing Assistant (CNA) #305 revealed a hire date of 06/03/21 and no evidence the CNA had received 12 hours of in-services annually (March 2024 24 through March 2025) nor had they received their annual performance evaluations to address areas of weakness during training and in-services. No evaluation was located for 2024.
Review of the personnel file for CNA #329 revealed a hire date of 03/04/05 and no evidence the CNA had received 12 hours of in-services annually (March 2024 24 through March 2025) nor had they received their annual performance evaluations to address areas of weakness during training and in-services. No evaluation was located for 2024.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 and CNA #329 did not receive 12 hours of in-services as required annually or their annual performance evaluations as indicated in the facility assessment.
Interview on 03/19/25 at 2:21 P.M. with the Administrator verified she was unable to locate any other in-services or education for staff from March 2024 through March 2025.

Based on record review, contract review, review of the facility policy and staff interview, the facility failed to ensure the medical director fulfilled his responsibilities related to the coordination of medical care, the implementation of facility policies and procedures and evidence of participation in Quality Assurance and Performance Improvement to ensure quality care is provided to residents. This affected all 54 residents who reside in the facility.
Findings include:
Review of available Medical Director reports from January 2024 through February 2025 revealed one report from February 2025. The report indicated the environment was clean and hazard free and residents appeared to be clean and comfortable with safety measures in place. There were no documented concerns relating to pressure areas, falls or changes in condition.
During an interview on 03/17/25 at 12:05 P.M., Medical Director #366 stated he had been the facility's Medical Director since 07/01/24. Medical Director #366 did not voice concerns relating to effective administration of the facility or indicate any areas that needed to be addressed by the facility to ensure they provided appropriate care and services to the residents.
Interview on 03/19/25 at 1:12 P.M. with Chief Operating Officer (COO) #300 verified the only Medical Director report available from the last 12 months was from February 2025. COO #300 stated the previous Director of Nursing did not keep this kind of documentation and should have.
Review of a medical director agreement with Physician #366 dated 06/10/24 revealed the Medical Director was to assist the facility in meeting the applicable standards established under state and federal law. The Medical Director shall be responsible for the implementation of policies related to the care of residents at the facility and for the coordination of medical care at the facility and was responsible for assisting the facility to provide appropriate care, both medical and clinical, to residents. The Medical Director shall monitor and ensure the implementation of resident care policies and provide oversight and supervision of the nursing, medical care and physician services rendered to residents of facility with respect to the implementation of policies related to care of residents at facility, physician shall be responsible for assisting in implementing policies related to admission, transfers/discharges, infection control, the use of restraints, physician privileges/practices, non-physician health care workers, accidents and incidents, ancillary services, use of medication, use/release of clinical information, patient rights, utilization review and any other policies related to the quality of care at facility as deemed necessary by facility and/or required by applicable law or regulation.
Review of the facility policy, Medical Director Policy and Procedure, dated 2025 revealed the medical director shall be responsible for the implementation of the coordination of the medical care in the facility. The medical director shall be responsible for the following areas of care/services: implementation of resident care policies, such as ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications; participation in the quality assessment and assurance (QAA) committee; addressing issues related to the coordination of medical care and implementation of resident care policies identified through the facility's QAA committee and other activities and active involvement in the process of conducting the facility assessment. Additional medical responsibilities include but are not limited to administrative decisions, quality of care, professional development, infection control, establishing policies, resident self-determination, identifying expectations and facilitating feedback an medical care intervention and oversight.

Based on record review, facility policy and procedure review and interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified concerns timely and effectively. This had the potential to affect all 54 residents in the facility.
Findings include:
Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the following plans without continued corrective action, evidence the plan was revised when necessary or changed once identified to be ineffective:
1. Review of QAPI meeting minutes revealed for the month of April 2024 (date not specified) there was an action plan to a (unidentified date) state agency survey with citations for dignity, not providing private communication, quality of care, notification of condition change, homelike environment, reporting allegations of abuse, investigating allegations of abuse, assistance with activities of daily living, activities to meet the needs of the residents, accidents/hazards, nutrition, significant medication errors, medication storage, notification of laboratory results and infection control. The plan referenced to see the plan of correction and indicated the department responsible for the corrective action. The columns under completion date and follow-up were blank. There was no additional information provided to verify the correction plan was completed.
During the current annual survey, repeat deficiencies were identified related to privacy, homelike environment, reporting abuse to the state agency, investigating allegations of abuse, activities of daily living assistance, quality of care, falls, significant medication errors and infection control in addition to additional citations due to a lack of oversight and monitoring.
2. Review of the July 2024 QAPI meeting minutes included an action plan related to a survey (not identified) with citations for food storage and appropriate garbage disposal. Under tasks, the minutes directed to see plan of correction (POC). Departments were assigned, completion dates were indicated as ongoing and no follow-up was identified. There was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to expired and undated foods.
3. Review of the second set of July 2024 QAPI meeting minutes included an action plan to address missing copies of Do Not Resuscitate (DNR) forms, also known as advance directives. Tasks were listed and staff were assigned. The columns under completion date and follow up were blank and there was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to advance directives.
4. Review of the August 2024 QAPI meeting minutes included an action plan related to a survey (not identified) with citations related to dignity, reporting allegations of abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder concerns, nutrition, significant medication errors and safe, homelike environment. Under tasks, the minutes directed to see plan of correction (POC). Staff were assigned, completion dates were indicated as ongoing and no follow-up was identified. There was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified in some of the identified areas including reporting alleged abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder, significant medication errors and a safe, homelike environment.
5. Review of the November 2024 QAPI meeting minutes included an action plan to address an in-house acquired pressure ulcer, affecting Resident #11. Tasks were listed and staff were assigned. The columns under completion date and follow up were blank and there was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to pressure ulcers. Resident #11, the resident with the identified in-house acquired pressure ulcer found on 11/23/24, had a task including weekly measurements of all areas input into the Electronic Medical Record (EMR) no longer than seven days apart. Record review and interview indicated Resident #11's wound was not measured again until 02/26/25. A deficiency was issued regarding pressure ulcers during the annual survey.
6. The February 2025 QAPI meeting minutes revealed an environmental PIP was started on 02/02/25 with weekly updates on the program documented in the minutes.
During the annual survey, concerns were identified related to the environment and deficiencies were issued.
Interview on 03/19/25 at 4:32 P.M. with the Administrator, Director of Nursing (DON) and Chief Operating Officer (COO) #300 revealed QAPI was a mechanism in place to use the support of the interdisciplinary team to identify and resolve issues. The facility preferred to meet monthly for QAPI instead of just quarterly, as well as any time there was a problem. The Administrator indicated if there was a self-reported incident (SRI) or if there was an outbreak of an illness, such as COVID-19 the facility could hold an ad hoc (not planned) QAPI meeting. Staff verified there was not an ad hoc QAPI meeting during December 2024 when the facility had an outbreak of COVID-19 but stated there should have been. During the interview, COO #300 was made aware none of the QAPI meeting minutes provided prior to February 2025 did not have a full PIP developed, evidence of auditing, education or other corrective measures completed to address the facility identified concerns or for ongoing monitoring to prevent reoccurrence. COO #300 was not aware of this prior to the interview and stated she relied on the facility's DON and the Administrator to follow up with any QAPI-related concerns. Staff verified the facility had one PIP in place for the environment but verified the hot water temperatures were not identified as part of the environmental issues leading to the development of their PIP. The Administrator verified as of the time of the interview, there was not yet a mechanism in place for residents and staff to report issues to the facility's QAPI program.
Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2025 revealed the facility implemented a comprehensive QAPI program which addresses all the care and unique services that the facility provides. To ensure continuous evaluation of the facility's systems the facility would ensure care delivery systems function consistently, accurately and incorporate current and evidence-based practice standards where available; preventing deviation from care processes, to the extent possible; identifying issues and concerns with the facility's systems as well as identifying opportunities for improvement; and developing and implementing plans to correct and/or improve identified areas. The facility would develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility would develop and implement systems that ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standard of practice. The facility shall maintain proper documentation of its QAPI program and provide evidence of its ongoing QAPI program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nursing assessments were completed on admission for residents. This affected one (Resident #48) of 28 residents reviewed for nursing assessments.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of the brain), hallucinations and alcohol use with withdrawal.
Review of Resident #48's electronic medical record and paper chart revealed there were no nursing admission assessments done when he arrived at the facility.
Interview on 03/19/25 at 11:45 A.M. with the Chief Operating Officer (COO) #300 verified Resident #48 did not have a nursing assessment performed on admission to the facility on [DATE].
The facility was unable to provide a policy related to nursing assessments and timing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments for residents were complete and accurate. This affected four (Residents #22, #24, #37 and #43) of 28 residents reviewed for the accuracy and completion of assessments. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #22 revealed section C for cognitive patterns was not completed. Question C100 was answered yes to interview for mental status. However, questions C200, C300, C400, C500, C600, C700, C800, C900, C1000 and C1310 were all answered with either not assessed or dashes. Section J revealed question J200 was answered yes to attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS assessments offsite. He stated Social Services Director (SSD) #355 was responsible of sections C and D on the MDS assessment. He stated he was unsure why sections C was coded for an interview to be conducted and then all the questions stated not assessed. For section J, he stated he would call into the facility and speak to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to review if the residents had pain. He stated he was not able to speak with anyone for Resident #22's pain assessment. He verified section J should have been completed.
Interview on 03/18/25 at 1:59 P.M. with SSD #355 verified she answered sections C and D on MDS assessments for residents, though not always during the time frame of the MDS assessment. She verified section C was not completed for Resident #22 on his MDS dated [DATE].
2. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses including dementia, Parkinson's Disease, anxiety and hypertension.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #24 revealed section C for cognitive patterns was not completed. Question C100 was answered yes to interview for mental status. However, questions C200, C300, C400, C500, C600, C700, C800, C900, C1000 and C1310 were all answered with either not assessed or dashes. Section D revealed question D100 was answered yes to conduct a mood interview with Resident #24. However, questions D150 and D160 were answered not assessed or had dashes. Section J revealed question J200 was answered yes to attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS assessments offsite. He stated SSD #355 was responsible of sections C and D on the MDS assessment. He stated he was unsure why sections C and D were coded for an interview to be conducted and then all the questions stated not assessed. For section J, he stated he would call into the facility and speak to the DON or ADON to review if the residents had pain. He stated he was not able to speak with anyone for Resident #22's pain assessment. He verified section J should have been completed.
Interview on 03/18/25 at 1:59 P.M. with SSD #355 verified she answered sections C and D on MDS assessments for residents, though not always during the time frame of the MDS assessment. She verified sections C and D were not completed for Resident #22 on his MDS dated [DATE].
3. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Review of the admission MDS 3.0 assessment dated [DATE] for Resident #37 revealed section J for pain was not completed. Section J revealed question J200 was answered yes to attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #37 revealed section J for pain was not completed. Section J revealed question J200 was answered yes to attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS assessments offsite. He stated for section J he would call into the facility and speak to the DON or ADON to review if the resident had pain. He stated he was not able to speak with anyone for Resident #37's pain assessment. He verified section J should have been completed.
4. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses including sepsis, paranoid schizophrenia, moderate protein-calorie malnutrition, osteomyelitis, and traumatic arthropathy of right knee.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed an interview for mental status should be conducted with Resident #43. The brief interview for mental status (BIMS) interview was marked as not assessed on MDS section C. An interview for mood should be conducted with Resident #43. Mood interview was marked as not assessed/no information on MDS section D.
Review of Medicare MDS Quarterly assessment dated [DATE] revealed Resident #43 received as needed pain medications. An interview for pain assessment should be completed for Resident #43. Pain assessment interview was marked as not assessed on MDS section J.
Interview on 03/18/25 at 1:12 P.M. with MDS Coordinator #365 revealed he had worked at the facility for a year and had been completing MDS assessments offsite. MDS Coordinator #365 indicated interviews for mental status and mood were completed by Social Service Designee (SSD) #355 and the interviews for pain were completed by Assistant Director of Nursing (ADON). MDS Coordinator #365 confirmed Resident #43's MDS sections C and D for 12/31/24 assessment and section J for 01/07/25 were incomplete.

Based on interview and record review, the facility failed to ensure resident authorized the facility to manage their personal funds and the authorization was witnessed by a third party. This affected two (Residents #30 and #207) of six residents reviewed for personal funds. The facility census was 54.
Findings include:
1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with diagnoses including heart disease, anxiety and dementia. He was discharged on 02/15/25.
Review of the Resident Fund Management Service (RFMS), undated, for Resident #30 revealed handwriting at the top of the form stating Human Resources Director (HR) #343 had opened the account. She had explained to the resident and over the course of a month he would not sign and stated he needed to read the form over.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #30 had a balance of $2,000.29.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #30 passed away on 02/15/25. She stated he had a guardian for financial decisions. She stated she had attempted to have Resident #30 sign the RFMS authorization, however, he wanted to read the form and then refused to sign. HR #343 stated the money he had in his account came from another facility and was deposited in the RFMS account on 10/15/24. She verified Resident #30 had a financial guardian and she had not reached out to them for authorization.
2. Review of the closed medical record for Resident #207 revealed an admission date of 03/19/20 with diagnoses including dementia and depression. She was discharged on 05/24/24.
Review of the RFMS, dated 06/04/20, for Resident #207 revealed the resident had not signed the form nor her representative. The form was also not witnessed by a third party.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #207 had a balance of $5,239.68.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #207 passed away on 05/24/24. She verified the form was not signed or witnessed.
Review of the facility policy titled, Resident Funds, dated 05/01/22, revealed the facility would establish uniform guidelines to protect personal funds managed by the facility on behalf of its residents. However, it did not state the process of having residents or their representatives sign for an RFMS account of have it witnessed by a third party.

Based on interview, record review, and facility policy review, the facility failed to ensure resident personal funds were disbursed to the resident's estate within 30 days. This affected two (Residents #30 and #207) of two residents reviewed for personal funds after death. The facility census was 54.
Findings include:
1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with diagnoses including heart disease, anxiety and dementia. He passed away on 02/15/25.
Review of the Resident Fund Management Service (RFMS) trial balance list dated 03/10/25 revealed Resident #30 had a balance of $2,000.29.
Interview on 03/18/25 at 8:43 A.M. with Human Resource Director (HR) #343 verified Resident #30 passed away on 02/15/25. She stated he had a guardian for financial decisions who she had attempted to contact. She was unaware of the required time frame to disperse the funds to his estate.
2. Review of the closed medical record for Resident #207 revealed an admission date of 03/19/20 with diagnoses including dementia and depression. Resident #207 passed away on 05/24/24.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #207 had a balance of $5,239.68.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #207 passed away on 05/24/24. She stated Resident #207 had a financial power-of-attorney. She was unaware of the required time frame to disperse the funds to her estate.
Review of the facility policy titled, Resident Funds, dated 05/01/22, revealed the facility would establish uniform guidelines to protect personal funds managed by the facility on behalf of its residents. However, it did not state the process of funds being disbursed after a resident had passed away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were able to use the phone when requested and in private. This affected one (Resident #206) of one resident reviewed for facility phone usage. The facility census was 54.
Findings include:
Review of the medical record for Resident #206 revealed an admission date of 02/27/25 with diagnoses including bipolar disorder (mental health condition that causes mood swings), anxiety and hypertension.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #206 had adequate hearing, clear speech, understood others and was able to be understood. He had impaired cognition. It was noted under section F for preferences for routines and activities that it was very important for him to use a phone in private.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed residents had access to a phone but would have to use the corded phone at the nurse's station. The phone number would be dialed and then handed through a hole in the plastic that sat on top of the nursing station counter. The resident would then have to use the phone in the hallway. She stated she was unaware of other private phones for the residents to utilize.
Observation and interview on 03/18/25 at 4:50 P.M. of Resident #206 revealed he wanted to use the phone at the west nursing station. He stated to LPN #325 that he needed to call someone and asked to use the phone. LPN #325 stated he could not use the phone as she had two admissions. Resident #206 then left the nursing station. LPN #325 stated Resident #206 had asked her six times to use the phone already and she was busy with admissions. She verified she had refused to allow him to use the phone.
Interview on 03/19/25 at 8:10 A.M. with Resident #206 verified he did eventually get to use the phone on 03/18/25. He stated there was no privacy with phone use as the nursing staff handed a corded phone out and he had to talk on the phone in the hallway.
The facility was unable to provide a policy on phone use or resident privacy with phone calls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected five residents (#7, #15, #20, #25 and #34) out of 24 resident records reviewed. The facility census was 54.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of [DATE] and diagnoses including schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes.
Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA) (indicating no life-sustaining interventions would be attempted in the event of cardiac or respiratory arrest).
Review of Resident #7's paper medical record revealed he had an advance directive of full code, indicating life-sustaining interventions, including cardiopulmonary resuscitation (CPR) would be attempted in the event of cardiac or respiratory arrest).
Interview on [DATE] at 3:34 P.M. with Social Service Designee (SSD) #355 indicated she was knowledgeable on many residents' advance directives due to conducting plan of care meetings. SSD #355 verified Resident #7's paper medical record was not accurate as he did not have an advance directive of full code.
2. Review of Resident #15's medical record revealed an admission date of [DATE] and diagnoses including dementia with agitation, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder, paranoid personality disorder and delusional disorders.
Review of Resident #15's EMR revealed he had an advance directive of DNRCCA.
Review of Resident #15's paper medical record revealed he had an advance directive of full code. No signed Do Not Resuscitate (DNR) form was available in the resident's record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #15's paper medical record was not accurate and did not match the EMR as Resident #15 did not have an advance directive of full code and no signed DNR was available in his chart.
3. Review of Resident #20's medical record revealed an admission date of [DATE] and diagnoses including type two diabetes, chronic kidney disease, traumatic brain injury, dementia with agitation and generalized anxiety disorder.
Review of Resident #20's EMR revealed he had an advance directive of DNRCCA.
Review of Resident #20's paper medical record revealed he had an advance directive of full code. No signed DNR form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #20's paper medical record was not accurate and did not match the EMR as Resident #20 did not have an advance directive of full code and no signed DNR form was available in his chart.
4. Review of Resident #25's medical record revealed an admission date of [DATE] and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety and depression.
Review of Resident #25's EMR revealed he had an advance directive of DNRCCA.
Review of Individual #25's paper medical record revealed a face sheet stating he had an advance directive of DNRCCA, but no signed DNR form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #25's paper medical record was not complete as no signed DNR form was available in his chart.
5. Review of Resident #34's medical record revealed an admission date of [DATE] and diagnoses including vascular dementia with psychotic disturbance, paranoid personality disorder, violent behavior, osteoarthritis and depression.
Review of Resident #34's EMR revealed he had an advance directive of DNRCCA.
Review of Individual #34's paper medical record he had an advance directive of full code. No signed DNR form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 revealed the previous DON responsible for ensuring residents had advance directives in place but the facility had a new DON at this time. SSD #355 indicated she was knowledgeable on many residents' advance directives due to conducting plan of care meetings. SSD #355 verified Resident #34's paper medical record was not accurate and did not match the EMR as Resident #34 did not have an advance directive of full code and no signed DNR was available in his chart.
Review of the facility policy, Advance Directives, dated [DATE] revealed upon admission the social worker and/or admission director will furnish information on advance directives. When a social worker is not available the Registered Nurse (RN) supervisor will give and review advance directive information and document in the medical record. A Do Not Resuscitate order is honored upon admission after reviewed with the individual/family member or surrogate by the social worker/or admission RN when they arrive to the facility to ensure continuation. Residents with DNR orders will be identified on the face sheet and in the resident's medical record Resident's advance directives will be reviewed upon admission, re-admission from the hospital, quarterly and annually by the social worker. Staff with direct care responsibilities will be knowledgeable of the location of resident's resuscitative status information throughout the facility. All facility staff including non direct care employees and temporary agency staff will be aware of facility procedure if they encounter a resident's arrest.

Based on observations, staff and resident interviews, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, door frames, and hand rails were without the need for repair. This affected all residents residing in the facility. The facility census was 54.
Findings include:
1. Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed the water was cold and the water pressure was low. Resident #48 indicated the shower room was broken.
Interview on 03/10/25 at 10:29 A.M. with Resident #203 revealed the shower was broken and he had been unable to get a shower.
Observation and interview on 03/10/25 at 10:29 A.M. with Resident #23 revealed her toilet had not been working for a week and Resident #23 reported the shower room was broken. Observation of Resident #23's toilet revealed it was not secured to the floor. Resident #23 reported hot water was also an issue, stating it was either too hot or too cold.
Observation and interview on 03/10/25 at 12:01 P.M. with Resident #27 revealed the resident had asked where she could use the bathroom and stated her toilet did not work. Housekeeper #311 was nearby and indicated she could use the one in her room. Housekeeper #311 went into Resident #27's bathroom in her room and confirmed the toilet was not secured to the floor and was not working appropriately. The bathroom was shared between two rooms, including Resident #23. Resident #27 was assisted by staff to a bathroom down the hall.
Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed a sign on the west side shower room indicating Do not use shower. Out of order.
Interview on 03/10/25 at 12:22 P.M. with Resident #22 revealed the shower room had not been working all weekend and he was unable to get a shower. Resident #22 stated the backed up water leaked out into the hallway.
Interview on 03/10/25 at 12:49 P.M. with Resident #44 revealed she could get showers, but the water was cold.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator revealed the shower room had been fixed and it had been out of order since 03/07/25.
Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any logged water temperatures or maintenance records for the last 12 months.
Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with Housekeeping and Maintenance Supervisor (HMS) #306 revealed most residents shared a bathroom between two rooms, but there were a few with private bathrooms. HMS #306 indicated there were no showers in resident rooms, and there were two shower rooms in the facility.
Observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 using the facility's digital thermometer revealed the following:
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Resident #18's sink water temperature was 101.5 degrees Fahrenheit (F).
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Resident #49's sink water temperature was 99.1 degrees F.
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Resident #48 and #203's sink water temperature was 101.9 degrees F.
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Resident #31 and Resident #45's sink water temperature was 96.1 degrees F.
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Resident #20's sink water temperature was 77.0 degrees F.
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Resident #5's sink water temperature was 90.5 degrees F.
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Resident #15's sink water temperature was 102.6 degrees F.
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Resident #14's sink water temperature was 98.4 degrees F.
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Resident #104's sink water temperature was 101.5 degrees F.
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Resident #205's sink water temperature was 81.7 degrees F.
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The [NAME] side shower room shower was 81.0 degrees F.
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The East side shower room shower was 97.3 degrees F.
Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with Resident #49 revealed the water was never hot.
Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with Resident #5 revealed the water did not get hot no matter how long it ran.
Interview on 03/12/25 at 11:42 A.M. with HMS #306 confirmed the water temperatures throughout the building were not within a comfortable range. HMS #306 indicated he had recently taken over the maintenance supervisor position and was unsure how to adjust the water temperatures. HMS #306 indicated the water was heated by a boiler system. HMS #306 indicated this was the first time he had taken water temperatures.
Review of the facility policy titled Water Temperature dated 05/01/22 revealed maintenance was responsible for checking temperature controls of water in the facility and recording the checks in a maintenance log. Water temperatures would be no more than 120 degrees.
2. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed Resident #8, Resident #34 and Resident #46 were observed with broken blinds in their rooms.
Interview on 03/10/25 at 12:50 P.M. with Resident #46 revealed the blinds in his room had been broken since he moved in.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the environmental findings for Resident #8, #34, and #46.
Follow up interview and tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident #38's room had broken mini blinds. The observations were confirmed with HMS #306 at the time of the observation.
Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed Resident #104's mini blinds were broken in their room and Resident #5's mini blinds were broken in their room.
Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed findings in Resident #5's room and Resident #104's room.
3. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed multiple discolored ceiling tiles observed across from the west side nursing station, in the hallway outside Resident #21 and Resident #15's room, in the east side shower room, and in hallway outside Resident #14's room. There were multiple patched and unpainted dents in walls on the memory care unit. The paint was chipped on the door frame leading to the 100 hallway, and there was paint chipped off the doors of Resident #37, Resident #33, Resident #8, Resident #1, Resident #23, and Resident #19's rooms. Resident #38's room had dented and paint chipped walls. There was a piece of plywood leaning against the wall in the occupied room. Resident #40's room had numerous white unpainted patches on the walls and there was blue painters' tape around cabinets, door frames, and lights.
Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a maintenance person currently and there was no one to report issues to. CNA #317 indicated if there was some kind of emergency she would report it to housekeeping.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the above environmental findings. The Administrator indicated there were some ceiling leaks when the ice was melting with the temperature changes.
Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any maintenance records for the last 12 months, including maintenance records regarding the discolored ceiling tiles, dents on the memory care walls, paint chipping from the doorway in the 100 hall, and paint chipping from the residents doors.
Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident #38's room also had two discolored and sagging ceiling tiles. Resident #1 and Resident #23's shared room was observed with a vanity with a missing drawer and mirror and it had two cabinet doors hanging off the hinges. The observations were confirmed with HMS #306 at the time of the observation.
Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed large holes were observed in the wall behind Resident #5's headboard.
Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed the findings in Resident #5's room.
4. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed the handrail extending between rooms #13 and #14 was loose on the wall, the handrail extending between rooms #36 and #37 was loose on the wall, and the handrail extending from the east side shower room door to the corner of the wall was loose.
Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a maintenance person currently and there was no one to report issues to. CNA #317 indicated if there was some kind of emergency she would report it to housekeeping.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with Administrator confirmed the above findings.
Interview on 03/11/25 at 1:08 P.M. with Administrator revealed she was unable to find any maintenance records for the last 12 months.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to prevent resident-to-resident physical abuse. This affected one resident (#23) out of five residents reviewed for abuse. Facility census was 54.
Findings include:
Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day look-back period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression and emotional outbursts and was also noted to make false accusations.
Review of a nurses' note dated 09/29/24 at 8:00 P.M. and authored by Licensed Practical Nurse (LPN) #327 revealed this nurse was notified of incident regarding this resident and co-resident. Resident #23 states that co-resident threw water at her, hit her with a wet floor sign, and a shoe. Resident #23 was observed sitting in wheelchair, wet and sobbing. Vitals taken, and resident skin assessed. This nurse noticed a small skin tear near Resident #23's heel. Resident #23 also complained of being sore after incident. This nurse escorted Resident #23 to bed and administered as-needed (PRN) pain medication along with before bed medications. Resident #23 was in compliance with neuro-checks and every 15-minute (Q15) safety checks. Resident #23 was in bed meditating, call light within reach and safety maintained. Physician and Director of Nursing (DON) notified.
Review of an interdisciplinary team note dated 09/30/24 at 4:46 P.M. and authored by Registered Nurse (RN) #313, who was the facility's DON at the time of the resident-to-resident altercation, revealed upon investigating physical altercation that occurred with male resident, Resident #23 alleges that male resident attacked her while coming from smoke break. Resident #23 alleges that he rode up in his motorized wheelchair, threw up a cup of water at her then proceeded to hit her in the head with wet floor sign. Resident #23 also alleges that Resident #10 hit her repeatedly with his house-shoe. Resident #23 states that altercation was unprovoked and denies any verbal exchange proceeding incident. This DON and Assisted Director of Nursing (ADON)/LPN #368 conducted interviews with nursing staff and residents present at time of altercation. Statements conclude that Resident #23 was being followed by male resident and that he ran up against her in motorized wheelchair. He then hit Resident #23 several times with house-shoe at the back of her head. While turning around to defend herself Resident #23 lost balance falling out of wheelchair onto her back and buttocks. Resident #23 does report complaints of headache, neck, and upper back soreness rated 8/10. PRN pain medications administered and effective with pain complaints at this time. Resident #23 was asked if she felt she needed emergency evaluation, resident states, No I should be fine. Resident educated by this nurse during assessment to notify nursing staff of increased pain. Neuro-checks and fall follow-up initiated at time of incident. Skin assessment completed by this nurse. Skin clear and intact at this time, with exception to a small skin tear of 0.2 centimeters (cm) by 0.1 cm to posterior ankle which is now scabbed over. No signs or symptoms of infection present at this time. Area is to be left open to air and monitored by nursing staff. Physician notified of altercation, resident who responsible for self is currently stable and 15 minute-checks in place for safety intervention at this time.
Review of Resident #10's closed medical record revealed an admission date of 03/29/24 and diagnoses including schizoaffective disorder, type two diabetes, depression, dysphagia and aphonia. Resident #10 was his own responsible party. Resident #10 discharged to an assisted living facility on 03/12/25.
Review of a quarterly MDS assessment dated [DATE] revealed Resident #10 had a BIMS score of 14, indicating he was cognitively intact. Resident #10 displayed verbal behaviors four to six days out of the seven-day look-back period.
Review of Resident #10's plan of care dated 04/10/24 and revised 10/02/24 revealed Resident #10 had impaired mood coupled with behaviors. Resident #10 had a history of being verbally aggressive and antagonist as well as physically aggressive with recent incidents on 09/25[/2024] and 09/29[/2024].
Review of a nurse's note dated 09/29/24 at 9:54 P.M. and authored by RN #348 revealed at approximately 8:00 P.M. this nurse was called to for incident involving Resident #10 and a co-Resident. Resident #10 stated that co-Resident struck him with an umbrella and Resident #10 retaliated by hitting her with his shoe. Resident #10 was assessed and obtained no injuries from altercation. Vitals were within normal limits and no complaints of pain were voiced. Resident is aware and in agreement of 15-minute checks for the next 48 hours as Resident #10 is his own responsible party. Physician and DON notified.
Review of a facility SRI dated 09/29/24 revealed an allegation of physical abuse between Resident #10 and Resident #23. Resident #10 initiated physical altercation with Resident #23 during smoke break and hit Resident #23 with a house-shoe. Interviews, assessments and notifications were completed and the facility substantiated the allegation of resident-to-resident physical abuse.
Review of a witness statement dated 09/29/24 and authored by Certified Nursing Assistant (CNA) #353 revealed the following information: I was on the patio [with] the smoking residents at 7:35 P.M. At 7:45 P.M. Resident #23 was finished smoking and went into the building and stopped in the hallway to talk to two other residents. Resident #10 came down the hall and behind Resident #23's wheelchair and started hitting Resident #23 in the back of her head from behind with his blue tennis shoe. Resident #23 started screaming and turned around to try to defend herself resulting in her wheelchair tipping backwards and Resident #23 falling out of her wheelchair. Resident #10 took off back down the hallway. I notified the nurse (not identified) and spoke to the DON.
Review of a witness statement dated 09/29/24 and authored by LPN #327 revealed the following information: I was not around to witness this incident. After the incident occurred I did witness Resident #23 sobbing and wet in her wheelchair.
Review of a witness statement dated 09/29/24 and authored by RN #313 on behalf of Resident #31 revealed the following information: I was sitting down next to Resident (not fully identified) and we were ordering chicken wings. Resident #23 comes around the corner screaming for her life and Resident #10 comes behind Resident #23 and hits her repeatedly in the back of her head with his shoe. Resident #23 turned around to defend herself and fell out of her wheelchair. The CNA (not identified) called for some back-up to help her. Resident #10 went around the corner and fled the scene. I did not see Resident #23 hit Resident #10 with anything.
Interview on 03/10/25 at 10:29 A.M. with Resident #23 reported she had past issues with Resident #10, including being hit with his shoe.
Interview on 03/19/25 at 11:13 A.M. with Chief Operating Officer (COO) #300 verified the content of the above SRI investigation between Resident #10 and Resident #23 on 09/29/24 and confirmed it was substantiated for resident-to-resident physical abuse.
Review of the facility policy, Abuse Prevention, dated 08/20/21 revealed the facility would not tolerate abuse, neglect, exploitation of its residents or misappropriation of resident property. The facility would complete the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff as part of its abuse prevention and identification interventions. The policy did not have specific response protocols for instances of resident-to-resident abuse.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to timely report allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse. Facility census was 54.
Findings include:
1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day lookback period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression and emotional outbursts and was also noted to make false accusations.
Review of a SRI dated 01/06/25 at 5:08 P.M. revealed Resident #23 reported to Registered Nurse (RN) #313, the Director of Nursing (DON) at the time of the allegation, that her tablet was missing. Resident #23 stated a Certified Nursing Assistant (CNA) who was taking care of her removed her dinner tray that the tablet was on. The time of the occurrence was identified as 01/06/25 at 3:07 P.M. An alleged perpetrator was listed as CNA #329. A search was completed for the tablet and the tablet was not found. Resident #23 was offered a lock box which she declined. The facility determined the allegation of misappropriation to be unsubstantiated.
Review of the facility's investigation for the SRI on 01/06/25 revealed two sheets of paper including a statement from Social Service Designee (SSD) #355 and a statement from CNA #353. No further evidence of investigation was available for review.
Review of the statement dated 01/07/25 and authored by SSD #355 revealed the following information: I interviewed Resident #23 on 01/07/25 and she stated she had an iPad (tablet) that was missing. Resident #23 stated she has two iPads, one with a purple and blue case and another Amazon iPad with a black case that had googly eyes and the words do not touch on the front of it. Resident #23 stated the iPad was on her tray table on top of her food tray and that it was removed by a CNA and never returned. An addendum was located at the bottom of SSD #355's statement which indicated on 01/10/25 Resident #23 found her missing iPad but no further information was available.
Review of the statement dated 01/09/25 and authored by CNA #353 revealed she had no knowledge of Resident #23's tablet.
Review of the facility's grievance and self-report tracking log for January 2025 revealed on 01/04/25, Resident #23 had reported her missing iPad. Under the 'Resolution' header, there was a notation the iPad was found on 01/10/25.
Interview on 03/12/25 at 11:09 A.M. with Resident #23 revealed in January 2025, her tablet was laying on her meal tray. Resident #23 identified her tablet as an Amazon Fire tablet, which she showed the surveyor during the interview. This tablet had a black cover with white writing with Resident #23's initials and the phrase don't touch my tablet on it. Resident #23 stated CNA #329 picked up her meal tray and took the tablet, then sold her tablet to Resident #10 for $100.00. She was able to activate an alarm on her tablet from her cell phone, which she found in Resident #10's room. Resident #23 could not state how much time had elapsed from when the tablet was observed gone to the time she found it in Resident #10's room. Resident #23 shared she had two Amazon Fire tablets, a 9-inch one and an 11-inch one and indicated the 9-inch one was the one that had been reported missing. Resident #23 verified the facility did not interview her regarding her allegation of misappropriation or have her write a witness statement.
Interview on 03/12/25 at 11:22 A.M. with CNA #329 revealed she was angry she was suspended over the allegation of misappropriation regarding Resident #23's missing tablet. CNA #329 stated she worked on 01/05/25 and did not have Resident #23 as her resident that date. CNA #329 reported Resident #23 made the complaint at lunch regarding her missing tablet, so she told Licensed Practical Nurse (LPN) #329 and CNA #353. CNA #353 had went into the kitchen to look through the trash for Resident #23's tablet and an agency nurse (not identified) was also aware of the missing tablet. On 01/06/25, the previous Director of Nursing (DON), RN #313 and previous Assistant Director of Nursing (ADON)/LPN #368 told her she was being suspended over the theft of Resident #23's tablet. CNA #329 stated she was not interviewed and the facility did not have her write a witness statement. CNA #329 stated they had her come in on 01/08/25 as the facility had found Resident #23's tablet as SSD #355 observed Resident #23 on the tablet and Resident #23 stated at that time CNA #329 had stole the tablet, sold it to Resident #10 then got her tablet back.
Interview on 03/12/25 at 11:38 A.M. with LPN #354 revealed she did not recall Resident #23's missing iPad and shared Resident #23 was always on an iPad in her room.
Interview on 03/12/25 at 11:45 A.M. with CNA #353 revealed she was aware of the allegation of misappropriation regarding Resident #23 and confirmed she had to write a witness statement. First, Resident #23 said a resident stole her iPad and she hit an alarm on it and it went off. Then, Resident #23 stated a kitchen staff had stolen her iPad and then she accused CNA #329 of stealing the iPad. CNA #353 stated the iPad was missing maybe four or five days, then it reappeared.
Interview on 03/12/25 at 11:53 A.M. with SSD #355 revealed she was in charge of keeping the facility's grievance and self-report tracking log. SSD #355 recalled someone (name not provided) had told her about the allegation and stated a CNA had taken Resident #23's meal tray which had her tablet on it and Resident #23 had thought someone had sold it to Resident #10. SSD #355 stated Resident #23 later found her tablet in Resident #10's room. When asked about the facility's grievance and self-report tracking log and the date of 01/04/25 regarding Resident #23's concern with her missing tablet, SSD #355 verified the date of 01/04/25 was accurate and was the date she was first made aware of Resident #23's missing tablet.
During an interview on 03/12/25 at 12:12 P.M. the Chief Operating Officer (COO) #300 was notified the allegation of misappropriation regarding Resident #23's missing tablet was first reported to SSD #355 on 01/04/25, but the facility failed to file a SRI regarding the misappropriation until 01/06/25. COO #300 verified the SRI was not reported timely as required per facility policy and procedure.2. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair. Resident #18 was hospitalized from [DATE] to 01/20/25.
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on floor by nurse aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit her head and had no complaints of pain at this time.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of a nurse's note dated 01/18/25 at 9:55 A.M. revealed Resident #18's was sent to hospital for evaluation related to abdominal pain and suspicious x-ray of abdomen.
Review of a Hospital Medicine History and Physical dated 01/18/25 revealed Resident #18 presented to hospital for concern of bowel obstruction. While in the emergency department (ED) a cat (CT) scan was completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was present at hospital and reported on 01/03/25 Resident #18 had a fall and had been complaining of pain to left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip. Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Review of a nurse's note dated 01/20/25 at 3:29 P.M. revealed the hospital reported Resident #18 had pelvic fracture with no surgical interventions. Resident #18 would return to facility weight bearing as tolerated.
Review of a nurse's note dated 01/20/25 at 6:30 P.M. revealed Resident #18 returned to the facility from the hospital.
Review of a NP progress note dated 01/21/25 revealed Resident #18 re-admitted to facility from hospital with diagnoses of left pelvic fracture. The NP noted prior to admission Resident #18 was totally dependent on staff for ADL care needs.
Interview on 03/18/25 at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of neglect in January 2025 and had provided videos as supporting evidence to facility staff. During the interview, the resident's sister also shared Resident #18 had a fall at the beginning of January 2025. An x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident and was unable to advocate for herself. The resident's sister revealed around the middle of January 2025 Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated while at the hospital Resident #18 was found to have a hip fracture.
Review of a family provided two minute and one second video dated 01/04/25 at 9:08 A.M. revealed Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353. Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39 second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57 second mark while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated 01/04/25 at 11:20 A.M. revealed Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide #353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident could be heard groaning (in pain) out loudly.
Review of an email provided by Resident #18's sister dated 01/05/25 timed 8:35 P.M. revealed Resident #18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on 01/03/25; however, she did not receive notification of results until 01/04/25 at 9:45 A.M. The sister indicated it was apparent Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated Resident #18 was unable to request pain medications. The sister included a series of videos in the email from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and did not appear to be knowledgeable of Resident #18's potentially broken left hip. The sister shared additional unrelated concerns related to the care of Resident #18 in the email.
Review of a facility Self-Reported Incident (SRI) dated 01/06/25 at 9:30 A.M. revealed Resident #18's sister made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with pain was not included on the SRI investigation.
Further review revealed there was no evidence of SRI filed for Resident #18's 01/18/25 pelvic fracture to rule out potential abuse.
During an interview on 03/18/25 at 2:04 P.M. with the Administrator and Chief Operating Officer (COO) #300, Resident #18's fall on 01/03/25, SRI on 01/06/25, and pelvic fracture on 01/18/25 were reviewed. COO #300 indicated she was unable to remember any details of Resident #18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional details related to Resident #18's fall and subsequent fracture including interventions, investigation, interdisciplinary review, or root cause analysis. COO #300 confirmed there was no reporting of injury of unknown origin to rule out abuse for Resident #18.
Review of facility policy Abuse Prevention dated 08/20/21 revealed the facility would investigate all alleged violations involving abuse including injuries of unknown origin. An injury of unknown origin is classified when the source of injury was not observed or could be explained by the resident and the injury is suspicious due to extent/location/number of injuries or injuries over time. Serious bodily injuries should be reported to Ohio Department of Health (ODH) immediately or no later than 2 hours after alleged incident. Follow up was required for injuries of unknown source to make necessary changes in resident's plan of care to protect against occurrence of another similar injury.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self-reported incident, review of the facility policy, record review and interview, the facility failed to thoroughly investigate allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse Facility census was 54.
Findings include:
1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day lookback period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression and emotional outbursts and was also noted to make false accusations.
Review of a SRI dated 01/06/25 at 5:08 P.M. revealed Resident #23 reported to Registered Nurse (RN) #313, the Director of Nursing (DON) at the time of the allegation, that her tablet was missing. Resident #23 stated a Certified Nursing Assistant (CNA) who was taking care of her had removed her dinner tray that the tablet was on. The time of the occurrence was identified as 01/06/25 at 3:07 P.M. An alleged perpetrator was listed as CNA #329. A search was completed for the tablet and the tablet was not found. Resident #23 was offered a lock box which she declined. The facility determined the allegation of misappropriation to be unsubstantiated.
Review of the facility's investigation for the SRI on 01/06/25 revealed two sheets of paper including a statement from Social Service Designee (SSD) #355 and a statement from CNA #353. No further evidence of investigation was available for review.
Review of the statement dated 01/07/25 and authored by SSD #355 revealed the following information: I interviewed Resident #23 on 01/07/25 and she stated she had an iPad (tablet) that was missing. Resident #23 stated she has two iPads, one with a purple and blue case and another Amazon iPad with a black case that had googly eyes and the words do not touch on the front of it. Resident #23 stated the iPad was on her tray table on top of her food tray and that it was removed by a CNA and never returned. An addendum was located at the bottom of SSD #355's statement which indicated on 01/10/25 Resident #23 found her missing iPad but no further information was available.
Review of the statement dated 01/09/25 and authored by CNA #353 revealed she had no knowledge of Resident #23's tablet.
Review of the facility's grievance and self-report tracking log for January 2025 revealed on 01/04/25, Resident #23 had reported her missing iPad. Under the 'Resolution' header, there was a notation the iPad was found on 01/10/25.
Interview on 03/12/25 at 11:09 A.M. with Resident #23 revealed in January 2025, her tablet was laying on her meal tray. Resident #23 identified her tablet as an Amazon Fire tablet, which she showed the surveyor during the interview. This tablet had a black cover with white writing with Resident #23's initials and the phrase don't touch my tablet on it. Resident #23 stated CNA #329 picked up her meal tray and took the tablet, then sold her tablet to Resident #10 for $100.00. She was able to activate an alarm on her tablet from her cell phone, which she found in Resident #10's room. Resident #23 could not state how much time had elapsed from when the tablet was observed gone to the time she found it in Resident #10's room. Resident #23 shared she had two Amazon Fire tablets, a 9-inch one and an 11-inch one and indicated the 9-inch one was the one that had been reported missing. Resident #23 verified the facility did not interview her regarding her allegation of misappropriation or have her write a witness statement.
Interview on 03/12/25 at 11:22 A.M. with CNA #329 revealed she was angry she was suspended over the allegation of misappropriation regarding Resident #23's missing tablet. CNA #329 stated she worked on 01/05/25 and did not have Resident #23 as her resident that date. CNA #329 reported Resident #23 made the complaint at lunch regarding her missing tablet, so she told Licensed Practical Nurse (LPN) #329 and CNA #353. CNA #353 had went into the kitchen to look through the trash for Resident #23's tablet and an agency nurse (not identified) was also aware of the missing tablet. On 01/06/25, the previous Director of Nursing (DON), RN #313 and previous Assistant Director of Nursing (ADON)/LPN #368 told her she was being suspended over the theft of Resident #23's tablet. CNA #329 stated she was not interviewed and the facility did not have her write a witness statement. CNA #329 stated they had her come in on 01/08/25 as the facility had found Resident #23's tablet as SSD #355 observed Resident #23 on the tablet and Resident #23 had stated at that time CNA #329 had stole the tablet, sold it to Resident #10 then got her tablet back.
Interview on 03/12/25 at 11:38 A.M. with LPN #354 revealed she did not recall Resident #23's missing iPad and shared Resident #23 was always on an iPad in her room.
Interview on 03/12/25 at 11:45 A.M. with CNA #353 revealed she was aware of the allegation of misappropriation regarding Resident #23 and confirmed she had to write a witness statement. First, Resident #23 said a resident stole her iPad and she hit an alarm on it and it went off. Then, Resident #23 stated a kitchen staff had stolen her iPad and then she accused CNA #329 of stealing the iPad. CNA #353 stated the iPad was missing maybe four or five days, then it reappeared.
Interview on 03/12/25 at 11:53 A.M. with SSD #355 revealed she was in charge of keeping the facility's grievance and self-report tracking log. SSD #355 recalled someone (name not provided) had told her about the allegation and stated a CNA had taken Resident #23's meal tray which had her tablet on it and Resident #23 had thought someone had sold it to Resident #10. SSD #355 stated Resident #23 later found her tablet in Resident #10's room. When asked about the facility's grievance and self-report tracking log and the date of 01/04/25 regarding Resident #23's concern with her missing tablet, SSD #355 verified the date of 01/04/25 was accurate and was the date she was first made aware of Resident #23's missing tablet.
During an interview on 03/12/25 at 12:12 P.M. the Chief Operating Officer (COO) #300 was notified the SRI and subsequent investigation regarding Resident #23's missing tablet was an insufficient investigation as it lacked resident interviews, additional staff interviews and an interview with the alleged perpetrator (CNA #329) and she did not agree or disagree.
Follow-up interview on 03/12/25 at 12:19 P.M. with COO #300, the Administrator and CNA #329 revealed CNA #329 was asked questions by facility staff regarding the allegation of misappropriation, but again no record of this was available for surveyor review. CNA #329 reiterated she was not asked to complete a written witness statement as a result of the allegation. 2. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair. Resident #18 was hospitalized from [DATE] to 01/20/25.
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on floor by nurse aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit her head and had no complaints of pain at this time.
Review of progress notes, nurse practitioner noted, and therapy notes from 01/03/25 to 01/18/25 revealed Resident #18 had complaints of pain to left hip and pelvic area. Resident #18 was medicated for pain throughout this time.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of a nurse's note dated 01/18/25 at 9:55 A.M. revealed Resident #18's was sent to hospital for evaluation related to abdominal pain and suspicious x-ray of abdomen.
Review of a Hospital Medicine History and Physical dated 01/18/25 revealed Resident #18 presented to hospital for concern of bowel obstruction. While in the emergency department (ED) a cat (CT) scan was completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was present at hospital and reported on 01/03/25 Resident #18 had a fall and had been complaining of pain to left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip. Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Interview on 03/18/25 at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of neglect in January 2025 and had provided videos as supporting evidence to facility staff. During the interview, the resident's sister also shared Resident #18 had a fall at the beginning of January 2025. An x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident and was unable to advocate for herself. The resident's sister revealed around the middle of January 2025 Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated while at the hospital Resident #18 was found to have a hip fracture.
Review of a family provided one minute and 48 second video dated 01/04/25 at 7:57 A.M. revealed Resident #18 was sitting in a recliner chair for breakfast. Nurse Aide #329 was sitting in a chair next to Resident #18. Nurse Aide #329 appeared distracted during the video.
Review of a family provided two minute and three second video dated 01/04/25 at 8:00 A.M. revealed Resident #18 was sitting in recliner chair for breakfast. Nurse Aide #329 was sitting in a chair next to Resident #18. Nurse Aide #329 appeared distracted during the video and at the 15 second mark stood in the hallway before returning to sit next to Resident #18.
Review of a family provided two minute and one second video dated 01/04/25 at 9:08 A.M. revealed Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353. Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39 second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57 second mark while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated 01/04/25 at 11:20 A.M. revealed Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide #353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident could be heard groaning (in pain) out loudly.
Review of a family provided two minute and two second video dated 01/04/25 at 6:07 P.M. revealed Resident #18 was in her room in wheelchair. Nurse Aide #329 and Nurse Aide #353 were observed to use sit to stand lift and take Resident #18 to bathroom.
Review of an email provided by Resident #18's sister dated 01/05/25 timed 8:35 P.M. revealed Resident #18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on 01/03/25; however, she did not receive notification of results until 01/04/25 at 9:45 A.M. The sister indicated it was apparent Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated Resident #18 was unable to request pain medications. The sister included a series of videos in the email from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and did not appear to be knowledgeable of Resident #18's potentially broken left hip. Sister requested Nurse Aide #329 be removed from taking care of Resident #18 due to mistreatment. Resident #18's sister also stated concerns with follow through on agreed plan of care for medications and care.
Review of a facility Self-Reported Incident (SRI) dated 01/06/25 at 9:30 A.M. revealed Resident #18's sister made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with pain was not included on the SRI investigation. There was no evidence of interview with Resident #18's sister nor inclusion of videos provided by sister. The facility unsubstantiated abuse.
Interview on 03/18/25 at 11:33 A.M. with Admissions/Social Services Designee (SSD) #355 confirmed she had received a series of videos from Resident #18's sister. SSD #355 indicated she forwarded the email onto the interim Administrator and former Director of Nursing (DON). SSD #355 indicated she did not watch the videos she received from sister of Resident #18.
Interview on 03/18/25 at 2:04 P.M. with Administrator and Chief Operating Officer (COO) #300 confirmed the videos from Resident #18's sister had been received and were not included in SRI investigation. COO #300 indicated there was nothing in the videos that appeared abusive. COO #300 confirmed information on Resident #18's fall was not included in the SRI investigation as well.
Interview on 03/19/25 at 2:45 P.M. with Administrator revealed Administrator agreed to view videos submitted by sister of Resident #18. The six videos provided were reviewed. Administrator indicated it would be important to include these videos in the investigation. Administrator indicated she did not note any abuse behavior but indicated Nurse Aide #329 displayed a customer service issue.
Review of facility policy Abuse Prevention dated 08/20/21 revealed once notifications of an abuse allegation were made and investigation would be conducted. The investigation should include interview with parties involved including resident, alleged perpetrator, and witnesses, expanded interviews to other residents and staff, review of resident medical records, obtain all medical reports and statements as applicable, and review employee record if they are identified as alleged perpetrator. All evidence of investigation should be documented.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a baseline care plan for Resident #48. This affected one (Resident #48) out of 19 residents reviewed for baseline care plans. The facility census was 54.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of your brain), hallucinations and alcohol use with withdrawal.
Review of Resident #48's electronic medical record and paper chart revealed there was no baseline care plan completed after admission.
Interview on 03/19/25 at 11:45 A.M. with Chief Operating Officer (COO) #300 verified Resident #48 did not have a baseline care plan completed since admission on [DATE].
Review of the facility policy titled, Baseline Plan of Care, dated 05/01/22, revealed the interdisciplinary team, resident, resident's representative and physician would develop and implement a baseline care plan upon admission which would include the instructions needed to provide effective and person-directed care of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety and depression.
Review of Resident #25's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). No care plan was available addressing Resident #25's advance directives.
Interview on 03/12/25 at 9:11 A.M. with Social Service Designee (SSD) #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #25 did not have a care plan developed addressing his advance directive and should have.
5. Review of Resident #34's medical record revealed an admission date of 08/21/23 and diagnoses including vascular dementia with psychotic disturbance, paranoid personality disorder, violent behavior, osteoarthritis and depression.
Review of Resident #34's EMR revealed he had an advance directive of DNRCCA. No care plan was available addressing Resident #34's advance directives.
Interview on 03/12/25 at 9:14 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #34 did not have a care plan developed addressing his advance directive and should have.Based on record review and interview, the facility failed to develop comprehensive care plans for residents. This affected seven (Residents #9, #22, #24, #25, #34, #48 and #49) out of 28 residents reviewed for comprehensive care plans. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the care plan dated 11/12/24 for Resident #22 revealed he needed assistance with his activities of daily living (ADLs). The goal was for him to maintain his current level of functioning through the next review. Interventions were listed for ADL's including bathing, bed mobility, dressing, toilet use and personal hygiene. However, the care plan did not specify what amount of assistance Resident #22 required from staff. The care plan stated as follows:
-Bathing/Showering: I require (specify what assistance) by staff with (specify bathing/showering) at least weekly and whenever I prefer.
-Bed mobility: I require (specify what assistance) by staff to turn and reposition me frequently while in bed.
-Dressing: I need (specify what assistance) by staff to dress me.
-Personal hygiene: I need (specify) assistance from you with personal hygiene and oral care.
-Toilet use: I need (specify assistance) by you for toileting.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #22's care plan for ADL's was not resident centered and would not provide staff with the information to care for his needs.
2. Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of the brain), hallucinations and alcohol use with withdrawal.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition and had depression. He used a walker and needed substantial to max assistance for toileting and showers.
Review of the comprehensive care plan for Resident #48 revealed he had a care plan for his advance directives dated 03/12/25, one for his emotional, intellectual, physical and social needs dated 02/21/25 and his nutritional risks dated 02/07/25.
Interview on 03/19/25 at 11:45 A.M. with the Chief Operating Officer (COO) #300 verified Resident #48's care plan was not a comprehensive look at the resident and would not provide staff with the information to care for his needs.
3. Review of the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Review of the care plan dated 01/31/25 for Resident #49 revealed he needed assistance with his activities of daily living (ADLs). The goal was for him to maintain his current level of functioning through the next review. Interventions were listed for ADL's including bathing, bed mobility, dressing, toilet use and personal hygiene. However, the care plan did not specify what amount of assistance Resident #22 required from staff. The care plan stated as follows:
-Bathing/Showering: I require (specify what assistance) by staff with (specify bathing/showering) at least weekly and whenever I prefer.
-Bed mobility: I require (specify what assistance) by staff to turn and reposition me frequently while in bed.
-Dressing: I need (specify what assistance) by staff to dress me.
-Personal hygiene: I need (specify) assistance ROM you with personal hygiene and oral care.
-Toilet use: I need (specify assistance) by you for toileting.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #49's care plan for ADL's was not resident centered and would not provide staff with the information to care for his needs.6. Review of the medical record for Resident #9 revealed an admission date of 04/12/24 and diagnoses including bell's palsy, systemic lupus erythematosus, congestive heart failure, hypertension, dementia, metabolic encephalopathy, malignant neoplasm of bronchus and lung, and chronic kidney disease.
Review of a nurses note dated 01/11/25 revealed Resident #9 was agitated and adamant she was going home. Resident #9's son came to the facility to try to calm her down. Son reported Resident #9 was exhibiting symptoms of a urinary tract infection (UTI) as she had in the past. Hospice and Physician were notified. The physician gave an order for Ciprofloxacin (antibiotic) for seven days and to collect urine sample.
Review of physician's order dated 01/12/25 revealed order for 500 milligrams (mg) Ciprofloxacin two times per day for seven days.
Review of physician's order dated 01/21/25 revealed order for 100 mg Macrobid (antibiotic) two times per day for an unspecified number of days. Order was discontinued on 02/04/25.
Review of the plan of care for January to March 2025 revealed no care plan related to infections was developed.
Interview on 03/19/25 at 3:37 P.M. with Director of Nursing (DON) confirmed Resident #9 did not have a care plan related to infections developed.
7. Review of the medical record for Resident #24 revealed admission date of 06/04/24 and diagnoses including dementia with psychotic disturbance, hypertension, hyperlipidemia, lymphedema, Parkinson's disease, anxiety disorder, atherosclerotic heart disease.
Review of hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital from [DATE] to 11/24/24 for cellulitis of left lower extremity. Resident #24 admitted for recurrent left lower extremity cellulitis and had previously been admitted from 11/05/24 to 11/11/24. Resident #24 was noted to have Methicillin-resistant Staphylococcus aureus (MRSA) growth on sputum culture, so Doxycycline (antibiotic) was added. Sputum culture appeared consistent with colonization.
Review of Nurse Practitioner (NP) progress note dated 11/25/24 revealed Resident #24 returned from hospital on [DATE] with diagnosis of cellulitis. NP noted Resident #24 was discharged on antibiotic for cellulitis and MRSA in sputum culture.
Review of NP progress note dated 12/16/24 revealed Resident #24 completed oral antibiotic treatment of Cephalexin for cellulitis and Doxycycline for MRSA of sputum on 12/02/24.
Review of Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS) report undated revealed Resident #24 had sputum culture collected on 11/10/24 while at hospital. Results of sputum culture returned on 11/27/24 and were positive for Citrobacter koseri and Klebsiella aerogenes. Klebsiella pneumoniae carbapenemase (KPC) was detected.
Review of the plan of care for March 2025 revealed no care plan related to infections or MDRO status.
Interview on 03/19/25 at 3:37 P.M. with Director of Nursing (DON) confirmed Resident #24 did not have a care plan related to infections or MDRO status developed.

Based on record review, interview and review of the facility policy, the facility failed to timely update care plans to address changes in residents' advance directives. This affected three residents (#7, #15 and #20) out of 26 residents reviewed for care planning. Facility census was 54.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of 05/07/15 and diagnoses including schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes.
Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). A plan of care revised 07/05/22 revealed Resident #7 had an advance directive of full code.
Review of Resident #7's paper medical record revealed he had an advance directive of full code.
Interview on 03/12/25 at 9:13 A.M. with Social Service Designee (SSD) #355 revealed the Minimum Data Set (MDS) nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #7's care plan was not revised to reflect his current advance directive of DNRCCA and should have been.
2. Review of Resident #15's medical record revealed an admission date of 08/01/16 and diagnoses including dementia with agitation, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder, paranoid personality disorder and delusional disorders.
Review of Individual #15's EMR revealed he had an advance directive of DNRCCA. A plan of care revised 01/02/22 revealed Resident #15 had an advance directive of full code.
Review of Individual #15's paper medical record revealed he had an advance directive of full code. No signed do not resuscitate (DNR) was available in his record.
Interview on 03/12/25 at 9:10 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #15's care plan was not revised to reflect his current advance directive of DNRCCA and should have been.
3. Review of Resident #20's medical record revealed an admission date of 11/07/17 and diagnoses including type two diabetes, chronic kidney disease, traumatic brain injury, dementia with agitation and generalized anxiety disorder.
Review of Individual #20's EMR revealed he had an advance directive of DNRCCA. A plan of care revised 07/23/19 revealed Resident #20 had an advance directive of full code.
Review of Individual #20's paper medical record revealed he had an advance directive of full code. No signed DNR was available in his record.
Interview on 03/12/25 at 9:10 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #20's care plan was not revised to reflect his current advance directive of DNRCCA and should have been.
Review of the facility policy, Baseline Plan of Care, dated 05/01/22 revealed the comprehensive plan of care will be developed within seven days after completion of the comprehensive assessment . The plan of care will be reviewed and revised by the interdisciplinary team after each MDS assessment, including both comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #15's medical record revealed an admission date of 08/01/16 and diagnoses including dementia with agitation, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder, paranoid personality disorder and delusional disorders.
Review of a quarterly MDS 3.0 assessment dated [DATE] revealed no mental status was completed on the assessment for Resident #15. Resident #15 was independent with bathing and mobility and rejected care one to three days in the seven-day look-back period.
Review of the facility shower schedule revealed Resident #15's room number was not listed on the schedule for staff to offer him showers.
Review of Resident #15's nurses' notes for February 2025 and March 2025 did not record any refusals of showers.
Review of Resident #15's resident tasks records revealed no shower data for the last 30 days.
Interview on 03/10/25 at 12:41 P.M. with Resident #15 revealed he had not had a shower or bed bath for the last three weeks and reported the shower door room was kept locked.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she did not have any shower sheets to provide for Resident #15.
Follow-up interview on 03/13/25 at 12:44 P.M. with the DON and Registered Nurse (RN)/Assistant Director of Nursing (ADON) #299 verified Resident #15 was not on the facility's shower schedule and should have been.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed some residents refused showers, but if this occurred Certified Nursing Assistants (CNAs) were to write 'refused' on the paper shower sheet and she would make a nurses' note about the refused shower as well.
Interview on 03/18/25 at 8:47 A.M. with CNA #357 revealed many residents refused their showers in the facility. CNA #357 stated if this occurred, she let the nurse know and she would write refuse on a paper shower sheet for that resident, and the nurse would take the shower sheets after that.
Review of the facility policy, Resident ADL Care, dated 07/01/23 the facility believed in supporting and encouraging the autonomy and independence of all residents in activities of daily living to the fullest extent possible. Residents will be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility. When autonomy and independence are no longer possible or feasible, the facility resident care staff will provide the necessary support in all ADL functioning. All residents will be expected to bathe, assisted as necessary, twice per week unless otherwise specified by the physician or the resident requests more frequent bathing.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
Based on record review, observation and interview, the facility failed to ensure showers were completed for independent residents. This affected three (Residents #15, #22 and #203) of three residents reviewed who were independent with activities of daily living (ADL). The facility census was 54.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had clear speech, understood staff and staff understood him. There was no cognitive assessment performed on this MDS. Resident #22 was noted to be independent for showers and dressing.
Review of the care plan dated 11/12/24 for Resident #22 revealed he needed assistance with his activities of daily living (ADLs). However, his care plan was incomplete and did not state the level of care he required for assistance with showers.
Review of the medical record for Resident #22 from 01/01/25 through 03/10/25, revealed there was no evidence he had received showers during that period of time.
Review of the shower schedule for the facility, undated, revealed Resident #22 would receive his showers on Wednesday and Saturday between 7:00 P.M. and 7:00 A.M.
Interview on 03/10/25 at 10:41 A.M. with Resident #22 revealed he hadn't received his showers as scheduled and per his preference due to the shower being broken.
Observation on 03/10/25 at 10:59 A.M. revealed the shower room on the west side of the building had a sign that stated the shower was broken.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she was unable to find any shower sheets for Resident #22. She stated the staff document all showers on shower sheets.
2. Review of the medical record for Resident #203 revealed an admission date of 03/04/25 with diagnoses including paranoid schizophrenia, depression and anxiety.
Review of the nursing assessment and baseline care plan dated 03/04/25 revealed Resident #203 preferred to receive a shower and needed set-up help only with bathing.
Review of the shower schedule for the facility, undated, revealed Resident #203 would receive his showers 7:00 P.M. to 7:00 A.M. on Wednesday and Saturday. With this schedule, Resident #203 would have received showers on 03/05/25, 03/08/25 and 03/12/25 .
Review of the medical record for Resident #203 from 03/04/25 through 03/13/25, revealed he refused a shower on 03/05/25. There were no other shower sheets in his record.
Interview on 03/10/25 at 10:30 A.M. with Resident #203 revealed he hadn't received his showers as scheduled and per his preference since being admitted to the facility.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she was unable to find any other shower sheets for Resident #203. She stated the staff document all showers on shower sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14 out of 15, indicating she was cognitively intact, was independent with most activities of daily living (ADLs) and required staff set up for showers/bathing.
Review of the facility shower schedule revealed Resident #23 was to receive showers on night shift (7:00 P.M. to 7:00 A.M.) on Mondays and Thursdays.
Review of Resident #23's nurses' notes for February 2025 and March 2025 did not record any refusals of showers.
Review of resident tasks records revealed no shower data for the last 30 days.
There were no paper shower sheets available to review for Resident #23.
Interview on 03/10/25 at 10:29 A.M. with Resident #23 reported she had not had a shower for the last two weeks, as both showers had not been working on the unit.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she did not have any shower sheets to provide for Resident #23.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed some residents refused showers, but if this occurred Certified Nursing Assistants (CNAs) were to write 'refused' on the paper shower sheet and she would make a nurses' note about the refused shower as well.
Interview on 03/18/25 at 8:47 A.M. with CNA #357 revealed many residents refused their showers in the facility. CNA #357 stated if this occurred, she let the nurse know and she would write refuse on a paper shower sheet for that resident, and the nurse would take the shower sheets after that.
Review of the facility policy, Resident ADL Care, dated 07/01/23 the facility believed in supporting and encouraging the autonomy and independence of all residents in activities of daily living to the fullest extent possible. Residents will be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility. When autonomy and independence are no longer possible or feasible, the facility resident care staff will provide the necessary support in all ADL functioning. All residents will be expected to bathe, assisted as necessary, twice per week unless otherwise specified by the physician or the resident requests more frequent bathing.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
Based on record review and interviews, the facility failed to ensure showers were provided as scheduled and per the resident preference for dependent residents. This affected four (Residents #23, #37, #43 and #48) of four dependent residents reviewed for activities of daily living. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] for Resident #37 revealed he had intact cognition and did not refuse care. He was dependent on staff for toileting, showers, dressing and transfers.
Review of the shower schedule for the facility, undated, revealed Resident #37 was scheduled for showers on Wednesdays and Saturdays from 7:00 A.M. to 7:00 P.M. for the date range of 01/01/25 through 02/25/25. On 02/26/25 his shower schedule was changed and were scheduled on Mondays and Wednesdays from 7:00 P.M. through 7:00 A.M.
Review of Resident #37's electronic medical record and paper chart revealed there were no shower sheets from 01/01/25 through 02/25/25. This resulted in Resident #37 not receiving 16 showers during that time frame. Review of shower sheets from 02/26/25 through 03/11/25 revealed he was not offered a shower on 02/26/25 and 03/10/25.
Interview on 03/10/25 at 10:58 A.M. with Resident #37 revealed he had not received a shower in nine months.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she was unable to find any other shower sheets for Resident #37 than what she had provided as above. She stated the staff documented all showers on shower sheets.
2. Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of the brain), hallucinations and alcohol use with withdrawal.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition. He used a walker and needed substantial to maximum assistance for toileting and showers.
Review of the shower schedule for the facility, undated, revealed Resident #48 was scheduled for showers on Wednesdays and Saturdays from 7:00 P.M. to 7:00 A.M.
Review of Resident #48's electronic medical record and paper chart revealed there was one shower sheet for 03/12/25 during the time frame of 01/31/25 through 03/13/25.
Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed he had not been able to take a shower since he was admitted . He stated the shower had been broken as well.
Observation on 03/10/25 at 10:59 A.M. revealed the shower room on the west side of the building had a sign that stated the shower was broken.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she was unable to find any other shower sheets for Resident #48 than what she had provided as above. She stated the staff documented all showers on shower sheets.
3. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses including sepsis, paranoid schizophrenia, moderate protein-calorie malnutrition, osteomyelitis, and traumatic arthropathy of right knee.
Review of Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #43 required partial/moderate assistance from staff for showering and bathing.
Review of shower schedule revealed Resident #43's showers were scheduled for Mondays and Thursdays on 7:00 P.M. shift.
Review of Bath/Shower Report Sheets from February 2025 to March 2025 revealed sheets for refusal on 02/20/25 for refusal on 02/23/25, for refusal on 03/03/25, for refusal on 03/06/25, for no bath given related to pain on 03/10/25, and a shower on 03/12/25.
Further review of the medical record for Resident #43 revealed no evidence of additional instances of bathing offered.
Interview on 03/10/25 at 2:13 P.M. with Resident #43 revealed he was unable to get assistance from staff for showering.
Interview on 03/13/25 at 8:46 A.M. with Director of Nursing (DON) confirmed she was unable to locate any additional bathing documentation for Resident #43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review, Centers for Disease Control (CDC) guidance on COVID-19 and interview the facility failed to provide timely and necessary intervention following changes in resident condition.
Actual Harm occurred on [DATE] when Resident #18 had unwitnessed fall resulting in increased pain, decreased functional ability and inability to participate in therapy services due to pain. On [DATE] (15 days following the fall) Resident #18 was transferred to the hospital and assessed to have an acute fracture of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum.
Actual Harm occurred on [DATE] when Resident #55 was admitted to the hospital for treatment of pneumonia and was experiencing dark, tarry stools. Resident #55 had tested positive for COVID-19 in the facility on [DATE] with symptoms including dry cough, nasal congestion, nausea, vomiting, and loose stools. The lack of timely and adequate medical treatment/intervention after testing positive for COVID-19 on [DATE] contributed to Resident #55's hospitalization and subsequent death on [DATE].
Actual Harm occurred on [DATE] when Resident #31 was transferred to the hospital and admitted for treatment of acute respiratory failure secondary to COVID-19. However, Resident #31 had been experiencing symptoms including nasal congestion, cough, nausea, vomiting, and loose stools since [DATE] that were not timely or adequately treated contributing to the hospitalization. During the hospitalization, Resident #31 was also noted to have pneumonia. Resident #31 was hospitalized from [DATE] to [DATE].
This affected one resident (#18) of three residents reviewed for falls/accidents and two residents (#31 and #55) of 28 residents reviewed for quality of care and treatment. The facility census was 54
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of [DATE] with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair. Resident #18 was hospitalized from [DATE] to [DATE].
Review of a physician's order dated [DATE] revealed order for Acetaminophen 650 milligrams (mg) every four hours as needed.
Review of a physician's order dated [DATE] revealed order for Tramadol 50 mg every six hours as needed.
Review of a physician's order dated [DATE] revealed order for Acetaminophen 500 mg once daily for mild to moderate pain.
Review of a nurse's note dated [DATE] at 7:35 A.M. revealed Resident #18 was found on floor by nurse aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit her head and had no complaints of pain at this time.
Review of an Orders Administration Note dated [DATE] at 5:40 P.M. revealed Resident #18 was administered as needed Acetaminophen for pain.
Review of a nurse's note dated [DATE] at 6:03 P.M. revealed Resident #18 received an unspecified x-ray.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 6:43 P.M. revealed Resident #18 was noted to have had fall in morning due to ambulating on own. Unable to ensure carry over of education to wait for staff for transfers due to poor cognition. During therapy session Resident #18 was unable to use sit to stand lift or ambulate due to pain to left hip while flexing hip. Resident #18 reported moderate to severe pain. Nursing was notified.
Review of Medicare Skilled Charting assessment dated [DATE] timed 6:55 P.M. revealed Resident #18 was alert and oriented to person and situation. Resident #18 had unsteady gait, impaired balance, weakness, and decreased sensation. Resident #18 required assistance for bed mobility and transfers. Resident #18 had pain to left hip/groin area status post fall and was noted to be grimacing. An x-ray was pending at time of assessment.
Review of an Orders Administration Note dated [DATE] timed 9:06 P.M. revealed Resident #18 was noted to be in pain.
Review of nurse's note dated [DATE] at 9:46 P.M. revealed Resident #18 complained of pain to groin and left hip to nurse. It was noted nursing staff and power of attorney (POA) argued through camera in room about Resident #18's bathing schedule. Resident #18 was noted to be upset during argument and yelled at POA. Resident #18 received a bed bath.
Review of a Patient Report dated [DATE] revealed Resident #18 had one view x-ray of left hip and pelvis. X-ray showed no acute fracture or dislocation. It was noted Resident #18 had enlargement of stool within the rectal vault. Results signed by interpreting physician on [DATE] at 3:19 A.M.
Review of an Orders Administration Note dated [DATE] at 9:45 A.M. revealed Resident #18 was noted to be in pain.
Review of an Orders Administration Note dated [DATE] at 10:56 A.M. revealed Resident #18 was administered as needed Tramadol for hip pain.
Review of an Orders Administration Note dated [DATE] at 8:26 P.M. revealed Resident #18 was administered as needed Tramadol for signs and symptoms of left hip and groin pain. Resident #18 was noted to guard areas of pain.
Review of an Orders Administration Note dated [DATE] at 9:26 P.M. revealed Resident #18 was noted to be in pain.
Review of an Orders Administration Note dated [DATE] at 8:08 A.M. revealed Resident #18 was administered as needed Tramadol.
Review of an Orders Administration Note dated [DATE] at 8:24 P.M. revealed Resident #18 was administered as needed Tramadol for complaints of generalized hip and groin pain.
Review of a nurse practitioner (NP) progress note dated [DATE] revealed on [DATE] Resident #18 complained of pain to left hip with range of motion during physical therapy. Resident #18 was status post fall on [DATE]. An x-ray was ordered and completed on [DATE] with no acute abnormalities. No new orders were obtained.
Review of a nurse's note dated [DATE] at 11:28 A.M. revealed nurse aide reported Resident #18 was complaining of pain to pelvic area. The NP was contacted and stated Resident #18's x-ray was negative.
Review of a nurse's note dated [DATE] at 1:00 P.M. revealed nurse aide reported Resident #18 complained of pain to pelvic area. Nurse notified Director of Nursing (DON), Assistant DON (ADON), NP and POA.
Review of a Pain Tool assessment dated [DATE] at 3:28 P.M. revealed Resident #18 had pain to the pelvic area. Pain was improved by Tylenol and resting and worsened by standing. Pain affected social activities, physical activities and mobility, and emotions.
Review of a nurse's note dated [DATE] at 12:56 A.M. revealed Resident #18 continued to complain of left sided pelvic pain and as needed Tramadol was administered.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:15 P.M. revealed Resident #18 declined to participate in transfer training due to complaints of left groin pain. Nursing aware.
Review of a physician's order dated [DATE] revealed order for Norco 5-325 mg twice daily for pain management for 10 days.
Review of a NP progress note dated [DATE] revealed no evaluation of continued pain. The NP noted pain regimen to be Acetaminophen 500 mg daily, Acetaminophen 650 mg every four hours as needed, Tramadol 50 mg every six hours as needed, and Norco 5-325 mg twice daily.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:55 P.M. revealed Resident #18 complained of pain through groin during therapy and limited participation. Nursing notified of pain present during session.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] timed 12:48 P.M. revealed Resident #18 continued to have intermittent pain persisting to left thigh and groin.
Review of a nurse's note dated [DATE] at 5:04 P.M. revealed Resident #18 received morning scheduled pain medication. During nap time Resident #18 complained of pain to nurse aide when being adjusted in bed and Resident #18 was administered as needed Tylenol.
Review of an Orders Administration Note dated [DATE] at 8:10 A.M. revealed Resident #18 complained of pain to leg and was administered Norco.
Review of a NP progress note dated [DATE] revealed no evaluation of the resident's continued pain.
Review of a nurse's note dated [DATE] at 1:48 P.M. revealed nurse aide reported bilateral swelling to Resident #18's lower extremities. The NP was notified, and the diuretic Lasix was ordered as needed.
Review of a NP progress note dated [DATE] revealed Resident #18 had increased edema to bilateral lower extremities. The NP ordered Furosemide (Lasix) 20 milligrams (mg) for three days and as needed. The NP noted Resident #18's bilateral lower extremities were shiny and firm.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of an Orders Administration Note dated [DATE] at 7:12 P.M. revealed Resident #18 was administered an as needed suppository for constipation.
Review of a Patient Report dated [DATE] revealed Resident #18 had an x-ray of the abdomen. The x-ray showed a few mildly dilated gas-filled loops of bowel, multiple non-dilated gas filled loops of bowel, and stool visualized in colon to level of hepatic flexure. Follow-up for resolution was recommended to rule out ileus or obstruction. Results signed by interpreting physician on [DATE] at 12:09 P.M.
Review of a nurse's note dated [DATE] at 9:55 A.M. revealed Resident #18's abdominal x-ray results were returned. An order was received to transfer the resident to the hospital for an evaluation. Ambulance services arrived at 9:16 A.M.
Review of a Hospital Medicine History and Physical dated [DATE] revealed Resident #18 presented to hospital for concern of bowel obstruction. Resident #18 had abdominal distension and stiffness. An abdominal x-ray completed prior to admission showed concern for high stool burden/obstruction. Resident #18 passed stool successfully while in hospital. While in the emergency department (ED) a cat (CT) scan was completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was present at hospital and reported on [DATE] Resident #18 had a fall and had been complaining of pain to left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip. Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Review of a nurse's note dated [DATE] at 3:29 P.M. revealed the hospital reported Resident #18 had pelvic fracture with no surgical interventions. Resident #18 would return to facility weight bearing as tolerated.
Review of a nurse's note dated [DATE] at 6:30 P.M. revealed Resident #18 returned to the facility from the hospital.
Review of a NP progress note dated [DATE] revealed Resident #18 re-admitted to facility from hospital with diagnoses of left pelvic fracture. The NP noted prior to admission Resident #18 was totally dependent on staff for ADL care needs.
Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #18 received as needed Acetaminophen 650 mg on [DATE] at 11:12 A.M. Resident #18 received as needed Tramadol 50 mg on [DATE] at 10:56 A.M. and 8:26 P.M., [DATE] at 8:08 A.M. and 8:24 P.M., and [DATE] at 12:56 P.M. Resident #18 received Norco 5-325 mg twice daily from [DATE] at 9:00 P.M. to [DATE] to 9:00 A.M. Resident #18 received routine Acetaminophen 500 mg once a day.
Review of plan of care revised [DATE] revealed there was no care plan developed related to Resident #18's pain status.
Interview on [DATE] at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of neglect in [DATE] and had provided videos as supporting evidence to facility staff. During the interview, the resident's sister also shared Resident #18 had a fall at the beginning of [DATE]. An x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident and was unable to advocate for herself. The resident's sister revealed around the middle of [DATE] Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated while at the hospital Resident #18 was found to have a hip fracture.
Review of a family provided two minute and one second video dated [DATE] at 9:08 A.M. revealed Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353. Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39 second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57 second mark while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated [DATE] at 11:20 A.M. revealed Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide #353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident could be heard groaning (in pain) out loudly.
Review of an email provided by Resident #18's sister dated [DATE] timed 8:35 P.M. revealed Resident #18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on [DATE]; however, she did not receive notification of results until [DATE] at 9:45 A.M. The sister indicated it was apparent Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated Resident #18 was unable to request pain medications. The sister included a series of videos in the email from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and did not appear to be knowledgeable of Resident #18's potentially broken left hip. The sister shared additional unrelated concerns related to the care of Resident #18 in the email.
Review of a facility Self-Reported Incident (SRI) dated [DATE] at 9:30 A.M. revealed Resident #18's sister made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with pain was not included on the SRI investigation.
Interview on [DATE] at 11:54 A.M. with Physical Therapy Assistant (PTA) #372 confirmed Resident #18 had been complaining of pain, during walking, after her fall on [DATE].
During an interview on [DATE] at 2:04 P.M. with the Administrator and Chief Operating Officer (COO) #300, Resident #18's fall was reviewed. COO #300 indicated she was unable to remember any details of Resident #18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional details related to Resident #18's fall and subsequent fracture including interventions, investigation, interdisciplinary review, or root cause analysis.
Interview and review of the incident with the DON on [DATE] at 3:18 P.M. verified there was no follow-up to Resident #18's continued pain. The DON said she was not employed by the facility at the time of the incident but questioned why there wasn't another X-ray completed, since the resident was still experiencing pain. She also verified the facility was unable to locate or provide any additional information regarding the resident's fall and delay in her treatment despite concerns shared from the resident's sister and no improvement in the resident's condition.
Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in the medical record information related to change in condition and notify attending physician and guardian.
Review of facility policy Falls and Incident Investigation dated [DATE] revealed resident falls would be documented and investigated to determine root cause and have plan developed to prevent reoccurrence. The nurse would assess the resident and provide as needed first aide, record vital signs, initiate head injury precautions, notify supervisor, initiate incident reporting and document on incident in progress note, and notify physician and family. The DON would reassess the resident for any additional monitoring or changes to plan of care, ensure investigation occurs promptly, obtain statements from staff, and document and ensure implementation of corrective interventions. The resident would be followed on the 24-hour report and progress notes for 72 hours post-accident. The interdisciplinary team would review falls.
2. Review of the closed medical record for Resident #55 revealed an admission date of [DATE] and discharge date of [DATE]. Resident #55 had diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage.
Review of the immunizations record revealed Resident #55 was not up to date with the COVID-19 vaccination with the last dose administered [DATE] and Resident #55 was not up to date with pneumococcal vaccinations as pneumococcal Polysaccharide Vaccine (PPSV) 23 was administered before the age of 65.
Review of the physician's order dated [DATE] revealed an order for a consult to oncology for a follow up to lung mass and a repeat chest x-ray on [DATE].
Review of the nurse's note dated [DATE] revealed Resident #55 tested positive for COVID-19.
Review of the physician's orders dated [DATE] revealed orders for contact and droplet precautions for five to 10 days if symptomatic, Dexamethasone six milligrams (mg) once daily, two to four liters of oxygen via nasal cannula to keep oxygen saturation above 92 percent, and vitals monitoring every shift.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Dexamethasone. Reason noted Medication not received by pharmacy.
Review of the Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #55 had nasal congestion. The NP ordered oxygen via nasal cannula to keep oxygen saturation above 92 percent, Dexamethasone six mg daily for seven days, and monitor temperature, pulse oximetry (ox), and respirations every shift for 10 days. The NP noted to continue Eliquis five mg twice per day, Acetaminophen 650 mg every six hours as needed, and Albuterol nebulizer every four hours as needed.
Review of a physician's order dated [DATE] revealed an order for Resident #55 for a complete blood count with differential (CBC with diff) to be obtained on [DATE]. Further review of the medical record revealed no evidence the laboratory services (labs) were obtained as ordered.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Dexamethasone. Reason noted on order.
Review of the physician's order dated [DATE] revealed Resident #55's chest x-ray was rescheduled to [DATE] due to current COVID-19 positive status.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Omeprazole. Reason noted was none in med cart.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Omeprazole. Reason noted was not available.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 required two liters of oxygen.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 had multiple episodes of diarrhea and as needed Polyethylene Glycol medication was held.
Review of the NP progress note dated [DATE] revealed Resident #55 was having loose stools and nausea. The NP ordered Zofran four mg every six hours as needed. Resident #55's second finger on the right hand was noted to be discolored and cool to touch. The NP noted all fingers on the right hand were noted to be discolored and the NP contributed this to peripheral vascular disease. The NP ordered an ultrasound of the residents right upper extremity.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered Acetaminophen for discomfort, headache and low-grade temperature of 99.1 degrees Fahrenheit (F).
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered Acetaminophen for stomach pain and Zofran for nausea and vomiting.
Review of the NP progress note dated [DATE] revealed Resident #55 had complaints of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP ordered to send Resident #55 to the emergency room for evaluation. The NP noted the ultrasound of the right upper extremity had not yet been completed.
Review of the nurse's note dated [DATE] revealed Resident #55 was transported to hospital for complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood thinner.
Review of the nurse's note dated [DATE] revealed Resident #55 was admitted to hospital for pneumonia. Review of the Ohio Department of Medicaid Facility Communication dated [DATE] revealed Resident #55 had passed away at the hospital on [DATE]. As of [DATE] the resident's death certificate was not available.
Interview on [DATE] at 8:03 A.M. with the legal guardian of Resident #55 confirmed Resident #55 had passed away at the hospital. The guardian indicated she had not received the resident's death certificate yet. Additional attempts to contact the legal guardian during the survey were unsuccessful.
Interview on [DATE] at 11:27 A.M. with the Administrator, COO #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident #55's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator, COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE] and were unaware Resident #55 had been hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a change in condition since testing positive for COVID-19 on [DATE].
Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence Resident #55 received the chest x-ray or labs as ordered.
Staff present during this time period when Resident #55 experienced this change in condition were not available for interview as they either no longer worked at the facility or were agency staff. Current staff interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed Practical Nurses (LPNs) #304, #327, #369, and Certified Nurse Aides #303, #305, #326, #337, #339, #352, #353, and #357 revealed they had no knowledge of Resident #55 or the resident's change in condition that occurred from [DATE] to [DATE].
Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in the medical record information related to change in condition and notify attending physician and guardian.
Review of facility policy COVID-19 Precautions and Prevention dated [DATE] revealed the facility would follow current guidelines and recommendations to ensure the facility was prepared to respond to COVID-19. A reportable outbreak was noted to be when one case had suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or three or more cases of new-onset respiratory symptoms within 72 hours.
Review of Centers for Disease Control (CDC) guidance on COVID-19 dated [DATE] revealed COVID-19 vaccination was recommended for prevention of severe health outcomes. Several antiviral medications were recommended including Paxlovid, Remdesivir, and Lagevriol as treatment for COVID-19 to help prevent severe illness and death.
3. Review of the medical record for Resident #31 revealed an admission date of [DATE] with diagnoses including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual disabilities. Resident #31 was hospitalized from [DATE] to [DATE].
Review of immunizations record revealed no evidence of Resident #31's COVID-19 or pneumococcal vaccinations status.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was independent for activities of daily living. The assessment revealed Resident #31 was not up to date on COVID-19 vaccinations and had not received pneumococcal vaccination.
Review of Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #31 complained of nasal congestion and not feeling well. The NP ordered to obtain pulse oximetry (ox), respirations, and temperature every shift for four days. There was no evidence of COVID-19 testing completed and/or any other intervention to treat the resident's symptoms at that time.
Review of the NP progress note dated [DATE] revealed Resident #31 continued to have nasal congestion and a cough. Resident #31 reported cough but was unable to clear anything. The NP ordered Mucinex 600 milligrams (mg) two times per day for seven days. There was no evidence of COVID-19 testing completed at this time.
Review of an NP progress note dated [DATE] revealed Resident #31 complained of not feeling well and told staff He feels like he is dying. Resident #31 observed with a dry cough and nasal congestion. Resident #31 reported an episode of vomiting. The NP ordered Vitamin C 250 milligrams daily and to continue Mucinex as needed for cough. There was no evidence of COVID-19 testing completed at this time.
Review of a nurse's note dated [DATE] revealed Resident #31 was experiencing a harsh, productive cough. Lung sounds were noted to be diminished. Resident #31 had four to five episodes of watery diarrhea and reported not being able to make it to the bathroom. A COVID-19 test was completed and negative. However, there was no evidence of any additional interventions being implemented at this time to treat the resident's symptoms.
Review of a NP progress note dated [DATE] revealed Resident #31 had an episode of vomiting and was ordered Zofran. Resident #31 continued to have dry cough. The NP ordered a chest x-ray and laboratory services (labs).
Review of a Patient Report dated [DATE] revealed Resident #31 had chest x-ray with no acute findings.
Review of a NP progress note dated [DATE] revealed Resident #31 continued to have cough and congestion. On [DATE] Resident #31 had a chest x-ray with no findings. On [DATE] Resident #31 had four to five watery stools and was ordered Loperamide two mg every six hours as needed for diarrhea. Resident #31 also complained of nausea and emesis. Labs were ordered on [DATE] and were not obtained. Resident #31's pulse ox was 92 percent on room air and the resident's heart rate was 109 (tachycardic). There was no evidence of COVID-19 testing completed. While the NP was visiting, she was alerted Resident #31 had fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated [DATE] revealed Resident #31 had been admitted to the hospital with acute hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19.
Review of a hospital note revealed Resident #31 was admitted to the step-down unit on [DATE] for acute hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis. Resident #31 continued to have intermittent coughing while hospitalized .
Review of a NP progress note dated [DATE] revealed Resident #31 had re-admitted to the facility from the hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on [DATE] at 4:50 P.M. with Chief Operating Officer (COO) #300 revealed the facility was unable to locate any type of facility COVID-19 tracking log or additional information related to a COVID-19 outbreak that occurred in the facility in [DATE].
Interview on [DATE] at 11:27 A.M. with Administrator, COO #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident #31's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator, COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE] and were unaware Resident #31 had been hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since [DATE].
Interview on [DATE] at 12:05 P.M. with Medical Director #366 revealed when a resident was having upper respiratory infection symptoms his first step would be to test for COVID-19. Medical Director #366 indicated if a resident was having cough and nasal congestion he would test for COVID-19.
Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence Resident #31 received labs as ordered. COO #300 confirmed Resident #31 had not been COVID-19 tested prior to [DATE] despite persisting symptoms from [DATE].
Interview on [DATE] at 9:52 A.M. with Resident #31 revealed he was educated regarding the influenza and pneumococcal vaccines by the facility and he did consent to and received the vaccines, but he could not remember when he had them or when the education was. Resident #31 stated he knew he had to go to the hospital because he was sick, but he could not remember when it was, and he also could not remember any treatments or medications he was given prior to the hospitalization. He stated he had poor memory.
Staff present during this time period when Resident #31 experienced this change in condition were not available for interview as they either no longer worked at the facility or were agency staff. Current staff interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed Practical Nurses (LPNs) #304, #327, #369, and Nurse Aides #303, #305, #326, #337, #339, #352, #353, and #357 revealed they had no knowledge of Resident #31 or[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #11's medical record revealed an admission date of 01/25/17 with diagnoses including vitamin D deficiency, depression, repeated falls, dysphagia, dementia with mood disturbance and urinary and fecal incontinence.
Review of Resident #11's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11 was cognitively impaired and dependent on staff for eating, toileting, lower body dressing and required substantial/maximal staff assistance to roll left and right. Resident #11 was noted to have a Stage III pressure ulcer, not present on admission.
Review of Resident #11's physician's orders revealed an order dated 08/01/24 to admit to hospice for end-stage cerebral infarction; an order dated 11/23/24 for ProSource oral liquid (nutritional supplement) 30 milliliters (ml) by mouth twice daily; an order dated 11/24/24 for pressure reduction boots as tolerated, when in bed; an order dated 11/24/24 for air mattress; an order dated 11/26/24 for hospice to change wound dressings on Tuesday and Thursday only every night shift for wound; an order dated 11/26/24 for monitor erythema to right foot, notify physician and hospice for signs/symptoms of infection, edema or drainage and discontinue when resolved. No as-needed (PRN) wound care orders were available on Resident #11's physician's orders list.
Review of an interdisciplinary team post-wound investigation summary for Resident #11 dated 11/23/24 at 10:33 (morning or evening not specified) and authored by Registered Nurse (RN) #313, who was the facility's previous DON, revealed aide (not named) informed nurse (not named) of suspected new area to the right foot. When assessed, new open areas were identified to the right shin, right lateral foot, and right pinky toe. The right foot peri-wound skin was reddened and edematous. No drainage or foul odors were noted upon assessment. Contributing factors included hospice client, limited physical activity, risk for impaired skin integrity and non-compliance with hygiene and refusals of care. Wound management completed by wound nurse practitioner, orders obtained and in place for daily treatment of wounds.
Review of a weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had a facility-acquired venous ulcer to his right lateral foot measuring 3.0 centimeters (cm) length by 2.5 cm width by 0.0 cm depth with a scab noted. The assessment indicated it was the first observation of the wound, and no odor or drainage was present. Prophylactic antibiotics (Augmentin) initiated for suspected cellulitis. Cleanse the area with normal saline, pat dry. Apply calcium alginate to the wound bed. Cover with an abdominal (ABD) pad and Kerlix gauze daily and as needed.
Review of the next available weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had a facility-acquired pressure ulcer to right lateral foot as of 12/18/24 that was originally a Stage III pressure ulcer and remained at that stage. The wound was unchanged, had a dry scab area and had no drainage or odor. The area measured 0 cm by 0 cm by 0 cm. Comments at the bottom indicated the wound nurse did not measure the area, leave area open to air. Treatment changed this date to Skin Prep (forms a film to protect the skin by reducing friction) to the scabbed area once daily.
Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had an improving Stage III pressure area to right lateral foot. No wound measurements were included on this assessment.
Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had an improving Stage III pressure area to the right lateral foot. No drainage or odor was noted. The wound measured 3.2 cm by 1.0 cm by 0.0 cm. The current treatment plan was listed as Skin Prep with ABD and Kerlix gauze change daily and PRN.
Review of Resident #11's nurses' notes from November 2024 through March 2025 revealed no wound measurements.
Review of Resident #11's plan of care for skin/pressure areas dated 02/03/17 listed an intervention dated 11/03/19 for monitor/document/report to physician PRN changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length by width by depth) and stage.
Interview on 03/11/25 at 11:48 A.M. with the DON revealed the wound nurse practitioner saw Resident #11 weekly and shared Certified Nurse practitioner (CNP) #364 told her she does not measure wounds in the facility. The DON verified she had no further wound tracking for Resident #11 as the wound started in November 2024, which was before she started her employment with the facility three weeks ago. The DON confirmed she began tracking all in-house wounds two weeks ago and indicated Resident #11's Stage III pressure ulcer on his foot was a scab and was improving. The DON verified Resident #11 did not have a PRN order for wound care in case the dressing needed to be changed in between the scheduled times and verified he should have had such an order. The DON also verified hospice completed Resident #11's wound dressing Tuesdays and Thursdays on night shift as ordered by the physician.
Interview on 03/12/25 at 2:33 P.M. with CNP #364 revealed she came to the facility weekly and sometimes every other week. CNP #364 verified she did not put wound measurements in her assessments as it was the responsibility of the facility to measure the wounds. CNP #364 indicated Resident #11's Stage III pressure wound to the foot had been improving and was now a scab.
Review of the facility policy, Wound Care, dated 05/01/22, revealed all residents' skin conditions would be properly tracked and cared for. The nursing staff and attending physician will assess and document and individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a) full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments including support surfaces and all active diagnoses. The staff will examine the skin of a new admission for ulcerations or alterations in skin. The physician will authorize pertinent orders related to wound treatments, including would cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agent if indicated for type of skin alteration .during resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds. The physician will help the staff review and modify the care plan as appropriate.
Based on observation, record review, facility policy review, and interview, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #49, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel and bladder, received timely and necessary pressure ulcer prevent and treatment. Additionally, the facility failed to ensure accurate and comprehensive weekly skin assessments for Resident #11's in-house acquired pressure ulcer. This affected two residents (#49 and #11) of two residents reviewed for pressure ulcers. The facility census was 54.
Actual Harm occurred beginning on 01/31/25 when nursing staff failed to comprehensively assess, implement effective interventions and provide timely and necessary treatment to prevent an open area to Resident #49's coccyx/buttocks area from deteriorating to a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer.
Findings include:
Review of the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively impaired, had no behaviors, was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene, rolling and transfers. There were no pressure ulcers/sores documented, however, the assessment noted the resident was at risk for developing one.
Review of the Nursing admission Assessment with Care Plan dated 01/31/25 revealed Resident #49 was alert, was always incontinent of bowel and bladder, had skin tears to the right and left knees and was a smoker. There was no initial care plan for skin integrity or skin impairment for the resident.
Review of a nursing progress note for Resident #49 revealed on 01/31/25 at 3:00 P.M. the resident arrived at the facility with skin tears to his knees, maceration to his abdominal folds and an open area to the coccyx. The progress note did not include any additional information related to the area on the coccyx, including staging or a description of the ulcer. In addition, there was no evidence pressure ulcer prevention measures/interventions were implemented at this time.
Review of the head-to-toe assessments for Resident #49 revealed on 01/31/25 there were skin tears noted to his right and left knees.
On 02/01/25, Nurse Practitioner (NP) #363 assessed Resident #49 and documented the resident had skin issues on admission with treatments in place. There was no documentation of the actual pressure ulcers by NP #363 in the resident's nursing progress notes.
Review of the admission MDS 3.0 assessment dated [DATE] revealed the resident had no skin conditions, no pressure ulcers, no turning and repositioning program and no pressure reducing devices for the chair or bed.
The head-to-toe assessment dated [DATE] included there was a pressure ulcer to the coccyx. However, there was no description or stage of the ulcer.
Review of the physician's orders for Resident #49 revealed pressure relieving interventions and wound treatments were not initiated until 02/10/25. In addition, an order dated 02/10/25 revealed head-to-toe skin check to be completed every night shift on Monday, Wednesday and Thursday was ordered.
The head-to-toe assessment on 02/13/25 included there was left elbow bruising and a pressure ulcer to the coccyx. Again, there was no description or staging of the coccyx ulcer.
On 02/18/25 a note at the bottom of the head-to-toe assessment revealed previously documented pressure sore to left buttock with treatment recommendations in place, no new areas noted.
On 02/21/25 a note at the bottom of the head-to-toe assessment revealed impaired skin on left buttocks, previously mentioned. There was a note that included resident was non-compliant with turning and repositioning. However, no additional care plan or documentation to support the non-compliance as it pertained to the impaired skin integrity.
On 02/26/25 at 7:05 P.M., nursing staff documented they did not have time to do a skin assessment during the shift.
Review of a Weekly Wound Healing Record for Resident #49 dated 02/26/25 revealed the resident had a Stage III pressure ulcer to the right medial buttock that was acquired on 01/31/25 when the resident was admitted to the facility. The pressure ulcer measured 2.0 centimeters in length by 2.0 centimeters width with 0.2 centimeters depth with granulation tissue and a small amount of bloody drainage. There was odor present to the wound. Treatment was initiated with Triad Paste and the wound progress was noted to be unchanged.
On 02/26/25 a treatment order was obtained for Triad Hydrophilic Wound Dress External Paste, apply to buttock topically two times a day for wound.
Review of a Weekly Wound Healing Record for Resident #49 dated 03/05/25 revealed the Stage III pressure ulcer to the right medial buttock was improving. The ulcer measured 2.0 centimeters by 2.0 centimeters by 0.1 centimeters. There was no change in treatment.
On 03/07/25 pressure relieving interventions were ordered to float the heels, have a pressure reducing mattress, utilize a pressure relieving cushion to wheelchair and turning and repositioning every two hours every shift. The medication administration record and treatment administration record corresponded to these orders for Resident #49.
Review of the care plan for Resident #49 dated 03/07/25 revealed the resident had potential/actual impairment to skin integrity of the right medial buttock related to fragile skin. Interventions included to encourage good nutrition and hydration, observe and document the location of skin impairment, and weekly treatment documentation to include measuring of each area of the skin breakdown's width, length, depth, type of tissue exudate and any other notable changes or observations.
Interview on 03/12/25 at 2:33 P.M. with NP #364 (the wound nurse) revealed she was at the facility weekly or biweekly. She stated she did not measure Resident #49's wounds and stated it was the responsibility of the facility staff to keep the measurements and document on pressure ulcers. NP #364 revealed Resident #49 had a Stage III pressure ulcer to his right medial buttock.
Interview on 03/12/25 at 3:40 P.M. with the Director of Nursing (DON) verified Resident #49 had no pressure ulcers documented on his 01/31/25 head-to-toe assessment. She verified the only documentation that revealed an open area to his coccyx was on a nursing progress note on 01/31/25. The DON revealed on Resident #49's head-to-toe assessment on 02/10/25 the Stage III pressure ulcer to his coccyx was documented the first time without measurements. She stated she started at the facility on 02/17/25 and initially saw Resident #49's pressure ulcer on 02/26/25. She stated the coccyx Stage III pressure ulcer was more to the right medial buttock with measurements of 2.0 centimeters by 2.0 centimeters by 0.2 centimeters. The DON stated she was the first person to document Resident #49's Stage III pressure as the facility had not been measuring/assessing it prior.
Interview on 03/17/25 at 2:29 P.M. with NP #363 revealed she was not aware the facility was not measuring any resident wounds.
Interview on 03/18/25 at 10:09 A.M. with the DON verified Resident #49 did not have a wound care plan until 03/07/25 for potential interventions to his coccyx/right buttock pressure ulcer. She also verified Resident #49 did not have any wound documentation by NP #364 from 01/31/25 through 02/26/25.
Observation on 03/12/25 at 2:33 P.M. of wound care to Resident #49 with NP #364 and the DON revealed the resident had a Stage III pressure ulcer measuring 1.6 centimeters by 1.0 centimeters by 0.1 centimeters. NP #364 stated the pressure ulcer was more to the right buttock than the coccyx.
Review of the facility policy titled, Wound Care, dated 05/01/22 revealed it was the policy of the facility to ensure that all residents skin conditions were properly tracked and cared for. The nursing staff would assess and document the resident's significant risk factors for developing pressure ulcers as well as the nurse would document a full assessment including location, stage, length, width, depth and presence of exudates or necrotic tissue. During resident visits, the physician would evaluate and document the progress of wound healing. The physician would help the staff review and modify the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds developed despite existing interventions. During monitoring, the physician would also evaluate and document the progress of the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #18 and Resident #204 to prevent falls. The facility also failed to ensure cigarette butts were properly disposed of after smoking. This affected two residents (#18 and #204) of three residents reviewed for falls/accidents and 19 residents (Residents #1, #2, #3, #9, #11, #12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203) identified by the facility as residents who smoke. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair.
Review of the st risk for falls related to deconditioning, balance problems, incontinence, intermittent aggressive behaviors, impaired safety awareness and impulse control initiated on 06/11/18 and revised on 05/13/24 revealed interventions including anticipate and meet resident's needs as able, call light reminder sign in room, custom wheelchair to allow the resident to sit upright/safely related to balance deficits; give the resident a reacher to pick up items off the floor when she drops them; locked bedside table that will remain in the side of the resident's recliner; provide a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light and personal items within reach.
Review of the medical record revealed Resident #18 was last assessed for fall risk on 03/15/23 and was identified as at risk.
Review of a physician's orders dated 02/29/24 revealed an order for a hand reacher tool at bedside for a fall intervention.
Review of a physician's order dated 12/20/24 revealed an order for Dycem (non-slip self-adhesive strips) to the recliner chair. Resident #18 also had an order, dated 12/20/24 for non-skid fall strips to the floor in front of the recliner chair for safety intervention.
Review of an Orders Administration Note dated 01/03/25 timed 2:09 A.M. revealed Resident #18 was having anxiety/agitation and was administered as needed Lorazepam.
Review of an Orders Administration Note dated 01/03/25 timed 6:10 A.M. revealed Resident #18 was having anxiety and was administered as needed Lorazepam. However, record review revealed no evidence the resident's safety needs and/or fall risk were evaluated related to the two doses of anti-anxiety medication administered approximately four hours apart on 01/03/25.
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on the floor by a nurse aide, lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit her head and had no complaints of pain at this time.
Review of an incident report dated 01/03/25 at 7:35 A.M. revealed Resident #18 was reaching for something on the floor and fell backwards (unwitnessed). Resident #18 was educated on the importance of call before you fall. Resident #18 was noted to be wheelchair bound. Factors contributing to the fall were ambulating without assistance and gait imbalance. Resident #18's physician and power of Attorney (POA) were notified. There was no mention of the use or availability of the ordered reacher.
Review of a nurse practitioner (NP) progress note dated 01/03/25 revealed Resident #18 had a fall and was found laying on her back in room. Resident #18 was noted to be a poor historian due to cognitive and psychiatric impairments. Resident #18 told staff she stood from the recliner chair to pick something up and fell backwards. Resident #18 denied hitting her head and denied pain. Resident #18 was noted to be dependent on a wheelchair and staff to help push the wheelchair. Interventions for falls included hand reacher tool at bedside, specialized wheelchair, Dycem to recliner chair, and non-skid strips to the floor in front of the recliner.
Review of a Medicare Skilled Charting assessment dated [DATE] at 6:55 P.M. revealed Resident #18 was alert and oriented to person and situation. Resident #18 had unsteady gait, impaired balance, weakness, and decreased sensation. Resident #18 required assistance for bed mobility and transfers.
Review of a fall follow-up assessment dated [DATE] at 2:09 A.M. revealed Resident #18 had a fall on 01/03/25. An intervention was noted to keep Resident #18 in the dining room during the day.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of the plan of care revised 02/14/25 revealed Resident #18 was at risk for falls. Interventions included keep adaptive reacher at bed side, anticipate and meet needs as able, call light reminder sign in room, custom wheelchair, Dycem to recliner and in front of recliner, encourage non-skid footwear, encourage resident to ask for assistance with toileting and ambulation, keep call light accessible, monitor for adverse effects of medications, and provide safe environment. Resident #18 had activities of daily living (ADL) self-care performance deficit related to severe cognitive impairment. Interventions included extensive assistance of two staff for transfers with mechanical stand up lift as Resident #18 does not stand without lift. Resident #18 does not walk, and uses tilt and space wheelchair.
Further review of Resident #18's medical record revealed no evidence of routine and appropriate fall follow up or monitoring, no evidence of implemented interventions, and no evidence of review by an interdisciplinary team.
During an interview on 03/18/25 at 2:04 P.M. Resident #18's fall was reviewed with the Administrator and Chief Operating Officer (COO) #300. COO #300 indicated she was unable to remember any details of Resident #18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional details related to Resident #18's fall including interventions, investigation, interdisciplinary review, or root cause analysis.
Review of facility policy Falls and Incident Investigation dated 07/22/22 revealed resident falls would be documented and investigated to determine root cause and have plan developed to prevent reoccurrence. The nurse would assess the resident and provide as needed first aide, record vital signs, initiate head injury precautions, notify supervisor, initiate incident reporting and document on incident in progress note, and notify physician and family. The DON would reassess the resident for any additional monitoring or changes to plan of care, ensure investigation occurs promptly, obtain statements from staff, and document and ensure implementation of corrective interventions. The resident would be followed on the 24-hour report and progress notes for 72 hours post-accident. The interdisciplinary team would review falls.
2. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of the fall risk assessment dated [DATE] revealed Resident #204 was at high risk for falls.
Review of the nursing admission assessment dated [DATE] for Resident #204 revealed he had a history of falls. His fall care plan stated he was at risk for falls and had a history of falls. Interventions included to ensure the call light was in reach and bed was in lowest position.
Review of the nursing progress notes for Resident #204 dated from 03/03/25 through 03/11/25 revealed nursing staff had not documented him having any falls while at the facility.
Observation on 03/10/25 at 2:26 P.M. of Resident #204 revealed he was on the mat on the floor beside his bed. He was repeatedly yelling for someone to help him. He was noted earlier in the shift on the mat on the floor as well. At 2:39 P.M., Licensed Practical Nurse (LPN) #362 verified Resident #204 was on the floor. With the assistance of two nurse aides, LPN #362 assisted Resident #204 back in bed. She did not perform an assessment on the resident prior to placing him back in bed.
Observation on 03/11/25 at 7:12 A.M. revealed Resident #204 in bed, however, the mat was not beside the bed on the floor. At 7:52 A.M., Resident #204 was yelling out for staff and leaning towards the side of the bed towards the floor. There was no mat on the floor next to the bed. At 7:59 A.M., LPN #304 verified Resident #204 did not have a mat next to his bed as care planned for his behaviors. She stated when Resident #204 would place himself on the mat on the floor, the nursing staff would not count it as a fall. She stated they were not performing assessments on him or implementing new interventions to assist in preventing future falls as they believed it was a behavior.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified there were no fall investigations for Resident #204's falls out of bed. She also verified there were no interventions put into place to assist in preventing future falls of Resident #204.
Review of the facility policy titled, Falls and Incident Investigation, dated 07/22/22, revealed all resident occurrences, whether falls or incidents, would be documented and investigated to ascertain root cause and have a plan developed to prevent reoccurrence. A fall was defined as any unexpected event that happens to a resident which results in any unintentional change in elevation. Following a fall, the nurse was to check the resident and provide first aid if needed, record vital signs, update the nursing supervisor, initiate an accident incident report, document the findings in a progress note and notify the physician and family.
3. Review of the facility document titled, Smoking List, undated, revealed 19 Residents #1, #2, #3, #9, #11, #12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203 who resided in the facility and smoked.
Observation on 03/10/25 at 11:05 A.M. of smoking in the courtyard revealed nine (Resident #2, #3, #11, #16, #23, #27, #43, #48 and #203) residents who smoked were in the designated smoking area. Activities Director #330 was present and provided the smoking materials to the residents. The observation revealed cigarette butts were in the mulch and rocks next to the building, in plastic flower pots, wooden flower beds, on the sidewalks and in the grass areas. Resident #27 was observed to take her cigarette and put it out in the wooden flower bed that she was sitting next to.
Interview on 03/10/25 at 11:05 A.M. with Activities Director #330 verified the cigarette butts on the ground, in the mulch, in the flower pots and in the wooden flower planters. She stated residents would throw their cigarettes on the ground and in the pots. She stated she attempted to clean the area everyday but residents would still continue to dispose of their cigarette butts improperly.
Review of the facility policy titled, Smoking, dated 05/01/22, revealed the facility would establish and maintain safe smoking practices, allowing resident's who wished to smoke while also doing it in a safe manner.

Based on record review, observation and interview, the facility failed to ensure an anchoring device for Resident #204's indwelling urinary catheter was implemented to prevent catheter-related complications. This affected one resident (Resident #204) of one resident reviewed for indwelling urinary catheters. The facility census was 54.
Findings include:
Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of Resident #204's physician's orders for March 2025 revealed there were no orders for an anchoring device for his urinary catheter.
Review of Resident #204's baseline care plan dated 03/03/25 revealed he had a catheter care plan. Interventions included providing a leg strap for the catheter (for anchoring of the catheter).
Observation on 03/10/25 at 2:26 P.M. revealed Resident #204 was on a mat on the floor beside his bed. His urinary catheter tubing was stretched tight and the drainage bag was under the mat. At 2:39 P.M. Resident #204 was still on the mat on the floor and his catheter drainage bag showed reddish-yellow urine in the drainage bag. Licensed Practical Nurse (LPN) #362 came to Resident #204's room and verified there was no anchoring device to assist in securing the urinary catheter tubing to prevent pain, potential injury or other catheter-related complications from the amount of tension on the catheter tubing due to a lack of an anchoring leg strap.
Interview on 03/12/25 at 10:15 A.M. with the Director of Nursing (DON) revealed and verified the facility did not have a urinary catheter policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility contract, review of the facility policy and interview, the facility failed to complete pre and post dialysis assessments as required and to collaborate care with the outside dialysis center. Also, the facility failed to ensure there was a valid contract between the facility and the outside dialysis center to ensure coordination of all care and services pertaining to dialysis treatment for Resident #25. This affected one resident (#25) of one resident reviewed for dialysis. The facility identified no other residents as receiving dialysis. The facility census was 54.
Findings include:
1. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety, depression and dependence on renal dialysis.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was cognitively impaired, independent with eating and required substantial/maximal assistance with toileting. The assessment indicated Resident #25 currently received hemodialysis.
Review of Resident #25's plan of care dated 09/21/24 revealed Resident #25 needed hemodialysis due to renal failure and chronic kidney disease. Resident #25 went to dialysis Mondays, Wednesdays and Fridays and had listed interventions including auscultate/palpate my shunt for a thrill and bruit each shift, monitor my vital signs as ordered and notify my doctor of any significant abnormalities and observe and report if I have any signs/ symptoms of renal insufficiency, such as changes in my level of consciousness, changes in my skin turgor, mouth or changes in my heart and lung sounds.
Review of Resident #25's physician's orders revealed no order specifically relating to Resident #25 receiving dialysis. In his electronic medical record (EMR) a special instruction across the top of the page read: Dialysis every Monday, Wednesday and Friday at 10:00 A.M. at Davita. A phone number was listed for Provide-A-Ride with pick up time listed as 8:45 A.M. There was an order dated 09/17/24 for checking dialysis catheter location: right chest port; an order dated 09/17/24 for post-dialysis dry weight every day shift every Monday, Wednesday and Friday for dialysis; an order dated 11/17/24 for vital signs before dialysis; and an order dated 11/17/24 for vital signs and blood glucose after dialysis.
Further review of the medical record for Resident #25 revealed no evidence the facility had pre and post dialysis assessment tools being completed to contain pertinent assessment information for the resident on the tool for communication of assessment findings with the dialysis center.
Interview on 03/12/25 at 2:26 P.M. with Licensed Practical Nurse (LPN) #362 revealed Resident #25 was supposed to return to the facility with a paper from the dialysis center but never did. LPN #362 indicated the facility did not have a dialysis binder with the dialysis communication sheets documenting pre and post dialysis assessments.
Interview on 03/12/25 at 4:30 P.M. with LPN #304 revealed Resident #25 did not come back to the facility from dialysis with any forms or assessments. While the facility did vitals and weights before and after dialysis, the facility did not have a dialysis form or binder with communication sheets.
Interview on 03/13/25 at 8:20 A.M. with LPN #325 revealed there was a dialysis form that was supposed to go with Resident #25 but the facility did not get the forms back. LPN #325 confirmed she never called the dialysis center to try to obtain the completed forms.
Interview on 03/13/25 at 8:32 A.M. with the Director of Nursing (DON) verified the facility did not have any dialysis communication forms for Resident #25 and confirmed there was not an assessment piece in use at this time for dialysis residents. The DON stated there should be some kind of assessment the nurse did prior to the resident leaving to include skin, weights and vitals, the assessment would go with the resident and then the information would come back from the dialysis center to the facility with the resident.
Review of the facility policy, Dialysis, reviewed 05/01/22 revealed risk factors related to potential for bleeding, alteration in fluid volume, potential for infection, alteration in fluid volume, potential for infection, psychosocial needs and risk for adverse medication effects should be identified, assessed and interventions to manage addressed in the individualized care plan. An individual care plan should be developed and followed in coordination with comprehensive assessment. A nutrition and hydration assessment should be completed and incorporated into the care plan. Arrangements should be made prior to admission for acquisition and storage of supplies, location and type of dialysis and accommodation. The policy did not identify how the facility would communicate pre and post dialysis assessment information with the dialysis center.
2. Review of the facility's dialysis transfer agreement between the facility and [NAME] Dialysis, Limited Liability Corporation (LLC) (affiliate of DaVita Incorporated) revealed it was signed by the Administrator and by the Regional Operations Director of [NAME] Dialysis, but no dates were noted on the contract or by either signature.
In an interview on 03/12/25 at 3:57 P.M. the Administrator was asked regarding the date of the facility's dialysis contract. The Administrator verified the contract was effective on this date, 03/12/25, and she did not put a date as the dialysis center representative did not put a date. The Administrator confirmed a previous contract with the dialysis center from prior to 03/12/25 was unavailable for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the personnel files, review of the facility assessment and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) #305 and #329 received annual performance reviews. This affected two of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility.
Findings include:
1. Review of the personnel file for CNA #305 revealed there were no annual performance evaluations in her file or 12 hours of in-services as required.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not have an annual performance evaluation in her personnel file. She stated the facility was unable to provide evidence of CNA #305 receiving 12 hours of in-services as required annually.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment also stated training topics for staff would include communication, resident rights, abuse, infection control, culture change and dementia management.
2. Review of the personnel file for CNA #329 revealed there were no annual performance evaluations in her file or 12 hours of in-services as required.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not have an annual performance evaluation in her personnel file. She stated the facility was unable to provide evidence of CNA #329 receiving 12 hours of in-services as required annually.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment also stated training topics for staff would include communication, resident rights, abuse, infection control, culture change and dementia management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure staff were providing necessary behavioral health care for residents to attain and maintain their highest physical, mental and psychosocial well-being. This affected one (Resident #204) of six residents reviewed for behaviors. The facility census was 54.
Findings include:
Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of the nursing admission assessment dated [DATE] for Resident #204 revealed he was alert to person only and had agitation.
Review of the care plan dated 03/03/25 for Resident #204 revealed he was dependent on staff for meeting his emotional, intellectual, physical and social needs. Interventions included for staff to invite him to scheduled activities, encourage him to participate and introduce him to others with similar background and interests. He also had a care plan dated 03/03/25 due to behavioral problems related to at times rolling himself off of the bed and onto a mattress on the floor and yelling out. Interventions included for staff to anticipate and meet his needs, assist him with more appropriate methods of coping and interacting, observe his behaviors, attempt to determine the underlying causes and provide a program of activities that met his interest.
Observation on 03/10/25 at 2:26 P.M. of Resident #204 revealed he was on the mat on the floor beside his bed. He was repeatedly yelling for someone to help him. He was noted earlier in the shift on the mat on the floor as well. At 2:27 P.M. Licensed Practical Nurse (LPN) #362 spoke to the resident who stated he wanted vegetable soup. LPN #362 told him they did not have vegetable soup. He then stated he would take any soup. LPN #362 stated to Resident #204 he would have to wait until dinner. At 2:39 P.M. LPN #362 verified Resident #204 was still on the floor and with the assistance of two nurse aides, the assisted Resident #204 back into bed. They did not offer Resident #204 any diversional activities or address his behaviors.
Observation on 03/11/25 at 7:52 A.M. of Resident #204 revealed he was yelling out for staff and leaning towards the side of the bed towards the floor. There was no mat on the floor next to the bed. At 7:59 A.M., LPN #304 verified Resident #204 did not have a mat next to his bed as care planned for his behaviors. She stated when Resident #204 would place himself on the mat on the floor, the nursing staff would not count it as a fall. She stated they were not performing assessments on him or implementing new interventions to assist in preventing future falls as they believed it was a behavior.
Observation on 03/11/25 at 12:15 P.M. revealed Resident #204 was still in bed and yelling out. Staff were not providing him with activities or diversions.
Interview on 03/12/25 at 10:40 A.M. with Certified Nursing Assistant (CNA) #305 verified staff were not getting Resident #204 out of bed. She stated due to safety concerns with kicking his legs out of the wheelchair, the staff were leaving him in bed. She was unable to state what activities or interventions they were providing to him for behaviors.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified staff should have been providing diversional activities for Resident #204 instead of leaving him in bed.
Interview on 03/19/25 at 2:21 P.M. with the Administrator revealed staff were in-serviced on 02/20/25 related to behaviors from the facility's in-house drug/alcohol program. She was able to provide the topics of the in-service which were care of residents with drug and alcohol withdrawal as well as behaviors of verbal aggression, demanding behaviors, drug seeking, seeking a replacement for the drug and isolation. She was unable to provide other education in the previous 12 months for behaviors.
The facility was unable to provide a behavioral healthcare policy and procedure.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and administered as ordered. This affected one (Resident #23) of 28 residents reviewed for medication administration. The facility census was 54.
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 06/27/24 with diagnoses including asthma, anxiety and chronic pain.
Review of the physician's orders for Resident #23 revealed she had an order for Fluticasone Propionate Nasal 50 micrograms (mcg) one time a day for allergy symptoms dated 09/18/24, Hydroxyzine HCl 10 milligrams (mg) three times a day for anxiety dated 12/31/24, Cran-B-OTC Oral Liquid 30 milliliters (mL) one time a day for supplement dated 01/21/25 and Tizanidine 2 milligrams (mg) three times a day for pain dated 02/20/25.
Review of the Medication Administration Record (MAR) for Resident #23 for January 2025 revealed Cran-B-OTC was not administered on 01/22/25 and 01/28/25 at 9:00 A.M. Hydroxyzine HCl 10 mg was not administered on 01/02/25 at 10:00 P.M. and at 6:00 A.M. on 01/03/25, 01/04/25, 01/08/25, 01/12/25, 01/17/25 and 01/22/25.
Review of the MAR for Resident #23 for February 2025 revealed Cran-B-OTC was not administered on 02/02/25 at 9:00 A.M. Fluticasone was not administered on 02/24/25 and 02/25/25 at 9:00 A.M. as it was unavailable and on order from the pharmacy.
Review of the MAR for Resident #23 for March 2025 revealed Hydroxyzine and Tizanidine were not administered on 03/06/25 at 6:00 A.M.
Interview on 03/19/25 at 11:45 A.M. with the Director of Nursing (DON) verified Resident #23's medications were not given as ordered as noted above.
Review of the facility policy titled, Medication Administration, dated 05/01/22, revealed medications were to be administered as prescribed.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.

Based on record review, review of the facility's self-reported incidents (SRI) #250112 and #250126, staff interview, and review of the facility's abuse policy, the facility failed to submit their SRI investigation findings within five working days. This affected three residents (#5, #21, and #37) of five reviewed for abuse. The facility census was 44.
Findings include:
Review of the medical record for Resident #5 revealed an admission date of 06/27/24 with diagnoses of fibromyalgia, post traumatic stress disorder, anxiety disorder, and major depressive disorder.
Review of the medical record for Resident #21 revealed an admission date of 01/05/24 with diagnoses of dementia with agitation, depression, moderate intellectual disability, and anxiety disorder.
Review of the medical record for Resident #37 revealed an admission date of 10/30/20 and readmission date of 03/06/24. Diagnoses included vascular dementia with psychotic disturbance, major depressive disorder, anxiety disorder, alcohol abuse in remission, cocaine use in remission, and other psychoactive substance use in remission.
Review of the facility's SRI #250112 revealed there was a resident-to-resident incident on 07/26/24 in which Resident #37 scratched Resident #21. The discovery date was 07/26/24 and the investigation completion date was 08/06/24, which was seven business days after the date of discovery.
Review of the facility's SRI #250126 revealed there was a resident-to-resident incident on 07/27/24 in which Resident #37 struck Resident #21 with her hand and then hit Residents #21 and #5 with a walker. The discovery date was 07/27/24 and the investigation completion date was 08/06/24, which was six business days after the date of discovery.
Review of the facility's policy titled Abuse Prevention, dated 08/20/21, revealed the investigation of allegations of abuse would be completed within five working days and the results of the investigation would be reported to the Department of Health no later than five working days after the discovery of the incident.
On 08/30/24 at 12:28 P.M., an interview with the Administrator verified the investigation results for SRIs #250112 and #250126 were not submitted within five working days of the date of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of camera footage, interview, record review and review of facility policy the facility failed to ensure Resident #21 was treated with dignity and respect. This affected one resident (Resident #21) out of three residents reviewed for dignity. The facility census was 40.
Findings include:
Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia.
Review of Resident #21's care plan initiated 06/11/18 included Resident #21 had bowel and bladder incontinence, was fixated on bladder urge, and was followed by urology. Resident #21 had a history of neurogenic bladder and took diuretics as needed. Resident #21 sometimes voiced the need for toileting after she was incontinent. Staff placed Resident #21 on toilet dated 01/13/23 with some spontaneous continent episodes noted. Resident #21, dated 03/15/23, was status post left nephrectomy. Interventions included to monitor for incontinence on rounds and as needed. Wash, rinse and dry perineum; change clothing as needed after incontinence episodes: staff might place Resident #21 on the toilet on routine rounds using a stand-up lift, Resident #21 was experiencing occasional spontaneous continent episodes when placed on the toilet.
Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Resident #21 was dependent on staff for toileting.
Observation of Resident #21's camera footage dated 05/26/24 at 5:33 A.M. revealed Resident #21 was lying on her bed naked, and did not have clothing, bed sheets, or blankets covering her. Resident #21 was wearing only black socks on both her feet. Resident #21's mattress did not have the fitted sheet covering the edges of the mattress and the bare mattress could be seen. State Tested Nursing Assistant (STNA) #243 walked to the bed with a towel in her hands, placed the towel on the bare mattress, picked up the towel, and used it to wipe Resident #21's skin in the area of her perineum, then placed the soiled towel back on the bare mattress. STNA #243 turned Resident #21 on her right side, tucked the fitted sheet underneath her, picked up the towel off of the bare mattress, and wiped Resident #21's left hip and buttock with the towel. After wiping Resident #21's hip and buttocks STNA #243 placed the soiled towel back on the bare mattress. STNA #243 turned Resident #21 on her left side, pulled the fitted sheet from under her, did not change her gloves, and with her soiled gloved left hand picked up Resident #21's stuffed animal off the bed and moved it towards the bottom of the bed.
Observation of Resident #21's camera footage dated 05/26/24 at 5:35 A.M. revealed STNA #243 with disposable gloves on her hands picked up Resident #21's stuffed animals, pillows and a plaid blanket off the bed and placed them on a chair. STNA #243 picked up the soiled sheets and linens off of Resident #21's bed and threw them on the floor, but left the towel she used to wipe Resident #21's perineum and buttocks on the bare mattress. Observation revealed Resident #21 was lying on a bare mattress with no clothes on and STNA #243 picked up the soiled towel and wiped Resident #21's perineal area with the towel before throwing it on top of the other sheets and linens she had previously thrown on the floor.
Observation of Resident #21's camera footage dated 05/26/24 at 5:37 A.M. revealed Resident #21 was lying naked on the bare mattress. STNA #243 walked to the side of Resident #21's bed carrying a towel. STNA #243 had Resident #21 roll onto her right side and wiped her buttocks and upper thighs with the towel and threw the soiled towel on the pile of soiled linens on the floor when she was finished and removed her gloves. While Resident #21 was naked and lying on the bare mattress STNA #243 had Resident #21 roll back onto her back, raised the head of the bed to about 60 degrees, Resident #21's arms were observed crossed and covering her breasts and the rest of her body was uncovered and exposed.
Observation of Resident #21's camera footage dated 05/26/24 at 5:40 A.M. revealed Resident #21 was sitting on the side of the bed, naked, and the mattress was bare and did not have any sheets, or linens on it. STNA #243 was observed assisting Resident #21 to put her shirt on, and once the shirt was on STNA #243 pulled the shirt over Resident #21's breasts, but left her abdomen exposed. STNA #243 then assisted Resident #21 to put her pants on, and once the pants were on STNA #243 pulled Resident #21's pants up to a little above her knees, leaving her perineum exposed. STNA #243 told Resident #21 to lay back, and Resident #21 laid back on the bed from the sitting position until her head was resting against the wall, her head was tilted to the right in an awkward manner, and her legs were dangling off the side of the bed. Resident #21's bare abdomen and perineum could be seen while she was lying back. STNA #243 picked up the soiled sheets and linens off the floor, left Resident #21 in the laid back position, legs dangling off the side of the bed, her abdomen and perineum exposed and left the room. It did not appear STNA #243 closed the door to Resident #21's room when she left the room, but it was unable to be determined for sure if the door was open or closed from the camera footage.
Observation of camera footage dated 05/26/24 at 5:43 A.M. through 5:45 A.M. revealed Resident #21 was lying back on the bare mattress with her abdomen and perineum exposed, her head resting against the wall at an awkward angle and her legs dangling off the edge of the bed. Resident #21's call light was observed laying on the floor and not in Resident #21's reach.
Observation of camer a footage on 05/26/24 at 5:48 A.M. revealed Resident #21 was lying back on the bare mattress with her abdomen and perineum exposed, her head resting against the wall at an awkward angle and her legs dangling off the edge of the bed. Resident #21's call light was observed laying on the floor and not in Resident #21's reach. STNA #243 returned to Resident #21's room with a second unidentified STNA, did not appear to close the door to the room, the two STNA's assisted Resident #21 off the bare mattress to use the sit-to-stand mechanical lift and was helped into the bathroom.
Review of Self-Reported Incident (SRI) number 248114 dated 05/30/24 and the allegation type was physical abuse and neglect. On 05/30/24 at approximately 9:00 A.M. the Administrator was notified of the incident via email sent by Resident #21's sister who was also her Guardian. Interview with Resident #21's Responsible Party (Guardian) revealed concerns with the amount of time it took STNA #243 to obtain a second person to operate the standing lift to assist Resident #21 with toileting. Resident #21's Responsible Party (Guardian) expressed concerns with Resident #21's positioning while waiting on STNA #243 to return. Resident #21's Responsible Party stated Resident #21 did not express signs of harm or distress. STNA #255 was interviewed as a witness because she provided assistance to STNA #243 on 05/26/24 when Resident #21 was assisted to use the sit-to-stand mechanical lift for transportation into the bathroom. STNA #255 confirmed she observed how Resident #21 was left in the room, but Resident #21 did not express signs of distress at the time. Interview on 05/30/24 with STNA #243 revealed she was caring for Resident #21 on the morning of 05/26/24, she was changing her clothing and left the room to get another aide to assist. STNA #243 stated it took longer than usual to find another STNA. STNA #243 stated the bedding was not on the bed when she was performing care because the bedding was soiled. STNA #243 stated she was not fully aware how she left Resident #21 and how long it took her to find another STNA to assist her.
Review of a Witness Statement dated 05/30/24 revealed on 05/26/24 STNA #243 was caring for Resident #21, and I was in the process of changing her clothes to get another aide. In the process of that STNA #243 changed Resident #21's bed because of soil.
Review of STNA #243's Disciplinary Action Form dated 05/30/24 for an incident on 05/26/24 included STNA #243 was given a second written warning for customer service and violation of company policy (peri care). A previous warning was given on 04/25/23 for unacceptable work performance related to operating a lift without assistance. STNA #243 was suspended on 05/30/24 for an allegation of neglect on 05/27/24 pending investigation.
Interview on 07/01/24 at 4:21 P.M. of Family Member (FM) #262 revealed on 05/29/24 she reviewed Resident #21's camera footage dated 05/26/24 around 5:30 A.M. FM #262 stated Resident #21 was soiled, and STNA #243 rolled Resident #21 over, removed her sheets, then rolled her onto her back onto the soiled mattress which did not have any bed linens on it. FM #262 stated then STNA #243 sat Resident #21 on the edge of the bed while she was naked, assisted to put her shirt on her, but did not pull it down over her breasts, and assisted Resident #21 with her pants but only pulled the pants up to her thighs. STNA #243 told Resident #21 to lay back, Resident #21 laid back, but her head and neck were at an awkward angle against the wall. STNA #243 walked out of the room leaving Resident #21's breasts and vaginal area exposed, with the door open. STNA #243 was gone for about six or seven minutes and returned to the room with a sit-to-stand mechanical lift and a second aide to assist her. FM #262 stated it was very upsetting for her to view the camera footage and see the way Resident #21 was treated.
Interview on 07/02/24 at 9:03 A.M. of Ombudsman #263 revealed Resident #21 was left unattended and unclothed while she was in bed. Resident #21 was told to lay back, she did so and the aide left her half in the bed when she left the room. The facility initiated an SRI regarding the situation.
Interview on 07/02/24 at 4:55 P.M. of the Administrator revealed she had concerns on 05/26/24 with STNA #243 and how resident care and peri-care was completed. The Administrator stated she was given camera footage for 05/26/24 from Family Member (FM) #262 who was also Resident #21's Guardian, and the footage revealed STNA #243 came to Resident #21's room, the bed was not made, and Resident #21 was lying across the bed half-dressed. The Administrator stated STNA #243 left Resident #21 in an odd position and went to find help with the stand-lift. The Administrator indicated it took about six minutes for STNA #243 to find another aide and come back to Resident #21's room, and this happened on 05/26/24 at around 5:40 A.M. The Administrator stated she opened a self-reported incident under physical abuse and neglect, and STNA #243 was suspended pending an investigation. The Administrator indicated STNA #243 said she was in the process of changing Resident #21, the bed needed changed because it was soiled, STNA #243 took the bedding off, needed help to put Resident #21 on the lift, and it took longer than expected to return to Resident #21's room. The Administrator stated STNA #243 was educated on proper peri-care, and the best policy was to have everything you need for the care including supplies and a second aide when you enter the room to provide the care. The Administrator confirmed Resident #21 was left half-naked on her bed when STNA #243 left the room to find a second staff member to assist with the sit-to-stand mechanical lift. The Administrator stated STNA #243 should have stayed with Resident #21, activated her call light, and waited for someone to answer the call light and have them assist with the sit-to-stand. The Administrator confirmed Resident #21's shirt was kind of lifted up, and her pants were half-way up. The Administrator stated STNA #243 said she closed Resident #21's door to her room, but it could not be determined from the video. The Administrator stated she was not sure if she still had the video, but she would check. The Administrator stated STNA #243 made the wrong decision, did not follow the peri-care policy, but she did not think it was neglect. The Administrator indicated the video was kind of alarming, Resident #21 did not seem like she was in distress, but she should have been covered and made more comfortable. STNA #243 still worked at the facility.
Review of the facility policy titled Resident Rights dated 05/01/22 revealed the facility would make every effort to assist each resident in exercising his or her rights to assure the resident was always treated with kindness, respect and dignity.
This deficiency represents non-compliance investigated under Complaint Number OH00154599.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure a thorough investigation of Resident #21's Injury of Unknown Origin on her bilateral arms. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40.
Findings include:
Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia.
Review of Resident #21's care plan dated 10/14/19 included Resident #21 had an ADL (Activity of Daily Living) self-care performance deficit related to severe cognitive impairment secondary to dementia, physical limitations, chronic and debilitating health conditions. Resident #21 was nearly dependent for all ADL's. Resident #21 would be clean, dry, appropriately groomed and dressed daily through the review date. Interventions included transfers required extensive assistance of two staff; Resident #21 required mechanical stand-up lift for transfers; Resident #21 did not stand without lift and did not walk; for toileting Resident #21 required two staff and stand-up lift for transfers on and off the toilet.
Review of Resident #21's care plan did not reveal a care plan for a DVT (deep vein thrombosis) or anticoagulant medication or interventions related to anticoagulant medication.
Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Resident #21 was dependent on staff for toileting.
Review of Resident #21's Treatment Administration Record (TAR) dated 06/23/24 revealed weekly skin check by licensed nurse every day shift every Sunday was documented it was completed.
Review of Resident #21's assessments and progress notes from 06/16/24 through 06/30/24 did not reveal a Weekly Head-To-Toe Assessment was completed. Further review did not reveal documentation Resident #21 had bruises on her arms.
Review of Resident #21's camera footage dated 06/28/24 from 9:36 P.M. through 9:39 P.M. revealed STNA #238 pushed Resident #21 into her room in what appeared to be a shower chair. STNA #238 assisted Resident #21 out of the shower chair and onto a sit-to-stand mechanical lift without another staff member helping him. STNA #238 transferred Resident #21 to her bed without assistance, helped her sit on the edge of the bed, remove the sling and help Resident #21 lay down in the bed. While STNA #238 was assisting Resident #21 two bruises on her right lower arm near the elbow could be seen, and one long bruise on her left lower arm could be seen.
Review of Resident #21's progress notes dated 06/30/24 at 11:48 A.M. included STNA #252 notified the nurse he noticed some bruising on Resident #21. Upon assessment four areas of bruising were discovered on Resident #21's arms. Resident #21 did not know where she got the bruises from, and did not complain of pain and vital signs were WNL (within normal limits). A complete head-to-toe assessment was completed and the bruises on Resident #21's arms were measured for reference and monitoring. Educated STNA's about the importance of being careful when toileting Resident #21 due to smaller bathroom. The DON, NP, Physician and POA were notified. Physician #269 was not concerned because Resident #21 took blood thinners.
Review of Resident #21's Weekly Head-To-Toe Assessment-Licensed Nurses dated 06/30/24 included Resident #21 had a bruise to her left upper arm and the length was measured at two inches, Resident #21 had a bruise on her left lower arm and measurements were length of four and a half inches and a width of one and a half inches. Resident #21 had a bruise to the right lower arm with a length of one inch, and another bruise on her right lower arm which measured a length of one and a half inches. Resident #21 had purple bruising on both arms. Resident #21 did not know the origin of the bruising. The DON, NP and POA were notified.
Review of the facility incident log dated 06/30/24 at 7:24 P.M. revealed Resident #21 had an injury of unknown cause.
Review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. included staff notified nurse of bruises to Resident #21's bilateral arms. Upon interviewing staff, Resident #21's arms had been witnessed bumping against door frame when on the mechanical lift and during transfer into the bathroom. Resident #21 recently moved to a new room with a smaller bathroom, narrow doorway. Resident #21 utilized a mechanical lift for transfers. Resident #21 was on anticoagulant therapy (Eliquis), was prone to bruising and Resident #21's physician was notified and there were no changes in orders. Staff was educated on monitoring arms and body positioning while using mechanical lifts to avoid injury. Resident #21's Guardian was contacted and arrangements were made to move Resident #21 back to her previous room due to bathroom was large enough to accomodate the mechanical lift and had enough doorway clearance to transfer Resident #21 safely.
Review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. revealed two Witness Statements. Witness Statement dated 06/30/24 of LPN #226 included an STNA notified her he noticed bruising on Resident #21's arms, she assessed Resident #21 and found four areas of bruising, two on each arm. The Director of Nursing and Assistant Director of Nursing were notified and risk management and a skin assessment were completed. Physician #269 was contacted, was not concerned due to Resident #21 received Eliquis. Resident #21's Guardian was notified and she mentioned she saw bruising the previous night while she observed Resident #21's bedtime routine, but had not mentioned it to anyone at the facility.
Further review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. revealed Witness Statement dated 06/30/24 of STNA #253 included every time STNA #253 helped operated the stand lift to assist Resident #21 into the bathroom it was a very tight squeeze trying to get Resident #21 in the bathroom without bumping her arms. Last time she worked with Resident #21 the aides had a hard time shielding her arms from the doorway.
Observation on 07/02/24 at 9:01 A.M. of State Tested Nursing Assistant (STNA) #252 and #254 revealed they used the sit-to-stand mechanical lift to transport Resident #21 from the bathroom to her bed. The sit-to-stand mechanical lift with Resident #21 fit through the doorway of the bathroom without hitting or rubbing Resident #21's arms on the door frame.
Interview on 07/02/24 at 4:30 P.M. of STNA #252 revealed on 06/30/24 he noticed Resident #21's bruises on her arms when she rolled her sleeves up. STNA #252 stated he immediately told Licensed Practical Nurse (LPN) #226 about the bruises. STNA #252 indicated he was not assigned to care for Resident #21 on 06/29/24 and 06/30/24 was the first time he saw the bruises.
Interview on 07/02/24 at 4:31 P.M. of STNA #254 revealed she did not work on 06/29/24 or 06/30/24, but on 06/28/24 she cared for Resident #21 and she did not have bruises on her arms.
Observation on 07/02/24 at 4:35 P.M. of Resident #21 with STNA #254 revealed Resident #21 had a large purple bruise on her lower left arm about six inches long and three inches wide. Resident #21 was unable to roll her sleeve up to show the bruise on her upper left arm. Further observation revealed two purple-green bruises on Resident #21's right forearm by the elbow and they were circular and one to two inches in diameter.
Interview on 07/02/24 at 4:41 P.M. of LPN #226 revealed STNA #252 saw bruises on Resident #21's arms after she pulled her sleeves up and he told her about them. LPN #226 stated she completed a full body assessment and lifted Resident #21's sleeves up all the way so she could see her entire arm. Resident #21 had two purple colored bruises on her right lower arm, one bruise on her left upper arm about two inches and circular, and a long purple bruise on her left lower arm. LPN #226 stated she did not work on 06/9/24 and we had no idea how the bruises happened. LPN #226 indicated she called Physician #269, he was not concerned because Resident #21 was taking Eliquis (anticoagulant) and was prone to bruises. LPN #226 stated she notified the DON and Family Member/Guardian #262 about the bruise and Family Member/Guardian #262 stated she saw Resident #21's bruises through the camera on Saturday night. LPN #226 stated the DON made sure she documented the bruises appropriately and there were no additional bruises. LPN #226 stated Resident #21 bruised easily, but the past bruises were small. LPN #226 indicated Resident #21 had a habit of banging her arm against the wall when she was done in the bathroom, but Resident #21 did not know how the bruises happened, and she did not complain of pain.
Interview on 07/02/24 at 4:55 P.M. of the Administrator revealed Resident #21 was on Eliquis (anticoagulant), Resident #21 was recently moved to the room she was currently in and the room had a smaller doorway to the bathroom, and was hard to get into using a sit-to-stand mechanical lift. The Administrator indicated Resident #21 was not conscious of her arms, and had a few night where she was banging on the wall. The Administrator stated they were trying to figure out how Resident #21 got the bruises, the aides said it was a tight squeeze going through the door to the bathroom, but did not say Resident #21's arms hit or rubbed the door frame. The Administrator stated Physician #269 was notified of Resident #21's bruises. The Administrator stated a facility incident report was opened, but a Self-Reported Incident (SRI) was not reported to the State Agency.
Interview on 07/03/24 at 8:55 A.M. of Family Member/Guardian #262 revealed Resident #21 was taken to the bathroom using a sit-to-stand mechanical lift. Family Member/Guardian #262 stated the room Resident #21 was now in was set up different than her other room, getting into the bathroom was real tight, and she heard banging while the aides transported Resident #21 to the bathroom using the sit-to-stand mechanical lift. Family Member/Guardian #262 stated she saw Resident #21's arm bruises on the camera footage before it was reported by the staff.
Interview on 07/03/24 at 9:49 A.M. of Chief Operating Officer (COO) #270 revealed the facility knew immediately what Resident #21's bruises were caused by and started education immediately. COO #270 stated the STNA's (State Tested Nursing Assistant's) saw Resident #21's arms hit the door frame, and that caused the bruises.
Interview on 07/03/24 at 11:59 A.M. of Licensed Practical Nurse (LPN) #228 revealed she worked on 06/29/24 and was assigned to the nursing unit Resident #21 resided on and she did not see bruises on Resident #21's arms, and no aides reported bruises on Resident #21's arms. LPN #228 stated when she administered Resident #21's medications she talked to her, asked how she was feeling, and she did not mention she had pain or bruises on her arms.
Interview on 07/03/24 at 1:17 P.M. of State Tested Nursing Assistant (STNA) #253 revealed she was assigned to care for Resident #21 on 06/29/24 and she did not notice bruises on her arms. STNA #253 indicated Resident #21 used a sit-to-stand lift for transportation into the bathroom, the aides had to block Resident #21's arms from hitting the door frame, and remind her to tuck her elbows in. STNA #253 stated she did not know how Resident #21 got the bruises on her arms, and she did not hurt her arms when STNA #253 transferred her using the sit-to-stand lift.
Interview on 07/08/24 at 6:50 A.M. of STNA #238 revealed he was very familiar with Resident #21. STNA #238 stated Resident #21 received her showers in the evening around 8:20 P.M., he gave her a shower last week and did not remember seeing bruises on her arms. STNA #238 stated the sit-to-stand mechanical lift was used to transfer Resident #21 to the toilet, her recliner and her bed. STNA #238 stated two people were needed to use the sit-to-stand mechanical lift, but confirmed sometimes he could not find anyone to help him and transferred Resident #21 by himself. STNA #238 stated Resident #21 did not hit her arms on the door frame, or anything else when he transported her to the bathroom.
Interview on 07/08/24 at 7:01 A.M. of STNA #242 revealed she did not remember seeing bruises on Resident #21's arms. STNA #242 stated Resident #21 banged the wall in the middle of the night when she wanted something, and sometimes threw her pillow across the room. STNA #242 stated if she saw bruises on Resident #21's arms she would have documented it and told the nurse. STNA #242 indicated Resident #21 used the sit-to-stand mechanical lift for transfers, there was always two staff members who assisted her with transfers, and Resident #21 tucked her arms in when she went through the doorway of the bathroom. STNA #242 stated the doorway to the bathroom was smaller than the room Resident #21 used to reside in, but Resident #21 could be transported through the doorway without brushing her arms, and the sit-to-stand could be turned in the bathroom without Resident #21 hitting her arms. STNA #242 stated it was not a squeeze, Resident #21 would be told to tuck her arms and she did. STNA #242 stated no aide would push her into the bathroom and let her arms hit the door frame, and if she did hit her arms on the door frame it would probably cause a skin tear because Resident #21 had fragile skin. STNA #242 stated she never saw Resident #21 hit her arms on the doorframe.
Interview on 07/08/24 at 7:18 A.M. of STNA #254 revealed Resident #21 could be transported through the bathroom door, there was plenty of room on either side of her arms, and the aides did not have to worry about Resident #21 hitting her arms on the door frame. STNA #254 stated she did not see Resident #21 hit her arms on the door frame.
Interview on 07/08/24 at 11:13 A.M. of STNA #243 revealed she did not assist Resident #21 with her care except when she was a second person when the sit-to-stand mechanical lift was used to transfer her. STNA #243 stated when she assisted with the lift she did not see Resident #21's arms hit the doorframe, or hear her call out because her arms hit the doorframe when she was transported to the bathroom.
Interview on 07/08/24 at 11:08 A.M. of the Director of Nursing (DON) confirmed Resident #21 did not have an anticoagulant care plan and Resident #21's Weekly Head-To-Toe Assessment due on 06/23/24 was not completed.
Review of the facility policy titled Abuse Prevention dated 08/20/21 included it was the facility policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator and to the State Department of Health. An injury was classified as an Injury of Unknown Source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident AND the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time.
This deficiency represents non-compliance investigated under Complaint Number OH00154653.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #18 and #21's incontinence care was completed timely, and followed appropriate standards of care. This affected two residents (Resident's #18 and #21) out of three residents reviewed for incontinence care. The facility census was 40.
Findings include:
1. Review of Resident #18's medical record revealed an admission date of 10/27/22 and diagnoses included unspecified dementia, unspecified severity with agitation, psychotic disorder with delusions due to known physiological condition, and Alzheimer's Disease.
Review of Resident #18's care plan dated 11/03/22 included Resident #18 had an ADL (activity of daily living) self-care performance deficit related to Alzheimer's Disease, dementia. Resident #18 would maintain his current level of function in ADL's through the review date of 06/03/24. Interventions included Resident #18 required assistance with incontinence care when incontinent. Resident #18 had episodes of bladder incontinence and was at risk for bowel incontinence related to cognitive impairment. Resident #18 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check on routine rounds and as needed for incontinence. Wash, rinse and dry perineum and change clothing as needed after incontinence episodes; monitor for nonverbal indicators of toileting needs (restlessness, pacing, pulling, tugging at perineal or buttock areas) and if toileting needs suspected attempt to take Resident #18 to the restroom.
Review of Resident #18's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had severe cognitive impairment. Resident #18 required partial to moderate assistance with toileting and was always incontinent of urine and bowel.
Observation on 07/03/24 at 8:38 A.M. of Resident #18 revealed he was walking in the hall of the secured memory care unit and was wearing only an incontinence brief. Further observation revealed the incontinence brief was extremely full and the weight of the brief from being soaked with urine was causing it to hang down toward the floor. State Tested Nursing Assistant (STNA) #239 walked quickly out of the common area and immediately assisted Resident #18 into the shower room. STNA #239 stated she arrived to work at 7:00 A.M., Resident #18 was sleeping, she did not wake him up for breakfast, and she had not checked him for incontinence. STNA #239 stated as soon as she arrived she had to start getting residents ready for the breakfast meal which usually arrived around 7:30 A.M. and she also had to assist with passing the meal trays. STNA #239 stated she just finished picking up the last breakfast tray after the residents finished eating when she saw Resident #18 walking in the hall without any clothes on except an incontinence brief. Observation revealed Resident #18's incontinence brief was so saturated with urine and a moderate amount of feces that urine was dripping out of the side of the brief onto the floor. STNA #239 removed Resident #18's incontinence brief, it was soaked and as she held the brief urine drained out of the brief onto the floor. STNA #239 had to soak the urine up with a towel. STNA #239 stated the night shift aides should have changed Resident #18's incontinence brief and there was no way they changed him before they left. STNA #239 stated Resident #18's incontinence brief would not have been in that condition if he was changed on last rounds around 5:00 A.M., and obviously his brief had been that way for awhile. STNA #239 indicated Resident #18 was always sweet and did not refuse care. Resident #18 did not have redness or open areas on his buttocks.
Review of the facility policy titled Resident ADL care dated 07/01/23 included the facility believed in supporting and encouraging the autonomy and independence of all residents in activities of daily living to the fullest extent possible given the limitations of their debility and disease. Residents would be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility. When autonomy and independence were no longer possible or feasible, the facility resident care staff would provide the necessary support in all ADL functioning. The procedure was to maintain infection control, maintain personal hygiene and grooming standards acceptable to communal living, maintain maximal functioning in ADL's and to promote the highest quality of life. Assistance and, or supervision would be provided as necessary with toileting and feeding.
2. Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia.
Review of Resident #21's care plan initiated 06/11/18 included Resident #21 had bowel and bladder incontinence, was fixated on bladder urge, and was followed by urology. Resident #21 had a history of neurogenic bladder and took diuretics as needed. Resident #21 sometimes voiced the need for toileting after she was incontinent. Staff placed Resident #21 on toilet dated 01/13/23 with some spontaneous continent episodes noted. Resident #21, dated 03/15/23, was status post left nephrectomy. Interventions included to monitor for incontinence on rounds and as needed. Wash, rinse and dry perineum; change clothing as needed after incontinence episodes: staff might place Resident #21 on the toilet on routine rounds using a stand-up lift, Resident #21 was experiencing occasional spontaneous continent episodes when placed on the toilet.
Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Resident #21 was dependent on staff for toileting.
Observation of Resident #21's camera footage dated 05/26/24 at 5:33 A.M. revealed Resident #21 was lying on her bed naked, and did not have clothing, bed sheets, or blankets covering her. Resident #21 was wearing only black socks on both her feet. Resident #21's mattress did not have the fitted sheet covering the edges of the mattress and the bare mattress could be seen. State Tested Nursing Assistant (STNA) #243 walked to the bed with a towel in her hands, placed the towel on the bare mattress, picked up the towel, and used it to wipe Resident #21's skin in the area of her perineum, then placed the soiled towel back on the bare mattress. STNA #243 turned Resident #21 on her right side, tucked the fitted sheet underneath her, picked up the towel off of the bare mattress, and wiped Resident #21's left hip and buttock with the towel. After wiping Resident #21's hip and buttocks STNA #243 placed the soiled towel back on the bare mattress. STNA #243 turned Resident #21 on her left side, pulled the fitted sheet from under her, did not change her gloves, and with her soiled gloved left hand picked up Resident #21's stuffed animal off the bed and moved it towards the bottom of the bed.
Observation of Resident #21's camera footage dated 05/26/24 at 5:35 A.M. revealed STNA #243 with disposable gloves on her hands picked up Resident #21's stuffed animals, pillows and a plaid blanket off the bed and placed them on a chair. STNA #243 picked up the soiled sheets and linens off of Resident #21's bed and threw them on the floor, but left the towel she used to wipe Resident #21's perineum and buttocks on the bare mattress. Observation revealed Resident #21 was lying on a bare mattress with no clothes on and STNA #243 picked up the soiled towel and wiped Resident #21's perineal area with the towel before throwing it on top of the other sheets and linens she had previously thrown on the floor.
Observation of Resident #21's camera footage dated 05/26/24 at 5:37 A.M. revealed Resident #21 was lying naked on the bare mattress. STNA #243 walked to the side of Resident #21's bed carrying a towel. STNA #243 had Resident #21 roll onto her right side and wiped her buttocks and upper thighs with the towel and threw the soiled towel on the pile of soiled linens on the floor when she was finished and removed her gloves. While Resident #21 was naked and lying on the bare mattress STNA #243 had Resident #21 roll back onto her back, raised the head of the bed to about 60 degrees, Resident #21's arms were observed crossed and covering her breasts and the rest of her body was uncovered and exposed.
Observation of Resident #21's camera footage dated 05/26/24 at 5:40 A.M. revealed Resident #21 was sitting on the side of the bed, naked, and the mattress was bare and did not have any sheets, or linens on it. STNA #243 was observed assisting Resident #21 to put her shirt on, and once the shirt was on STNA #243 pulled the shirt over Resident #21's breasts, but left her abdomen exposed. STNA #243 then assisted Resident #21 to put her pants on, and once the pants were on STNA #243 pulled Resident #21's pants up to a little above her knees, leaving her perineum exposed. STNA #243 told Resident #21 to lay back, and Resident #21 laid back on the bed from the sitting position until her head was resting against the wall, her head was tilted to the right in an awkward manner, and her legs were dangling off the side of the bed. Resident #21's bare abdomen and perineum could be seen while she was lying back. STNA #243 picked up the soiled sheets and linens off the floor, left Resident #21 in the laid back position, legs dangling off the side of the bed, her abdomen and perineum exposed and left the room. It did not appear STNA #243 closed the door to Resident #21's room when she left the room, but it was unable to be determined for sure if the door was open or closed from the camera footage.
Observation of camera footage dated 05/26/24 at 5:43 A.M. through 5:45 A.M. of Resident #21's camera footage revealed she was lying back on the bare mattress with her abdomen and perineum exposed, her head resting against the wall at an awkward angle and her legs dangling off the edge of the bed. Resident #21's call light was observed laying on the floor and not in Resident #21's reach.
Observation of camera footage dated 05/26/24 at 5:48 A.M. of Resident #21's camera footage revealed she was lying back on the bare mattress with her abdomen and perineum exposed, her head resting against the wall at an awkward angle and her legs dangling off the edge of the bed. Resident #21's call light was observed laying on the floor and not in Resident #21's reach. STNA #243 returned to Resident #21's room with a second unidentified STNA, did not appear to close the door to the room, the two STNA's assisted Resident #21 off the bare mattress to use the sit-to-stand mechanical lift and was helped into the bathroom.
Interview on 07/01/24 at 4:21 P.M. of Family Member (FM) #262 revealed on 05/26/24 around 5:30 A.M. she viewed Resident #21's camera footage. FM #262 stated Resident #21 was soiled (her incontinence brief was soiled), and STNA #243 rolled Resident #21 over, removed her sheets, then rolled her onto her back onto the soiled mattress which did not have any bed linens on it. FM #262 stated then STNA #243 sat Resident #21 on the edge of the bed while she was naked, assisted to put her shirt on her, but did not pull it down over her breasts, and assisted Resident #21 with her pants but only pulled the pants up to her thighs. STNA #243 told Resident #21 to lay back, Resident #21 laid back, but her head and neck were at an awkward angle against the wall. STNA #243 walked out of the room leaving Resident #21's breasts and vaginal area exposed, with the door open. STNA #243 was gone for about six or seven minutes and returned to the room with a sit-to-stand mechanical lift and a second aide to assist her. FM #262 stated it was very upsetting for her to view the camera footage and see the way Resident #21 was treated.
Interview on 07/02/24 at 9:03 A.M. of Ombudsman #263 revealed Resident #21 was left unattended and unclothed while she was in bed. Resident #21 was told to lay back, she did so and the aide left her half in the bed when she left the room. The facility initiated a self-reported incident regarding the situation.
Interview on 07/02/24 at 4:55 P.M. of the Administrator revealed she had concerns on 05/26/24 with STNA #243 and how resident care and peri-care was completed. The Administrator stated she was given camera footage for 05/26/24 from Family Member (FM) #262 and the footage revealed STNA #243 came to Resident #21's room, the bed was not made, and Resident #21 was lying across the bed half-dressed. The Administrator stated STNA #243 left Resident #21 in an odd position and went to find help with the stand-lift. The Administrator indicated it took about six minutes for STNA #243 to find another aide and come back to Resident #21's room, and this happened on 05/26/24 at around 5:40 A.M. The Administrator stated she opened a self-reported incident under physical abuse and neglect, and STNA #243 was suspended pending an investigation. The Administrator indicated STNA #243 said she was in the process of changing Resident #21, the bed needed changed because it was soiled, STNA #243 took the bedding off, needed help to put Resident #21 on the lift, and it took longer than expected to return to Resident #21's room. The Administrator stated STNA #243 was educated on proper peri-care, and the best policy was to have everything you need for the care including supplies and a second aide when you enter the room to provide the care. The Administrator confirmed Resident #21 was left half-naked on her bed when STNA #243 left the room to find a second staff member to assist with the sit-to-stand mechanical lift. The Administrator stated STNA #243 should have stayed with Resident #21, activated her call light, and waited for someone to answer the call light and have them assist with the sit-to-stand. The Administrator confirmed Resident #21's shirt was kind of lifted up, and her pants were half-way up. The Administrator stated STNA #243 said she closed Resident #21's door to her room, but it could not be determined from the video. The Administrator stated she was not sure if she still had the video, but she would check. The Administrator stated STNA #243 made the wrong decision, did not follow the peri-care policy, but she did not think it was neglect. The Administrator indicated the video was kind of alarming, Resident #21 did not seem like she was in distress, but she should have been covered and made more comfortable. STNA #243 still worked at the facility.
Observation on 07/03/24 at 9:46 A.M. of STNA #252 revealed he was assisting Resident #21 off the toilet. Observation of Resident #21's buttocks revealed they were dark purple and red in color. Resident #21's buttocks blanched when her skin was pressed. STNA #252 stated this was how Resident #21's buttocks typically looked.
Review of the facility policy titled Peri Care dated 05/01/22 included the policy was to provide cleanliness and comfort to the resident, prevent infections and skin irritation and observe the resident's skin condition. The procedure included to gather necessary equipment for the procedure, provide privacy, place equipment on clean surface within easy reach, provide hand hygiene and apply gloves. Assist with position of the resident into a safe, comfortable position, avoid overexposing the resident's body. Use a clean area of cloth for each area cleansed. Use multiple cloths, if necessary, to maintain infection control practices. Place the call light within easy reach of the resident.
This deficiency represents non-compliance investigated under Complaint Number OH00154599.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility self-reported incident (SRI) review, and review of facility policy the facility failed to ensure Resident #21's Injury of Unknown Origin was reported to the State Agency. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40.
Findings include:
Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia.
Review of Resident #21's care plan dated 10/14/19 included Resident #21 had an ADL (Activity of Daily Living) self-care performance deficit related to severe cognitive impairment secondary to dementia, physical limitations, chronic and debilitating health conditions. Resident #21 was nearly dependent for all ADL's. Resident #21 would be clean, dry, appropriately groomed and dressed daily through the review date. Interventions included transfers required extensive assistance of two staff; Resident #21 required mechanical stand-up lift for transfers; Resident #21 did not stand without lift and did not walk; for toileting Resident #21 required two staff and stand-up lift for transfers on and off the toilet.
Review of Resident #21's care plan did not reveal a care plan for a DVT (deep vein thrombosis) or anticoagulant medication or interventions related to anticoagulant medication.
Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Resident #21 was dependent on staff for toileting.
Review of Resident #21's Treatment Administration Record (TAR) dated 06/23/24 revealed weekly skin check by licensed nurse every day shift every Sunday was documented it was completed.
Review of Resident #21's assessments and progress notes from 06/16/24 through 06/30/24 did not reveal a Weekly Head-To-Toe Assessment was completed. Further review did not reveal documentation Resident #21 had bruises on her arms.
Review of Resident #21's camera footage dated 06/28/24 from 9:36 P.M. through 9:39 P.M. revealed STNA #238 pushed Resident #21 into her room in what appeared to be a shower chair. STNA #238 assisted Resident #21 out of the shower chair and onto a sit-to-stand mechanical lift without another staff member helping him. STNA #238 transferred Resident #21 to her bed without assistance, helped her sit on the edge of the bed, remove the sling and help Resident #21 lay down in the bed. While STNA #238 was assisting Resident #21 two bruises on her right lower arm near the elbow could be seen, and one long bruise on her left lower arm could be seen.
Review of Resident #21's progress notes dated 06/30/24 at 11:48 A.M. included STNA #252 notified the nurse he noticed some bruising on Resident #21. Upon assessment four areas of bruising were discovered on Resident #21's arms. Resident #21 did not know where she got the bruises from, and did not complain of pain and vital signs were WNL (within normal limits). A complete head-to-toe assessment was completed and the bruises on Resident #21's arms were measured for reference and monitoring. Educated STNA's about the importance of being careful when toileting Resident #21 due to smaller bathroom. The DON, NP, Physician and POA were notified. Physician #269 was not concerned because Resident #21 took blood thinners.
Review of Resident #21's Weekly Head-To-Toe Assessment-Licensed Nurses dated 06/30/24 included Resident #21 had a bruise to her left upper arm and the length was measured at two inches, Resident #21 had a bruise on her left lower arm and measurements were length of four and a half inches and a width of one and a half inches. Resident #21 had a bruise to the right lower arm with a length of one inch, and another bruise on her right lower arm which measured a length of one and a half inches. Resident #21 had purple bruising on both arms. Resident #21 did not know the origin of the bruising. The DON, NP and POA were notified.
Review of the facility incident log dated 06/30/24 at 7:24 P.M. revealed Resident #21 had an injury of unknown cause.
Review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. included staff notified nurse of bruises to Resident #21's bilateral arms. Upon interviewing staff, Resident #21's arms had been witnessed bumping against door frame when on the mechanical lift and during transfer into the bathroom. Resident #21 recently moved to a new room with a smaller bathroom, narrow doorway. Resident #21 utilized a mechanical lift for transfers. Resident #21 was on anticoagulant therapy (Eliquis), was prone to bruising and Resident #21's physician was notified and there were no changes in orders. Staff was educated on monitoring arms and body positioning while using mechanical lifts to avoid injury. Resident #21's Guardian was contacted and arrangements were made to move Resident #21 back to her previous room due to bathroom was large enough to accommodate the mechanical lift and had enough doorway clearance to transfer Resident #21 safely.
Review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. revealed two Witness Statements. Witness Statement dated 06/30/24 of LPN #226 included an STNA notified her he noticed bruising on Resident #21's arms, she assessed Resident #21 and found four areas of bruising, two on each arm. The Director of Nursing and Assistant Director of Nursing were notified and risk management and a skin assessment were completed. Physician #269 was contacted, was not concerned due to Resident #21 received Eliquis. Resident #21's Guardian was notified and she mentioned she saw bruising the previous night while she observed Resident #21's bedtime routine, but had not mentioned it to anyone at the facility.
Further review of Resident #21's IDT (interdisciplinary team) Post Incident Investigation Summary dated 06/30/24 at 7:24 P.M. revealed Witness Statement dated 06/30/24 of STNA #253 included every time STNA #253 helped operated the stand lift to assist Resident #21 into the bathroom it was a very tight squeeze trying to get Resident #21 in the bathroom without bumping her arms. Last time she worked with Resident #21 the aides had a hard time shielding her arms from the doorway.
Review of the facility SRI history revealed the facility did not submit a SRI for Resident #21's injury of unknown origin on 06/30/24.
Observation on 07/02/24 at 9:01 A.M. of State Tested Nursing Assistant (STNA) #252 and #254 revealed they used the sit-to-stand mechanical lift to transport Resident #21 from the bathroom to her bed. The sit-to-stand mechanical lift with Resident #21 fit through the doorway of the bathroom without hitting or rubbing Resident #21's arms on the door frame.
Interview on 07/02/24 at 4:30 P.M. of STNA #252 revealed on 06/30/24 he noticed Resident #21's bruises on her arms when she rolled her sleeves up. STNA #252 stated he immediately told Licensed Practical Nurse (LPN) #226 about the bruises. STNA #252 indicated he was not assigned to care for Resident #21 on 06/29/24 and 06/30/24 was the first time he saw the bruises.
Interview on 07/02/24 at 4:31 P.M. of STNA #254 revealed she did not work on 06/29/24 or 06/30/24, but on 06/28/24 she cared for Resident #21 and she did not have bruises on her arms.
Observation on 07/02/24 at 4:35 P.M. of Resident #21 with STNA #254 revealed Resident #21 had a large purple bruise on her lower left arm about six inches long and three inches wide. Resident #21 was unable to roll her sleeve up to show the bruise on her upper left arm. Further observation revealed two purple-green bruises on Resident #21's right forearm by the elbow and they were circular and one to two inches in diameter.
Interview on 07/02/24 at 4:41 P.M. of LPN #226 revealed STNA #252 saw bruises on Resident #21's arms after she pulled her sleeves up and he told her about them. LPN #226 stated she completed a full body assessment and lifted Resident #21's sleeves up all the way so she could see her entire arm. Resident #21 had two purple colored bruises on her right lower arm, one bruise on her left upper arm about two inches and circular, and a long purple bruise on her left lower arm. LPN #226 stated she did not work on 06/29/24 and we had no idea how the bruises happened. LPN #226 indicated she called Physician #269, he was not concerned because Resident #21 was taking Eliquis (anticoagulant) and was prone to bruises. LPN #226 stated she notified the DON and Family Member/Guardian #262 about the bruise and Family Member/Guardian #262 stated she saw Resident #21's bruises through the camera on Saturday night. LPN #226 stated the DON made sure she documented the bruises appropriately and there were no additional bruises. LPN #226 stated Resident #21 bruised easily, but the past bruises were small. LPN #226 indicated Resident #21 had a habit of banging her arm against the wall when she was done in the bathroom, but Resident #21 did not know how the bruises happened, and she did not complain of pain.
Interview on 07/02/24 at 4:55 P.M. of the Administrator revealed Resident #21 was on Eliquis (anticoagulant), Resident #21 was recently moved to the room she was currently in and the room had a smaller doorway to the bathroom, and was hard to get into using a sit-to-stand mechanical lift. The Administrator indicated Resident #21 was not conscious of her arms, and had a few night where she was banging on the wall. The Administrator stated they were trying to figure out how Resident #21 got the bruises, the aides said it was a tight squeeze going through the door to the bathroom, but did not say Resident #21's arms hit or rubbed the door frame. The Administrator stated Physician #269 was notified of Resident #21's bruises. The Administrator stated a facility incident report was opened, but a Self-Reported Incident (SRI) was not reported to the State Agency.
Interview on 07/03/24 at 8:55 A.M. of Family Member/Guardian #262 revealed Resident #21 was taken to the bathroom using a sit-to-stand mechanical lift. Family Member/Guardian #262 stated the room Resident #21 was now in was set up different than her other room, getting into the bathroom was real tight, and she heard banging while the aides transported Resident #21 to the bathroom using the sit-to-stand mechanical lift. Family Member/Guardian #262 stated she saw Resident #21's arm bruises on the camera footage before it was reported by the staff.
Interview on 07/03/24 at 9:49 A.M. of Chief Operating Officer (COO) #270 revealed the facility knew immediately what Resident #21's bruises were caused by and started education immediately. COO #270 stated the STNA's (State Tested Nursing Assistant's) saw Resident #21's arms hit the door frame, and that caused the bruises.
Interview on 07/03/24 at 11:59 A.M. of Licensed Practical Nurse (LPN) #228 revealed she worked on 06/29/24 and was assigned to the nursing unit Resident #21 resided on and she did not see bruises on Resident #21's arms, and no aides reported bruises on Resident #21's arms. LPN #228 stated when she administered Resident #21's medications she talked to her, asked how she was feeling, and she did not mention she had pain or bruises on her arms.
Interview on 07/03/24 at 1:17 P.M. of State Tested Nursing Assistant (STNA) #253 revealed she was assigned to care for Resident #21 on 06/29/24 and she did not notice bruises on her arms. STNA #253 indicated Resident #21 used a sit-to-stand lift for transportation into the bathroom, the aides had to block Resident #21's arms from hitting the door frame, and remind her to tuck her elbows in. STNA #253 stated she did not know how Resident #21 got the bruises on her arms, and she did not hurt her arms when STNA #253 transferred her using the sit-to-stand lift.
Interview on 07/08/24 at 6:50 A.M. of STNA #238 revealed he was very familiar with Resident #21. STNA #238 stated Resident #21 received her showers in the evening around 8:20 P.M., he gave her a shower last week and did not remember seeing bruises on her arms. STNA #238 stated the sit-to-stand mechanical lift was used to transfer Resident #21 to the toilet, her recliner and her bed. STNA #238 stated two people were needed to use the sit-to-stand mechanical lift, but confirmed sometimes he could not find anyone to help him and transferred Resident #21 by himself. STNA #238 stated Resident #21 did not hit her arms on the door frame, or anything else when he transported her to the bathroom.
Interview on 07/08/24 at 7:01 A.M. of STNA #242 revealed she did not remember seeing bruises on Resident #21's arms. STNA #242 stated Resident #21 banged the wall in the middle of the night when she wanted something, and sometimes threw her pillow across the room. STNA #242 stated if she saw bruises on Resident #21's arms she would have documented it and told the nurse. STNA #242 indicated Resident #21 used the sit-to-stand mechanical lift for transfers, there was always two staff members who assisted her with transfers, and Resident #21 tucked her arms in when she went through the doorway of the bathroom. STNA #242 stated the doorway to the bathroom was smaller than the room Resident #21 used to reside in, but Resident #21 could be transported through the doorway without brushing her arms, and the sit-to-stand could be turned in the bathroom without Resident #21 hitting her arms. STNA #242 stated it was not a squeeze, Resident #21 would be told to tuck her arms and she did. STNA #242 stated no aide would push her into the bathroom and let her arms hit the door frame, and if she did hit her arms on the door frame it would probably cause a skin tear because Resident #21 had fragile skin. STNA #242 stated she never saw Resident #21 hit her arms on the doorframe.
Interview on 07/08/24 at 7:18 A.M. of STNA #254 revealed Resident #21 could be transported through the bathroom door, there was plenty of room on either side of her arms, and the aides did not have to worry about Resident #21 hitting her arms on the door frame. STNA #254 stated she did not see Resident #21 hit her arms on the door frame.
Interview on 07/08/24 at 11:13 A.M. of STNA #243 revealed she did not assist Resident #21 with her care except when she was a second person when the sit-to-stand mechanical lift was used to transfer her. STNA #243 stated when she assisted with the lift she did not see Resident #21's arms hit the doorframe, or hear her call out because her arms hit the doorframe when she was transported to the bathroom.
Review of the facility policy titled Abuse Prevention dated 08/20/21 included it was the facility policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator and to the State Department of Health. An injury was classified as an Injury of Unknown Source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident AND the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time.
This deficiency represents non-compliance investigated under Complaint Number OH00154653.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review the facility failed to complete Resident #20's Speech Therapy evaluation was ordered to ensure safe eating and adequate nutrition. This affected one resident (Resident #20) out of three residents reviewed for nutrition. The facility census was 40.
Findings include:
Review of Resident #20's medical record revealed an admission date of 09/11/18 and diagnoses included Alzheimer's Disease, dementia without behavioral, psychotic disturbance, mood disturbance and anxiety, atherosclerotic heart disease, and major depressive disorder. Resident #20 resided in the secured unit for dementia.
Review of Resident #20's care plan revised 01/02/22 included Resident #20 had an ADL (Activity of Daily Living) self-care performance deficit related to Alzheimer's Disease, dementia and other diagnoses. Resident #20 would maintain her current level of function with ADL's and mobility through the review date. Interventions include Resident #20 was independent, supervised, cued with eating. Resident #20 had a nutritional problem or potential nutritional problem related to disease process and had a history of difficulty chewing and dysphagia. Resident #20 would maintain weight plus or minus five percent. Interventions included to monitor, document, report as needed signs and symptoms of dysphagia such as coughing, choking, several attempts at swallowing, appearing concerned during meals.
Review of Resident #20's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required supervision or touching assistance with eating.
Review of Resident #20's physician progress notes dated 04/17/24 and written by Certified Nurse Practitioner (CNP) #264 included nursing noticed Resident #20 coughing during meals and after medications were given. Resident #20's current diet was regular, puree texture, thin liquids. Resident #20 ate her meals very slowly. Resident #20 stated she had a hard time swallowing and had to cough a lot. Resident #20 had a history of swallowing difficulties and had a modified barium swallow and esophagram completed in 2022. Referral would be made to speech therapy for evaluation and treatment.
Review of Resident #20's physician orders dated 04/17/24 revealed Speech Therapy screen and, or evaluation or treatment.
Review of Resident #20's medical record including physician progress notes, progress notes and assessments from 04/17/24 through 07/02/24 did not reveal evidence Resident #20's Speech Therapy screen or evaluation was completed.
Observation on 07/02/24 at 8:31 A.M. of Resident #20 with Licensed Practical Nurse (LPN) #232 revealed Resident #20 was sitting on the side of her bed with her breakfast meal (pureed food) in front of her on a bedside table, and she was eating her breakfast. There was no staff in the room while Resident #20 was eating. Observation revealed while LPN #232 was administering Resident #20's medications, Resident #20 started coughing and clearing her throat repeatedly. LPN #232 stated Resident #20 often did that when she had medications administered and while she was eating.
Interview on 07/03/24 at 11:08 A.M. of the Administrator, Director of Nursing and Director of Rehab (DOR) #271 revealed the facility changed systems on 05/01/24 and DOR #271 did not have access to the previous system. DOR #271 stated Resident #20 did not have a Speech Therapy evaluation or treatment from 05/01/24 through 07/02/24, but she would check with the corporate office to see if they could find if Resident #20 had a Speech Therapy and Evaluation from 04/17/24 through 05/01/24.
Interview on 07/08/24 at 8:09 A.M. of State Tested Nursing Assistant's (STNA)'s #239 and #240 revealed Resident #20 did not like to eat in the dining room and preferred to eat her meals in her room. STNA #239 stated the aides helped set her food up and Resident #20 let them know if she needed help. STNA's 239 and #240 stated Resident #20 did have something with her throat and they had seen her cough and kind of gag, while eating, but mostly she did it with her medications.
Interview on 07/08/24 at 10:10 A.M. of Chief Operating Officer (COO) #270 revealed Resident #20 did not have a Speech Therapy Evaluation or treatment completed from 04/17/24 through 07/02/24.
This deficiency represents non-compliance investigated under Complaint Number OH00154653.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure a safe environment, and equipment was functioning and available for preparation of resident food. This had the potential to affect all residents served food from the kitchen. The facility census was 40.
Findings include:
Observation on 07/02/24 at 11:00 A.M. of the facility kitchen revealed staff were very busy, moving about the kitchen hurriedly and were preparing the lunch meal.
Interview on 07/02/24 at 11:00 A.M. of Cook/Dietary Aide #266 revealed the kitchen staff were behind preparing the lunch meal because they had a mandatory meeting today and the meeting had just finished. Cook/Dietary Aide #266 stated the lunch meal would be about a half hour behind because of the meeting.
Observation on 07/02/24 at 11:05 A.M. of the kitchen with Cook/Dietary Aide #266 revealed a Steamer sitting on the counter that was not being used. Cook/Dietary Aide #266 stated the Steamer did not work and had not worked for quite a while. Further observation of the kitchen floor revealed tiles were missing on the floor, and the area where the tiles were missing created a trip hazard because the floor was uneven.
Interview on 07/02/24 at 11:43 A.M. of Dietary Supervisor (DS) #267 revealed the Steamer did not work, and had not worked since she started working at the facility about two months ago. DS #267 stated she told Maintnence Supervisor (MS) #219 and the Administrator about the Steamer not working. DS #267 stated Regional Dietary Manager (RDM) #268 talked to MS #219 about the Steamer. DS #267 stated the kitchen staff were using metal pans without handles designed for the oven, to cook food on top of the stove, because the Steamer was not working.
Interview on 07/02/24 at 12:53 P.M. of MS #219 revealed he started working as the Maintenance Supervisor about a month ago, and before that he worked in housekeeping. MS #219 stated the Steamer had been broken since he started working at the facility. MS #219 stated a former kitchen staff employee asked him if he could fix the Steamer when he became the Maintenance Supervisor, and he found a company that could do it but they wanted to paid up front because the facility owed them money. MS #219 indicated he was told to submit an invoice for the work, but the company would not come to the facility to give an estimate on how much it would cost to fix the Steamer until they were paid. MS #219 stated a new food management company took over, he was not sure who was responsible to fix the Steamer, but thought the new food management company would make sure the Steamer was fixed. MS #219 stated he had been very busy since becoming the Maintenance Supervisor and fixing the Steamer fell between the cracks. MS #219 stated the Administrator told him to get invoices when he needed to have things fixed.
Interview on 07/02/24 at 2:37 P.M of the Administrator revealed she did not know the Steamer was broken before today. The Administrator stated before the current food company managed the kitchen the facility managed the kitchen and the Steamer not working never came up. The Administrator stated DS #267 did not mention the Steamer was not working, and MS #219 did not tell her the Steamer was not working. The Administrator stated she did not get food complaints because the Steamer did not work. The Administrator confirmed she knew about the broken floor tiles in the kitchen, but did not address it. The Administrator confirmed the old owners of the facility did not pay some of their bills, the new owners did not want to pay bills from old owners, vendors refused to come until they were paid, and it took awhile to get everything sorted out.
This deficiency represents non-compliance investigated under Complaint Number OH00154653.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility policy the facility failed to ensure Resident #21 was free from significant medication error and medications were administered per physician orders. This affected one resident (Resident #21) out of three residents reviewed for medications administered per physician orders. The facility census was 40.
Findings include:
Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia.
Review of Resident #21's care plan initiated 06/11/18 included Resident #21 received psychoactive medications (antipsychotic, anxiolytic) to treat mental illness. Resident #21 would receive the lowest possible dosage of the prescribed psychotropic drugs to ensure maximum functional ability both mentally and physically through the next review date. Interventions included to administer medication as prescribed by the physician and implement behavior interventions; notify physician of side effects, decline in function or worsening of symptoms.
Review of Resident #21's physician orders dated 03/01/23 revealed CBC (complete blood count) with diff now and every four weeks while on clozaril, every shift starting on the second and ending on the second every month.
Review of Resident #21's physician orders dated 01/26/24 revealed Clozaril (antipsychotic medication) oral tablet 100 mg, give 100 mg by mouth two times a day related to Parkinson's Disease.
Review of Resident #21's physician orders dated 01/26/24 revealed Clozaril oral tablet 50 mg, give one tablet by mouth at bedtime related to Parkinson's Disease, administer with 100 mg tablet to equal 150 mg.
Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Resident #21 was taking an antipsychotic medication.
Review of Resident #21's Treatment Administration Record (TAR) dated 06/02/24 revealed CBC with diff now and every four weeks while on Clozaril was documented as completed.
Review of Resident #21's TAR dated 06/11/24 revealed CBC, Thyroid panel, BMP (base metabolic panel), B12, lipid panel, full thyroid panel with T3, TFree T4, ANC (measures neutrophils in the blood), and Clozaril levels every three weeks was documented as completed.
Review of Resident #21's progress notes dated 06/18/24 at 10:40 P.M. revealed pharmacy phoned for update on Clozapine (Clozaril). The Tech (pharmacy tech) stated medication would not be delivered because labs were not sent. Labs from 05/06/24 were printed and faxed to the pharmacy. Tech unsure if new prescription was needed and would update the facility.
Review of Resident #21's progress notes dated 06/19/24 at 11:56 A.M. revealed Clozaril oral tablet 100 mg, give 100 mg two times a day related to Parkinson's Disease was on order.
Review of Resident #21's physician progress notes dated 06/19/24 written by Certified Nurse Practitioner (CNP) #264 included Resident #21 took Clozaril (antipsychotic) twice a day. Nursing stated pharmacy needed a new prescription. Nursing notified Resident #21's psychiatrist. Required labs were ordered for tomorrow morning. Labs would be faxed to the Psychiatrist's office once they resulted for prescription.
Review of Resident #21's physician orders dated 06/19/24 revealed CBCWD (complete blood count with differential), thyroid panel, BMP, B12, lipid panel, T3, FT4, ANC, clozaril level was ordered for 06/20/24.
Review of Resident #21's Medication Administration Record (MAR) revealed Clozaril oral tablet 50 mg (Clozapine), give one tablet by mouth at bedtime related to Parkinson's Disease, administer with 100 mg tablet to equal 150 mg was documented it was administered on 06/19/24 at 9:00 P.M. (although it was not available to administer). Further review on 06/20/24 at 9:00 P.M. revealed documentation Clozaril was not administered.
Review of Resident #21's MAR revealed Clozaril oral tablet 100 mg (Clozapine), give 100 mg by mouth two times a day related to Parkinson's Disease revealed on 06/19/24 at 9:00 A.M. Clozaril was not administered. Further review on 06/19/24 at 9:00 P.M. revealed documentation Clozaril was administered (although was not available to administer). On 06/20/24 at 9:00 A.M. Clozaril was documented it was administered (although was not available to administer) and on 06/20/24 at 9:00 P.M. Clozaril was documented it was not administered.
Review of Resident #21's progress notes dated 06/20/24 at 8:56 P.M. revealed Clozaril oral tablet 100 mg, give 100 mg by mouth two times a day related to Parkinson's Disease, labs faxed to pharmacy.
Review of Resident #21's progress notes dated 06/20/24 at 8:57 P.M. revealed Clozaril oral tablet 50 mg, give one tablet by mouth at bedtime related to Parkinson's Disease, administer with 100 mg tablet to equal 150 mg. Labs faxed to pharmacy.
Review of Resident #21's progress notes dated 06/20/24 at 11:24 P.M. revealed STAT (immediately) labs faxed to pharmacy. Clozaril would be in tonight's tote.
In addition to Resident #21 not receiving Clozaril as ordered, review of Resident #21's physician orders and MAR dated 06/18/24, 06/23/24, 06/24/24, 06/25/24, 06/26/24 and 06/28/24 did not reveal evidence Resident #21's Carbidopa-Levodopa oral tablet 25-100 mg, give one tablet by mouth in the evening related to Parkinson's Disease was administered at 6:00 P.M. as ordered.
Review of Resident #21's MAR dated 06/18/24, 06/23/24, 06/24/24, 06/25/24, 06/26/24 and 06/28/24 did not reveal evidence Resident #21 also did not receive Ipratropium-Albuterol Solution 0.5-2.5 mg per three milliliters, one dose inhale orally two times a day for increased SOB (shortness of breath) and secretions as ordered at 6:00 P.M.
Interview on 07/01/24 at 4:21 P.M. of Family Member (FM)/Guardian #262 revealed the facility ran out of Resident #21's antipsychotic medication, Clozaril, and she was not sure how long Resident #21 did not receive the Clozaril.
Interview on 07/02/24 at 3:49 P.M. of the Director of Nursing (DON) revealed Resident #21 had labwork drawn every three weeks, which was set up on Emed lab to be done every three weeks, and once the results come back Clozaril levels were sent to the pharmacy and to Resident #21's Psychiatry Nurse Practitioner (PNP) #265. PNP #265 would update the profile and that gave the pharmacy the ability to refill Resident #21's Clozaril. The DON stated Resident #21's labwork was placed in Emed to queue every three weeks, but it could only be queued for so many months, and after the specified time the lab would fall off the queue and need to be reordered. The DON stated the labwork to be drawn in 05/2024 was missed because the lab fell off, she was not aware the lab fell off, and Resident #21's labwork was not sent to PNP #265 or the pharmacy. The DON indicated when the facility realized Resident #21 was out of Clozaril, it was looked into and they found out Resident #21's labs had not been completed and her Clozaril could not be sent. The DON stated Resident #21's labs were drawn, including a neutrophil level which was included in the CBC. The DON indicated when Resident #21's CBC results came back, including the neutrophil level, pharmacy was able to drop ship her Clozaril. The DON stated Resident #21 missed four doses of Clozaril, two on 06/19/24 and two on 06/20/24. The DON stated Resident #21 had tremors when her Clozaril was not available to be administered and she was administered as needed medications for pain and anxiety to help with her symptoms.
Interview on 07/03/24 at 1:11 P.M. of the DON confirmed Resident #21 did not receive Clozaril on 06/19/24 or 06/20/24. The DON stated the nurse's signed off the Clozaril was given on 06/19/24 at 9:00 P.M. and on 06/20/24 at 9:00 A.M. but we did not have it to give and the documentation on Resident #21's MAR was incorrect.
Interview on 07/08/24 at 11:32 A.M. of the DON confirmed Resident #21's TAR had documentation her bloodwork was drawn on 06/02/24 and 06/11/24 but it was not drawn on those dates. The DON stated the nurse was supposed to double check the draw list for residents receiving labwork, and the requisitions with each residents TAR to make sure all residents who were supposed to have labwork collected had their labs completed. Resident #21 was not on the draw list and did not have a requisition, and the nurse did not double check her TAR to make sure she had her blood drawn. The nurse signed off Resident #21's TAR but did not check the draw list. The DON confirmed Resident #21's TAR had days where there was no documentation her Sinemet (Carbidopa-Levodopa) was given, but it was given and the nurse forgot to sign off she gave it because it was close to shift change. The DON stated Resident #21 got breathing treatments twice a day, and confirmed there were days when she did not receive her evening treatment. The DON stated the nurses were educated on the importance of Resident #21's breathing treatments and now she received the treatments as ordered.
Review of the facility policy titled Medication Administration dated 05/01/22 included medications should be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. As required or indicated for a medication, the individual administering the medication would record in the resident's medical record, including the date and time the medication was administered, the dosage, the route of administration and the signature and title of the person administering the drug.
This deficiency represents non-compliance investigated under Complaint Number OH00154599.

Based on observations and interview the facility failed to ensure food was stored in a manner to prevent food borne illness and failed to maintain a sanitary kitchen. This had the potential to affect all residents except Resident #34 who did not receive nutrition by mouth. Facility census was 38.
Findings include:
Observations of the kitchen on 05/28/24 at 8:10 A.M. revealed thawed raw boneless/skinless chicken breast in a bag lying in a bin in the refrigerator; the Ziplock bag holding the chicken breast was dated 05/19/24 and the juices from the chicken had leaked out filling the bottom of the bin. There was a bag of cooked barbeque chicken in a Ziplock bag that was dated 05/19/24 to 05/26/24, a carton of whole eggbeaters dated 05/06/24, two opened containers of beef base dated 11/27/23 and 01/05/24, and a carton of imitation vanilla was capped with aluminum foil dated 02/24. A large garbage can next to the stove was covered with a dirty lid. The microwave had dried food debris on the inside, there was loose miscellaneous debris covering the top the dishwasher, and the air vents in the ceiling located over the cooked food storage area were covered with a layer of blackish dust. Interview during the observations with the Dietary Manager verified the findings.
Review of a dietary list provided by the facility revealed Resident #34 did not receive nutrition by mouth.
This deficiency represents non-compliance investigated under Complaint Number OH00153987.

Based on observations and interview the facility failed to dispose of garbage and refuse appropriately. This had the potential to affect all 38 residents residing in the facility.
Findings include:
Observations on 05/20/24 at 7:56 A.M. of the main dumpster area revealed trash was contained within the walls of the dumpster except for two used latex gloves. Further observation revealed a large garbage can located against the wall just outside the back door to the kitchen. The garbage can had no lid and was full of food, a wash basin, and miscellaneous items. A smaller can without a lid was observed against the wall next to the larger can, which contained food, Styrofoam plates and other miscellaneous items.
Continued observations of the area surrounding the facility revealed empty wooden pallets lying against the wall of the facility, broken boards form the pallets lying on the ground with paper and miscellaneous debris, five broken wheelchairs, broken bed side trays, two pieces of plywood leaning against the facility, a bag of soiled incontinence supplies lying in a bin that was not covered, and a large garbage can filled with standing water. Interview during the observations with the Dietary Manager revealed she had been employed since 05/05/24 and was unaware of the area surrounding the facility. Dietary Manager verified all observations.
This deficiency represents non-compliance investigated under Complaint Number OH00153987.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, record review and review of the policies, the facility failed to maintain infection control practices of hand washing and during oxygen therapy. This affected four (#2, #6, #16 and #17) of six residents reviewed for infection control. The facility census was 40.
Findings include:
1. Review of Resident #17's medical record revealed an admission date of 01/19/24. Diagnosis included diabetes mellitus.
Record review of the admission Minimum Data Set (MDS) revealed Resident #17 was severely cognitively impaired.
Record review of the physician order dated 01/09/24. for Resident #17 revealed an order for accu checks (blood sugar checks) before meals and at bedtime for diabetes.
Observation on 02/20/24 at 10:18 A.M., of Licensed Practical Nurse (LPN) #225 assess Resident #17's blood sugar using a glucometer revealed LPN #225 removed the glucometer from the medication cart drawer. LPN #225 took the glucometer in Resident #17's room, sat the glucometer directly on Resident #17's nightstand and put on a pair of disposable gloves. LPN #225 did not clean the area on the nightstand or use a barrier. LPN #225 then assessed Resident #17's blood sugar using a lancet and the glucometer. LPN #225 then left Resident #17's room (did not remove the gloves or wash her hands), returned to the medication cart, removed her gloves, put the glucometer back in the medication cart (did not clean the glucometer before putting it away), then documented the blood sugar value in the electronic medical record. LPN #225 then reviewed orders for Resident #6.
2. Review of #6's medical record revealed an admission date of 11/30/23. Diagnosis included diabetes mellitus.
Record review of the physician order for Resident #6 revealed an order for check blood sugar twice a day and as needed for signs of hypoglycemia or hyperglycemia.
Observation on 02/20/24 at 10:34 A.M. of LPN #225 assesses Resident #6's blood sugar using a glucometer revealed LPN #225 removed the glucometer (the same glucometer used for Resident #17) from the medication cart drawer. LPN#225 took the glucometer in Resident #6's room, sat the glucometer directly on Resident #6's table and put on a pair of disposable gloves. LPN #225 did not clean the area on the table or use a barrier. LPN #225 then assessed Resident #6's blood sugar using a lancet and the glucometer. LPN #225 then left Resident #6's room (did not remove the gloves or wash her hands), returned to the medication cart, removed her gloves, put the glucometer back in the medication cart (did not clean the glucometer before putting it away), documented the blood sugar value in the electronic medical record).
Interview on 02/20/24 at 10:38 A.M., with LPN #225 verified she did not wash her hands or use hand sanitizer at any point before, during or after assessing Resident #17's blood sugar, she did not wash her hands or use hand sanitizer prior to or after assessing Resident #6's blood sugar. LPN #225 verified she did not clean the area or place a barrier in Resident #17's or #6's room prior to setting the glucometer down and verified she did not clean the glucometer after using the glucometer on Resident #17 and before using the glucometer on Resident #6 and before putting the glucometer back in the medication cart after assessing Resident #6's blood sugar.
3. Review of Resident #16's medical record revealed an admission date of 03/19/20. Diagnoses included unspecified dementia, dysphagia following cerebral infarction, and need for assistants with personal care.
Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident 16 was moderately cognitively impaired. Resident required substantial/maximum assistants with personal hygiene.
Review of the physician orders revealed Resident #16 received a physician order on 01/05/24 gently wash peg tube site with soap and warm water, pat dry, sprinkle nystatin powder and cover with drain sponge daily and as needed.
Observation on 02/20/24 at 4:03 P.M., of Licensed Practical Nurse (LPN) #259 complete the dressing change to Resident #16's peg tube site revealed LPN #259 removed the old dressing which was undated at Resident #16's peg tube site. The site was deep red and had a moderate amount of thick yellow drainage at the site. LPN #259 removed the dressing then removed her gloves, did not wash hands, then left the room and returned with gauze. LPN #259 again did not wash her hands, cleansed the site with normal saline, did not wash her hands after cleansing the site, applied the clean dressing and tape. LPN #259 then disposed of the old dressing supplies and left the room (without washing her hands). LPN #259 then went back to her medication cart and opened the drawer of the cart. LPN #259 verified she never washed her hands or used hand sanitizer at any time during or after Resident #16's dressing change to her peg tube site.
4. Review of Resident #2's medical record revealed an admission date of 11/20/18. Diagnoses included chronic obstructive pulmonary disease, traumatic brain injury, pulmonary hypertension, and presence of right artificial hip joint.
Review of the quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact.
Record review of the physician orders for Resident #2 included:
1. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams (mg) per milliliter (ml) give one dose inhale orally via nebulizer four times a day for shortness of breath dated 11/04/23.
2. Oxygen at four liters to maintain (pulse oximetry) SPO2 above 92% every shift dated 04/28/22.
3. Change all oxygen tubing on Sunday night shift, date time and initial all tubing, place in clear bag with date, time, and initials on it when not in use. Change if soiled, includes concentrator and aerosol machine tubing and mask/inhalation tubing, dated 01/08/23.
Observation on 02/20/24 at 1:49 P.M. revealed Resident #2 was not in his room. Observation revealed an oxygen e-tank was sitting next to the bed. The oxygen tubing and nasal cannula for the e-tank were lying on the floor. The nasal cannula tips of the tubing were both dark brown. The tubing was undated. Further observation revealed the nasal cannula tubing connected to the concentrator was also lying on the floor. The nasal cannula tips of the tubing were both dark brown. The tubing was undated. Observation of the aerosol mask revealed the mask and tubing were both lying on the floor. Observation revealed the mask or tubing was not dated. There were no bags for storage of the oxygen supplies visibly present.
Observation on 02/21/24 at 8:35 A.M., of Resident #2 revealed Resident #2 was lying in his bed watching TV. Resident #2 had his oxygen on using the nasal cannula from the concentrator. Resident #2 revealed he did not know if the facility changed his oxygen tubing but when he removed the tubing it would often fall from the bed onto the floor.
Observation on 02/21/24 at 9:10 A.M., with Corporate Nurse Registered Nurse (RN) #291 confirmed Resident #2's oxygen e-tank was sitting next to the bed. The oxygen tubing and nasal cannula for the e-tank were lying on the floor. The nasal cannula tips of the tubing were both dark brown. The tubing was undated. Further observation revealed the nasal cannula tubing connected to the concentrator was also lying on the floor. The nasal cannula tips of the tubing were both dark brown. The tubing was undated. Observation of the aerosol mask revealed the mask and tubing were both lying on the floor. Observation revealed the mask or tubing was not dated. There were no bags for storage of the oxygen supplies visibly present. Further observation revealed the floor was very dirty, unkept. Corporate Nurse Registered Nurse (RN) #291 confirmed these were the tubing's Resident #6 routinely used daily for oxygen needs and aerosol treatments. Corporate Nurse Registered Nurse (RN) #291 confirmed the tubing's should be stored in bags when not in use and dated. The visibly soiled cannula's should have been replaced before further use.
Review of the policy titled, Oxygen Administration dated 05/01/22, revealed oxygen tubing should be changed weekly, nasal cannula tubing may need to be changed more frequently.
Review of the policy titled, Infection Control Overview dated 05/01/22, included employees must wash their hands for 20 seconds using soap and water under the following conditions: after contact with blood or other body fluids, after removing gloves, after removing items potentially contaminated with blood or body fluids or secretions. In most situations, the preferred method of hand hygiene is with an alcohol based handrub for the following situations: Before or after direct contact with a resident, before performing any non-surgical invasive procedure, before handling clean or soiled dressing, gauze, pad, etc; before moving from a contaminated body site to a clean body site, after handling used dressings and after removing gloves.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

Based on observation, resident interview, and staff interview, the facility failed to ensure residents were provided dignified dining experience when meals were not provided on non-disposable plates. This affected 13 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #37, #60, #90 and #92) who were served all meals on Styrofoam plates due to the facility not having a sufficient number of plates. The facility census was 40.
Findings include:
Interview on 02/20/24 at 11:47 A.M., with Dietary Manager #282 revealed he started working at the facility in June 2023. Dietary Manager #282 revealed he did not have enough plates for all the residents when he started working at the facility. Dietary Manager #282 revealed there were 27 plates and 40 residents. Dietary Manager #282 revealed he brought it to the Administrator's attention in December 2023 and has been waiting for approval to purchase more plates since then. Dietary Manager #282 revealed all the residents in memory care were served on Styrofoam plates and two additional residents outside of memory care would also have to be served on Styrofoam plates for each meal every day because there were no other plates to serve residents on.
Observation on 02/20/24 at 11:55 A.M., revealed two (#37 and #60) of 12 residents in the dining room outside of the Memory Care Unit were served on Styrofoam plates.
Interview on 02/20/24 at 11:56 A.M., with Resident #60 revealed no response when asked about his Styrofoam plate, Resident #60 just looked away.
Interview on 02/20/24 at 11:57 A.M., with Resident #37 revealed, I guess it doesn't matter when asked about eating on Styrofoam plates. Resident #37 revealed he ate on regular plates at home.
Observation on 02/20/24 at 11:59 P.M., of the Memory Care Unit revealed all residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #90 and #92) were served their meal on Styrofoam plates.
Interview at the time of the observation with Licensed Practical Nurse (LPN) #225 revealed, All residents use Styrofoam in Memory Care, I don't know why.
Interview on 02/20/24 at 5:00 P.M., with Administrator revealed she was at the facility less than two weeks and was unaware residents were using Styrofoam plates for each meal.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

Based on observation, record review, resident interview, staff interview, and review of the policy, the facility failed to provide a phone for residents to use that would be located in a private area to allow for private conversations. This affected one (#37) and had the potential to affect all residents except (Resident #34, #6, #10, #60, #25, #9, #23, and #11) who did not use the facility phones. The facility census was 40.
Findings include:
Review of Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included obstructive uropathy and depression.
Review of the quarterly minimum data set (MDS) assessment revealed Resident #37 was cognitively intact.
Observation on 02/20/24 at 4:17 P.M., revealed Resident #37 was standing in front of the nurses station talking on the phone. Observation revealed residents and staff near the area. Resident #37's conversation could be heard clearly by anyone near the area.
Interview on 02/20/24 at 4:24 P.M., with Resident #37 revealed he was talking with a family member. Resident #37 revealed this was the only phone he could use; he would rather have a private conversation, but he had no choice.
Interview on 02/20/24 at 4:25 P.M., with Director of Nursing (DON) confirmed the residents were only allowed access to the phone in front of the nurses station. DON confirmed the conversations were not private and could be heard by anyone near the area.
Review of the undated policy titled, Resident Rights, revealed the resident has the right to have reasonable access to the use of a telephone and a place in the facility where calls cannot be overheard.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy, the facility failed to timely notify a resident's Guardian, after a fall. This affected one (#1) of three residents reviewed for notification to the responsible party after a fall. The facility census was 20.
Findings include:
Review of Resident #1's medical record revealed an admission date of 05/07/15. Diagnosis included unspecified dementia.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired.
Review of the resident profile revealed Resident #1 had a Guardian of Person. The Guardian of Person was the primary contact person and Resident #1's legal Guardian.
Review of the progress note dated 01/23/24 at 11:00 A.M., completed by Licensed Practical Nurse (LPN) #259 revealed, This nurse was alerted by activities that this resident had fell. This nurse went to the lounge where this resident was found sitting on his behind. This nurse assessed the patient. Resident stated, I tripped over my cane but I'm alright. Resident was able to pick himself up off the floor. Resident complained of generalized pain. Resident was given PRN (as needed) pain medication for discomfort.
Review of the progress note dated 01/24/24 at 11:40 A.M., completed by Registered Nurse (RN) #292 revealed, Notified by (Nurse Practitioner) NP that resident was complaining of head pain behind his ear and is to be sent to emergency room (ER) via 911 due to the fall on 01/23/24 and hitting his head at time of fall and receiving Xarelto. Emergency 911 called, and a call was placed to guardian. Message left for guardian to call facility. Resident transported to ER via 911.
Interview on 02/26/24 at 2:00 P.M., with previous Director of Nursing (DON) #291 revealed she would notify the family of a resident of fall as soon as possible, within 15 minutes of the fall occurring. Previous DON #291 revealed she was aware LPN #259 did not contact the guardian at any time after his fall on 01/23/24. Previous DON #291 revealed there was no excuse, she, or someone should have notified the Guardian Resident #1 had the fall as soon as possible on 01/23/24.
Review of the policy titled, Change in Condition Monitoring, dated 05/01/22, included our facility shall promptly notify the resident, his or her attending physician, and Family/ POA/Guardian of changes in the residents medical/mental condition and or status.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and review of the policy, the facility failed to provide a clean, comfortable homelike environment for residents. This affected four (#1, #2, #8, and #26) of 22 resident rooms observed. The facility census was 40.
Findings include:
1. Review of Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, psychosis, morbid severe obesity, polyosteoarthritis, and need for assistants with personal care.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 was moderately cognitively impaired. Resident #8 required substantial maximum assistants with toileting and lower body dressing. Resident #8 was occasionally incontinent of urine.
Review of the care plan for Resident #8 dated 02/15/24 revealed Resident #8 experiences frequent bladder incontinence and is at risk for episodes of bowel incontinence related to activity intolerance, limited mobility, morbid obesity, mental illness, and low motivation. Interventions included prefers bedside commode at the bedside, monitoring for incontinence, assist as needed with incontinence care. Assist to change clothing after each incontinent episode.
Observation on 02/20/24 at 10:00 A.M., revealed Resident #8 was sitting up in her wheelchair sleeping. At the end of Resident #8's bed, against the wall was a bedside commode. The bedside commode was between half and three fourths full of urine and stool. To the side of the bedside commode, on the floor were two pairs of urine soiled pants. In front of and under the bedside commode was a large puddle of urine. The room had a strong foul odor. Observed on the floor throughout the room was trash products, food reminisces, and a buildup of dirt and grime in the creases and cracks of the floor. The bathroom entrance also had a large buildup of dirt and grime on the floor and the lower door frame on the left side to the entrance to the bathroom had multiple pieces missing and broken.
Observation on 02/20/24 at 1:32 P.M., revealed Resident #8 was sitting up in her chair. The bedside commode was still between half and three fourths full of urine and stool. To the side of the bedside commode, on the floor were two pairs of urine soiled pants. In front of and under the bedside commode was a large puddle of partially dried urine. The room had a strong foul odor. Observed throughout the floor was trash products, food reminiscences, and a buildup of dirt and grime in the creases and cracks of the floor. Resident #8's lunch tray was still sitting on the table.
Interview with Resident #8, at the time of the observation, the resident stated, Of course I want my room cleaned, they just don't always do it.
Observation on 02/20/24 at 2:30 P.M., with Maintenance Director/Housekeeping Supervisor #263 of Resident #8's room, confirmed at the end of Resident #8's bed, against the wall was a bedside commode. The bedside commode was three fourths full of urine and stool. To the side of the bedside commode, on the floor were two pairs of urine soiled pants (the same two pair from the morning and afternoon observation). In front of and under the bedside commode was a large puddle of dried urine. The room had a strong foul odor. Throughout the floor was trash products, food reminisces, and a buildup of dirt and grime in the creases and cracks of the floor. The bathroom entrance also had a large buildup of dirt and grime on the floor and the lower door frame on the left side to the entrance to the bathroom had multiple pieces missing and broken. Maintenance Director/Housekeeping Supervisor #263 stated each room should be cleaned daily.
2. Review of Resident #1's medical record revealed an admission date of 05/07/15. Diagnoses included diabetes mellitus and chronic pain.
Review of the quarterly MDS assessment dated [DATE] resident was moderately cognitively impaired.
Observation on 02/20/24 at 1:47 P.M., revealed Resident #1's room was very cluttered. There was a large stack of clothes next to the bed overflowing in a box onto the floor. The floor was dirty with a buildup of dirt and grime. The bedside table had old food wrappers and partially cups of liquids. In Resident #1's bathroom was a large buildup of dirt and grime. The roll of toilet paper was sitting on the floor. The holder on the wall was missing the roll holder.
Interview with Resident #1, at the time of the observation, revealed there was nowhere to put the toilet paper because the roll holder was missing. Resident #1 revealed the staff cleaned when they wanted to.
Observation on 02/20/24 at 2:30 P.M., with Maintenance Director/Housekeeping Supervisor #263 of Resident #1's room confirmed Resident #1's room was very cluttered. There was a large stack of clothes next to the bed overflowing in a box onto the floor. The floor was dirty with a buildup of dirt and grime. The bedside table had old food wrappers and partially cups of liquids. In Resident #1's bathroom was a large buildup of dirt and grime. The roll of toilet paper was sitting on the floor. The holder on the wall was missing the roll holder.
3. Review of Resident #2's medical record revealed an admission date of 11/20/18. Diagnoses included chronic obstructive pulmonary disease, traumatic brain injury, personal history of traumatic fracture, and presence of right artificial hip joint.
Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #2 received as needed pain medication for frequent pain.
Observation on 02/20/24 at 1:49 P.M. revealed Resident #2 shared the bathroom with Resident #1. Resident #2's room also had a large buildup of dirt and grime throughout the floor, in all corners and in the bathroom shared with Resident #1.
Observation on 02/20/24 at 2:32 P.M., with Maintenance Director/Housekeeping Supervisor #263 of Resident #2's room confirmed Resident #2's room also had a large buildup of dirt and grime throughout the floor, in all corners an in the bathroom shared with Resident #1.
4. Review of Resident #26's medical record revealed an admission date of 08/01/16. Diagnoses included unspecified convulsions and recurrent depression.
Review of the annual MDS assessment dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 was independent with toileting, personal hygiene, and ambulation.
Observation on 02/20/24 at 2:10 P.M., with Maintenance Director/Housekeeping Supervisor #263 of Resident #26's room revealed seven of the ceiling tiles were stained brown from dried water and two large tiles were bowed out from the ceiling. Maintenance Director/Housekeeping Supervisor #263 revealed the facility had a leaky roof a few months ago and confirmed the tiles were not replaced. Observation revealed the bathroom floor was still wet, Maintenance Director/Housekeeping Supervisor #263 confirmed the housekeepers just finished cleaning Resident #26's room and bathroom. Observation revealed the toilet in the bathroom had dried urine dripping and small hair particles on the rim of the toilet. The bowl had a large brown ring inside the bowl. The top of the toilet and toilet paper holder had a thick buildup of dust. Surrounding the toilet on the floor was a large buildup of dirt and grime. Maintenance Director/Housekeeping Supervisor #263 confirmed the toilet had not been cleaned and the floor had a large buildup of dirt and grime. The sink used for Resident #26 to wash in was located in the bedroom. The handle for the hot water was missing. Inside the sink was a large ring of scum buildup. Maintenance Director/Housekeeping Supervisor #263 verified the missing hot water handle and verified there was no way for Resident #26 to use his hot water in the sink. Maintenance Director/Housekeeping Supervisor #263 revealed Housekeeper #212 and #265 just finished cleaning Resident #26's room.
Interview and observation on 02/20/24 at 2:16 P.M., with Maintenance Director/Housekeeping Supervisor #263, Housekeeper #212 and #265 confirmed Housekeeper #212 and #265 finished cleaning Resident #26's room [ROOM NUMBER] to 30 minutes ago. Housekeepers #212 and #265 stated they forgot to clean the toilet rim, seat, bowl, and top. They also forgot to clean the sink.
Interview on 02/20/24 at 2:20 P.M., with Resident #26 revealed he would like his room to be clean, but it was not. Resident #26 revealed he didn't say anything because it doesn't do any good. Resident #26 revealed he had been telling them about the missing handle on the hot water for over a year. It doesn't do any good, they never fixed it, so he just got tired of telling them.
Review of the policy titled, Homelike Environment, dated 05/01/22, revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personal homelike environment. The characteristics include a clean, sanitary, and orderly environment.
This deficiency represents an incidental finding investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident council minutes, review of staff schedules, review of Self-Reported Incidents (SRI), staff interview and review of the policy, the facility failed to report an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40.
Findings include:
1. Review for Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, morbid severe obesity and need for assistants with personal care.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. Resident #8 required assistants with activities of daily living.
2. Review for Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following cerebral infarction, and acquired absence of left leg below the knee.
Review of the annual MDS dated [DATE] revealed Resident #32 was moderately cognitively impaired. Resident #32 used a wheelchair for mobility. Resident #32 required substantial/maximum assistants with transfers and wheelchair mobility.
Review of the Resident Council minutes dated 12/12/23, unsigned, revealed State Tested Nursing Assistant (STNA) (#220) night shift is not the best; STNA #242-night shift is rough; residents wished nurses would take residents more seriously; and agency night nurses aren't good. Under the section in the Resident Council minutes titled: Concerns Not Covered included stuff being stolen from rooms.
Interview on 02/22/24 at 11:36 A.M., with Registered Nurse (RN) Corporate MDS Nurse/Previous Director of Nursing (DON) #291 revealed she was the Acting DON at the facility up until three weeks ago. Previous DON #291 revealed she attended the Resident Council meeting on 12/12/23. Previous DON #291 revealed she heard Resident #8 say the word mean not rough and they were two different words. Previous DON #291 revealed if she would have heard rough, she would have investigated the concern because that to her would mean hands on rough, mean meant something more verbal. Previous DON #291 revealed she spoke with Resident #8 after the meeting, and she asked Resident #8 what happened. Resident #8 said, they were mean, they kept telling her to go back to bed. Previous DON #291 revealed Resident #8 did not specify what happened, Resident #8 changed the subject and went on to say she did not receive her medication either. Previous DON #291 revealed she did not discuss the concern any further with Resident #8 about the staff being mean or rough or not receiving her medications. Previous DON #291 confirmed there was no reporting or SRI completed regarding Resident #8's concern with staff being mean or rough, she did not question any other residents to see if they had concerns with staff, and she never spoke with either STNA or any other staff to discuss the concern of staff being mean or rough. Previous DON #291 revealed both STNA's continued to work their regular schedule, neither was suspended or talked to about the situation with staff being mean or rough. Previous DON #291 confirmed the statement from the residents regarding stuff being stolen from rooms was also not investigated. Previous DON #291 revealed there was a resident who would go in three other residents rooms and take stuff and either put it in his room or throw it on the roof. Previous DON #291 revealed she thought they (the residents in resident council) just made a funny remark about it and confirmed there was no reporting or SRI completed for either concern. Previous DON #291 confirmed Resident #28 would take things from Resident #32's room because he did not like him.
Interview on 02/22/24 at 11:50 A.M., with Activities Director #287 revealed she attended the Resident Council meeting on 12/12/23 and typed the minutes. Activities Director #287 revealed Resident #8 expressed the concern of STNA #220 and #242 on night shift and used the word rough. Activities Director #287 revealed Resident #8 did not explain how or what the STNA's did and confirmed Previous DON #291 was present. Activities Director #287 confirmed residents also reported in the meeting they were concerned with stuff being stolen from their rooms. Resident #28 would take things from Resident #32's room because he did not like him.
Interview on 02/22/24 at 11:59 A.M., with Administrator, revealed she was employed at the facility for less than two weeks. The administrator revealed if a resident made the statement of staff being rough or mean, she would do a reporting and submit an SRI immediately. Administrator confirmed no SRI or reporting was completed for the concerns from Resident Council on 12/12/23 and STNA #242 was never interviewed or suspended for any reporting and was still employed at the facility.
Review of the staff file and scheduled time worked for STNA #242 revealed STNA #242 worked night shift on 12/04/23, 12/05/23, 12/06/23, 12/10/23, 12/13/23, 12/14/23, 12/18/23, 12/19/23, 12/20/23, 12/24/23, 12/27/23, 12/28/23, 01/02/24, 01/07/24, 01/10/24, 01/11/24, 01/14/24, 01/15/24, 01/17/24, 01/21/24, 01/24/24, 01/25/24, 01/29/24, 01/31/24, 02/04/24, 02/07/24, 02/11/24, 02/14/24, 02/17/24, and 02/18/24.
Review of the Enhanced Information Dissemination and Collection (EIDC) system for SRI reporting revealed no evidence of the two allegations being reported.
Review of the policy titled, Abuse Prevention dated 08/20/21, included the facility will not tolerate Abuse, Neglect, Exploitation of its residents or Misappropriation of Resident Property. It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation of its residents or Misappropriation of Resident Property. Facility staff should immediately report all such allegations to the Administrator and to the State Department of Health.
This deficiency represents an incidental finding investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident council minutes, staff interview and review of the policy, the facility failed to investigate an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40.
Findings include:
1. Review for Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, morbid severe obesity and need for assistants with personal care.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. Resident #8 required assistants with activities of daily living.
2. Review for Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following cerebral infarction, and acquired absence of left leg below the knee.
Review of the annual MDS dated [DATE] revealed Resident #32 was moderately cognitively impaired. Resident #32 used a wheelchair for mobility. Resident #32 required substantial/maximum assistants with transfers and wheelchair mobility.
Review of the Resident Council minutes dated 12/12/23, unsigned, revealed State Tested Nursing Assistant (STNA) (#220) night shift is not the best; STNA #242-night shift is rough; residents wished nurses would take residents more seriously; and agency night nurses aren't good. Under the section in the Resident Council minutes titled: Concerns Not Covered included stuff being stolen from rooms.
Interview on 02/22/24 at 11:36 A.M., with Registered Nurse (RN) Corporate MDS Nurse/Previous Director of Nursing (DON) #291 revealed she was the Acting DON at the facility up until three weeks ago. Previous DON #291 revealed she attended the Resident Council meeting on 12/12/23. Previous DON #291 revealed she heard Resident #8 say the word mean not rough and they were two different words. Previous DON #291 revealed if she would have heard rough, she would have investigated the concern because that to her would mean hands on rough, mean meant something more verbal. Previous DON #291 revealed she spoke with Resident #8 after the meeting, and she asked Resident #8 what happened. Resident #8 said, they were mean, they kept telling her to go back to bed. Previous DON #291 revealed Resident #8 did not specify what happened, Resident #8 changed the subject and went on to say she did not receive her medication either. Previous DON #291 revealed she did not discuss the concern any further with Resident #8 about the staff being mean or rough or not receiving her medications. Previous DON #291 confirmed there was no investigation completed regarding Resident #8's concern with staff being mean or rough, she did not question any other residents to see if they had concerns with staff, and she never spoke with either STNA or any other staff to discuss the concern of staff being mean or rough. Previous DON #291 revealed both STNA's continued to work their regular schedule, neither was suspended or talked to about the situation with staff being mean or rough. Previous DON #291 confirmed the statement from the residents regarding stuff being stolen from rooms was also not investigated. Previous DON #291 revealed there was a resident who would go in three other residents rooms and take stuff and either put it in his room or throw it on the roof. Previous DON #291 revealed she thought they (the residents in resident council) just made a funny remark about it and confirmed there was no investigation completed for either concern. Previous DON #291 confirmed Resident #28 would take things from Resident #32's room because he did not like him.
Interview on 02/22/24 at 11:50 A.M., with Activities Director #287 revealed she attended the Resident Council meeting on 12/12/23 and typed the minutes. Activities Director #287 revealed Resident #8 expressed the concern of STNA #220 and #242 on night shift and used the word rough. Activities Director #287 revealed Resident #8 did not explain how or what the STNA's did and confirmed Previous DON #291 was present. Activities Director #287 confirmed residents also reported in the meeting they were concerned with stuff being stolen from their rooms. Resident #28 would take things from Resident #32's room because he did not like him.
Interview on 02/22/24 at 11:59 A.M., with Administrator, revealed she was employed at the facility for less than two weeks. The administrator revealed if a resident made a statement of staff being rough or mean, she would do an investigation immediately. Administrator confirmed no investigation was completed for the concerns from Resident Council on 12/12/23 and STNA #242 was never interviewed or suspended for any investigation and was still employed at the facility.
Review of the policy titled, Abuse Prevention dated 08/20/21, included the facility will not tolerate Abuse, Neglect, Exploitation of its residents or Misappropriation of Resident Property. It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation of its residents or Misappropriation of Resident Property. Facility staff should immediately report all such allegations to the Administrator and to the State Department of Health.
This deficiency represents an incidental finding investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility did not provide or offer resident showers or baths as care planned. This affected one (#9) of three residents reviewed for showers/bathing. The facility census was 20.
Findings include:
Observation on 02/20/22 at 1:40 P.M., revealed Resident #9 was sitting up in her wheelchair. Resident #9 was not answering questions. Resident #9's hair was disheveled and had a body odor.
Record review for Resident #9 revealed an admission date of 03/30/21. Diagnoses included muscle weakness, aphasia following cerebral infarction, muscle weakness and need for assistants with personal care. Resident #9 received Hospice services effective 01/26/24.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was unable to complete the interview. Resident #9 required substantial/maximum assist with bathing.
Review of the care plan dated 12/28/23 revealed Resident #9 had a self-care performance deficit and required extensive/total assist with showering.
Record review of the shower schedule revealed Resident #9 had a scheduled shower every Wednesday and Saturday.
Record review of the shower sheets on 02/21/24 for February 2024 for Resident #9 revealed Resident #9 received a shower on 02/07/24 and 02/14/24.
Interview on 02/22/24 at 3:42 P.M., with Director of Nursing (DON) revealed each resident was offered two showers a week and as needed. The facility staff documented on the shower sheets when residents received or refused a shower. DON confirmed Resident #9 was only offered two showers by the facility staff from 02/01/24 through 02/22/24. Resident #9 received hospice services and the Hospice services also completes showers in addition to the two offered by the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, activity calendar review, resident interview and staff interview, the facility failed to prove structured meaningful group activities for residents residing in the Memory Care Unit. This affected three (#7, #17, and #92) and had the potential to affect all 11 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #90 and #92) residing in the Memory Care Unit. The facility census was 40.
Findings include:
1. Review for Resident #17's medical record revealed an admission date of 01/19/24. Diagnoses included malignant neoplasm of the brain and diabetes mellitus. Resident #17 resided in the Memory Care (MC) Unit.
Review of the admission minimum data set (MDS) assessment revealed Resident #17 was severely cognitively impaired. Resident #17 required set up or clean up assistants with activities of daily living. Residents were independent with transfers and ambulation.
Review of the Activity Calendar posted in the Memory Care Unit for 02/21/24 revealed 10:00 A.M. Bingo; 11:00 A.M. Memory Care corner; and 2:00 P.M. Games. The activity calendar included activities daily for the month of February 2024 from 10:00 A.M. until 2:00 P.M., with the exception of Sundays when there were AA meetings scheduled at 6:00 P.M.
Observation on 02/21/24 at 10:00 A.M., revealed there were no activities (Memory Care Corner) going on in the memory care unit. Residents were observed wandering, sleeping, or sitting in a chair doing nothing. There was no music playing or staff interaction observed.
Interview at the time of the observation, with Central Supply/State Tested Nursing Assistant (STNA) #204 confirmed there were no activities at this time in the MC unit, but it was posted on the Activity Calendar.
Observation on 02/21/24 at 10:19 A.M., revealed Activity Director #287 was sitting in her office filling out blank activity forms for the entire month of February 2024 for Residents. Activity Director #287 confirmed the activity forms for the Residents in Memory Care were all blank for the entire month of February 2024 and she was trying to get caught up and get them filled in. Activity Director #287 revealed she had no training on activities, no certifications, she was the only staff member doing activities and she was also the Licensed Social Worker Designee for the facility. There was no other Licensed Social Worker or Licensed Social Worker Designee, so she had to do both jobs. Activity Director #287 confirmed there was no activity in the MC unit as scheduled at 10:00 A.M. because she had to catch up on her other work. Activity Director #287 revealed there were no actual group activities that ever occurred in the MC unit, she would do 1:1 every day, each resident in the MC unit would get 1:1 time talking, watching TV, or doing something two times a week. Activity Director #287 confirmed there were no structured group activities that occurred in the MC unit.
Interview on 02/21/24 at 10:50 A.M., with Licensed Practical Nurse (LPN) #222 revealed she never seen activities for the residents in the MC Unit. LPN #222 revealed sometimes Resident #90, #20, and #13 goes out of the MC Unit when other activities are going on like Bingo, but no other residents leave. LPN #222 revealed the residents in the MC Unit would benefit from structured activities and they would all be able to participate, if they had more to do, they would do more, they have nothing to do back here but watch TV.
Observation and interview on 02/21/24 at 10:55 A.M., revealed Resident #17 was lying in his bed staring at the ceiling. Resident #17 revealed he would like more things to do, he was bored and there was nothing to do.
2. Review for Resident #92's medical record revealed an admission date of 08/05/22. Diagnoses included vascular dementia. Review of the quarterly MDS revealed residents had a short term and long-term memory problem. Resident #92 resided in the Memory Care Unit.
Review of the care plan dated 12/28/23 revealed Resident #92 was dependent on staff for activities, cognitive stimulation, and social interaction. Interventions included inviting residents.
Observation and interview on 02/21/24 at 10:57 A.M., of Resident #92 revealed Resident #92 was sitting in his chair. Resident #92 revealed he would like more things to do.
3. Review of Resident #7's medical record revealed an admission date of 06/22/15. Diagnoses included unspecified dementia, restlessness, agitation, and wandering. Resident #7 resided in the Memory Care Unit.
Review of the quarterly MDS dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 was independent with ambulation.
Review of the care plan for Resident #7 included to explain to Resident #7 the importance of social interaction, leisure activity time and encourage Resident #7's participation.
Observation and interview on 02/21/24 at 11:00 A.M., with Resident #7 revealed Resident #7 was sitting in his chair. Resident #7 revealed he would like to sing in a quartet, play cards, draw pictures, Resident #7 revealed they don't do none of that here.
Interview on 02/21/24 at 11:07 A.M., with State Tested Nurse Aide (STNA) #246 revealed there were no activities in the MC Unit because those residents were not able to focus.
Interview on 02/21/24 at 11:23 A.M., with Office Personnel #281 revealed she was the Administrator Assistant. Office Personnel #281 revealed she held the activities license because she was certified in activities, but Activity Director #287 was the Activity Director. Office Personnel #281 revealed she was told the facility had to have someone certified in activities, so she kept her certification up, but she never worked in activities since 2020. Office Personnel #281 confirmed she did not complete or review the activities schedule; she did not participate or perform in any activities, and she did not oversee the program.
Interview on 02/21/24 at 11:35 A.M., with Administrator confirmed Office Personnel #281 did not participate or oversee any activities for residents residing in the facility. The administrator confirmed the MC Unit did not have any group activities or programming except for 1:1 two days a week. The administrator revealed the MC Unit should have programming specific for those residents.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to implement a physician order timely for treatment to a wound for a resident and complete wound treatments as ordered. This affected two (#9 and #16) of five residents reviewed for wound treatments. The facility census was 40.
Findings include:
1. Review of Resident #9's medical record revealed an admission date of 03/30/21. Diagnoses included blister to the right thigh, muscle weakness, age related nuclear cataract bilateral, contracture of the left hand, need for assistants with personal care, and nicotine dependence, cigarettes.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was unable to complete the interview. Resident #9 required assistants with activities of daily living.
Review of the progress note dated 11/21/23 at 12:59 A.M., completed by Certified Nurse Practitioner CNP #290 revealed Chief Complaint/Reason for this visit was the facility requested visit for wound to right thigh. Staff were assisting Resident (#9) with bathroom/hygiene care, and they noticed a blister on the right thigh. Staff also noticed a hole burned in the same location of her sweatpants. Resident had returned from smoke break recently. Treatment to the right thigh blister - apply bacitracin or stock topical antibacterial ointment and dry dressing to the right thigh wound daily until healed.
Review of the Treatment Administration Record (TAR) for Resident #9 for November and December 2023 revealed there was no treatment completed for Resident #9's burn to the right thigh. Review of the physician orders revealed the order for the wound care was put into the electronic medical record on 11/21/24 for Resident #9 but was not scheduled a time for the nurse to implement and complete the daily treatment. Review of the January 2024 TAR revealed the treatment for Resident #9's wound to the right thigh was initiated on 01/05/24.
Interview on 02/22/24 at 3:42 P.M., with Director of Nursing (DON) verified Resident #9 had a cigarette burn to her right thigh that occurred on 11/21/23. DON verified there was no treatment initiated to the burn on the right thigh until 01/05/24.
Observation on 02/22/24 at 3:44 P.M., with DON of Resident #9's right thigh revealed a small circular scar to the thigh. DON confirmed that was where the cigarette burns healed.
Interview on 02/26/24 at 10:12 A.M., with Previous DON #291 verified the order for Resident #9's wound care to the right thigh was put in the electronic medical record but did not carry over anywhere to where the nurses could see or complete it. The wound care to the right thigh was ordered 11/21/23 and not initiated until 01/05/24.
2. Review of Resident #16's medical record revealed an admission date of 03/19/20. Diagnosis included unspecified dementia, dysphagia following cerebral infarction, and need for assistants with personal care.
Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #16 was moderately cognitively impaired. Resident #16 required substantial/maximum assistants with personal hygiene. Resident had a feeding tube.
Review of the care plan dated 12/18/23 revealed Resident #16 required a tube feeding related to a history of dysphagia. Interventions included treatment of feeding tube insertion site as ordered. Monitor the area of signs and symptoms of infection when completing the treatment.
Review of the physician orders revealed on 10/20/22, Resident #16 received a physician order to cleanse the peg site with normal saline, apply xeroform and cover with drain sponge. Change daily.
Review of the physician orders revealed Resident #16 received a physician order on 01/05/24, gently wash peg tube site with soap and warm water, pat dry, sprinkle nystatin powder and cover with drain sponge daily and as needed.
Review of the TAR for February 2024 revealed both orders for Resident #16 for peg tube site care were present and signed daily by the same nurse.
Observation on 02/20/24 at 4:03 P.M., with Licensed Practical Nurse (LPN) #259 complete the treatment for Resident #16's peg tube site revealed LPN #259 removed the undated dressing to Resident #16's peg tube site. The insertion site was deep red and crusty dry drainage was on the old dressing and the insertion site along with a moderate amount of thick yellow drainage. There was a foul odor from the site. LPN #259 verified the drainage and odor. After removing the old dressing, LPN #259 removed her gloves, did not wash hands, then left the room and returned with gauze. LPN #259 again did not wash her hands, cleansed the peg tube site with normal saline, put a clean drain sponge over the site, taped and dated the dressing. LPN #259 then left the room and returned to her medication cart without washing her hands.
Interview at the time of the observation, revealed LPN #259 verified she cleansed the site with normal saline, nothing was applied but the drain sponge.
Interview on 02/26/24 at 10:30 A.M., with Registered Nurse (RN) Corporate MDS Nurse/Previous DON #291 revealed when the new order for the treatment for Resident #16's peg tube site was written on 01/05/24, they should have discontinued the old order written 10/20/22.
Interview on 02/27/24 at 8:00 A.M., with Registered Nurse (RN) #215 confirmed when she completed Resident #16's dressing change to the peg tube site, she would put nystatin on the site then the xeroform, she would combine both orders then sign both orders.
Review of the policy titled, Wound Care dated 05/01/22 included it is the policy of this facility to ensure that all residents skin conditions are properly tracked and cared for.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy, the facility failed to ensure fall prevention interventions were in place and ensure a resident was provided a smoking apron intervention to prevent burns. This affected six (#3, #9, #14, #27, #32, and #34) of seven residents reviewed for incidents and accidents. The facility census was 40.
Findings include:
1. Review of Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following cerebral infarction, and acquired absence of left leg below the knee.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 was moderately cognitively impaired. Resident #32 used a wheelchair for mobility. Resident #32 required substantial/maximum assistants with transfers and wheelchair mobility.
Review of the care plan for Resident #32 dated 12/28/23, revealed Resident #32 was at risk for falls related to gait/balance problems, impaired communication/comprehension, impaired safety awareness and impulsivity. The care plan did not include the intervention for dycem.
Review of the physician orders for Resident #32 dated 04/24/23 revealed an order for dycem to the wheelchair seat.
Observation on 02/20/24 at 3:26 P.M., revealed Resident #32 was sitting up in his wheelchair. Resident #32 revealed he did not have dycem in his chair. Resident #32 revealed he wasn't sure what that was, but staff never put anything under him to sit on.
Observation and interview 02/20/24 at 3:27 P.M., with State Tested Nursing Assistant (STNA) #219 confirmed Resident #32 did not have dycem in his wheelchair. Observation in Resident #32's room revealed there was no dycem in Resident #32's room. STNA #219 revealed she was unsure where dycem was kept.
Interview on 02/20/24 at 3:32 P.M., with STNA #256 revealed she worked with Resident #32 all the time and Resident #32 never had dycem to his wheelchair.
2. Review of Resident #27's medical record revealed an admission date of 01/25/17. Diagnoses included cerebrovascular disease, dementia, and repeated falls.
Review of the quarterly MDS dated [DATE] revealed Resident #27 was severely cog impaired and required substantial maximum assist with bed mobility, transfers, and wheelchair mobility.
Record review of the care plan dated 12/28/23 revealed Resident #27 was at risk for falls related to weakness, immobility, impulsiveness, impaired decision making and safety awareness. Interventions included dycem to wheelchair seat.
Record review of the physician orders for Resident #27 revealed an order dated 05/05/22 for dycem to the wheelchair.
Observation on 02/20/24 at 3:30 P.M., with STNA #219 and #246 confirmed Resident #27 was sitting up in his wheelchair. Resident #27 did not have dycem in his chair.
Interview on 02/20/24 at 3:32 P.M., with STNA #256 revealed she worked with Resident #27 all the time and Resident #27 never had dycem to his wheelchair.
3. Review of Resident #34's medical record revealed an admission date of 01/26/16. Diagnoses included Alzheimer's disease with early onset, hemiplegia and hemiparesis following cerebral infarction, spastic hemiplegia affecting left dominant side, Parkinson's disease, muscle weakness, unsteady on feet, and need for assistants with personal care.
Review of the quarterly MDS dated [DATE] revealed Resident #34 had a short- and long-term memory problem. Resident #34 used a wheelchair and was dependent for a chair to bed transfer and required substantial to max assist with wheelchair mobility.
Review of the care plan dated 01/28/24 revealed Resident #34 was at risk for falls related to incontinence, weakness, impaired safety awareness, impaired cognition, left hemiparesis, and impaired decision making. Interventions included antiroll back brakes and anti-tippers to the wheelchair and applying dycem to the wheelchair seat.
Review of the physician orders for Resident #34 included dycem to wheelchair at all times dated 05/19/20 and anti-tippers and anti-rollback to the wheelchair dated 01/29/18.
Observation on 02/21/23 at 10:50 A.M., revealed Resident #34 was sitting up in his wheelchair in the hall. Observation and interview with Licensed Practical Nurse (LPN) #222 confirmed Resident #34 did not have anti-tippers or anti-rollback to the wheelchair. LPN #222 also confirmed Resident #34 did not have dycem. LPN #222 revealed she was unsure when Resident #34 last had anti-tippers or anti-rollback to the wheelchair, but it must have been a long time ago.
4. Review of Resident #3's medical record revealed an admission date of 04/14/21. Diagnoses included Wernicke's encephalopathy, Parkinson's disease, degeneration of the nervous system, muscle weakness and history of falling.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 used a walker, required partial/ moderate assistants to stand and to ambulate.
Review of the care plan for Resident #3 revealed is at risk for falls related to a history of falls, psychoactive medications, syncope. Resident is impulsive- paces much of the day. Interventions included to encourage use of hipster padded undergarments to reduce risk of serious injury.
Observation and interview on 02/21/24 at 4:30 P.M., with STNA #283 and #213 of Resident #3 confirmed Resident #3 was not wearing hipsters and had none were available in his room. STNA #213 revealed she believed Resident #3 was supposed to wear hipsters, but none was available. Resident #3 revealed he would wear hipsters if he had them.
Interview on 02/27/24 at 10:40 A.M., with DON confirmed Resident #3 had no hipsters available in the facility. Observation of the laundry storage area with DON confirmed the facility had one small pair of hipsters, no other hipsters were available. DON confirmed Resident #3 wore a large. DON revealed staff were not offering or applying the hipsters.
5. Review of Resident #9's medical record revealed an admission date of 03/30/21. Diagnoses included anxiety disorder, muscle weakness, age related nuclear cataract bilateral, unspecified convulsions, contracture of the left hand, need for assistants with personal care, and nicotine dependence, cigarettes.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was unable to complete the interview. Resident #9 required assistants with activities of daily living.
Review of the care plan dated 04/08/21 revealed Resident #9 had potential for injury due to smoking habit. Resident #9 required supervision/monitoring for assistants while smoking. Interventions included Resident #9 was to utilize a smoking apron and a cigarette holder device while smoking.
Review of the progress note dated 11/21/23 at 12:59 A.M. completed by Certified Nurse Practitioner CNP #290 revealed Chief Complaint/Reason for this visit was the facility requested visit for wound to right thigh. Staff were assisting (Resident #9) with bathroom/hygiene care, and they noticed a blister on the right thigh. Staff also noticed a hole burned in the same location of her sweatpants. Resident had returned from smoke break recently. She wears fire resistant bib when out on smoke breaks. Resident was a current smoker every day. A treatment was ordered to the right thigh blister. Staff to ensure proper placement of fire resistance bib when out smoking.
Interview on 02/22/24 at 3:42 P.M., with DON verified Resident #9 had a cigarette burn to her right thigh that occurred on 11/21/23. DON revealed on the day Resident #9 obtained the burn to the right thigh, the cherry of the cigarette fell on her thigh. DON revealed staff was with Resident #9 on that day but did not have her smoking apron on. DON revealed after the burn occurred, staff were verbally in serviced to assure they placed the smoking apron on Resident #9 while smoking but nothing was in writing.
Observation on 02/22/24 at 3:44 P.M., with DON of Resident #9's right thigh revealed a small circular scar to the thigh. DON confirmed that was where the cigarette burns healed.
6. Review of Resident #14's medical record revealed an admission date of 02/25/21. Diagnoses included Tourette's syndrome, intervertebral disc degeneration, unspecified dementia, scoliosis, and repeated falls.
Review of the quarterly MDS dated [DATE] revealed Resident #14 was severely cognitively impaired. Resident #14 was independent with sit to stand, transfers and ambulation.
Review of the care plan dated 12/28/23 revealed Resident #14 was at risk for falls related to significant cognitive impairment, diminished safety awareness, wandering, and forgetting to use assistive devices. Interventions included to encourage resident to wear hipsters at all times.
Review of the physician orders for Resident #14 dated 12/28/21 revealed encourage hipsters to be worn when out of bed as tolerated. May remove for personal care.
Observation on 02/21/24 at 10:00 A.M., with STNA #219 confirmed Resident #14 was not wearing hipsters.
Review of the Treatment Administration Record (TAR) for Resident #14 for February 2024 revealed the hipsters were signed for each shift.
Interview on 02/27/24 at 10:40 A.M., with DON confirmed the TAR for Resident #14 was being signed by nurses and revealed the hipsters were offered. DON confirmed Resident #14 wore a size medium hipster and there was none available in the facility to offer. DON revealed she was aware nurses were signing the TAR without reading or completing the task they signed for.
Review of the policy titled, Fall and Incident Investigation dated 07/22/22, included in compliance with federal and state regulations, all resident occurrences, whether falls or incidents will be documented and investigated to ascertain root cause and have a plan developed to prevent reoccurrence.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

Based on observation, staff interview, and record review, the facility failed to provide nutritional supplements per physician orders. This affected one (#9) of three residents reviewed for supplements. The facility census was 40.
Findings include:
Review of Resident #9's medical record revealed an admission date of 03/30/21. Diagnoses included aphasia, dysphagia, and protein calorie malnutrition.
Review of the quarterly Minimum Data Set (MDS) for Resident #9 revealed the resident was unable to complete the cognitive status interview. Resident had weight loss not on prescribed weight loss regimen.
Review of the care plan dated 12/28/23 revealed Resident #9 had a nutritional problem related to disease process per nutritional assessment with a history of difficulty with chewing and swallowing. Interventions included providing supplements per order and provide and serve diet as ordered.
Review of the physician orders for February 2024 included Resident #9 was to receive a mechanical soft diet with thin liquids and a magic cup two times a day.
Observation on 02/20/24 at 4:30 P.M., revealed Dietary Manager #282 was serving resident trays. Dietary Manager #282 revealed the kitchen staff provided magic cups (frozen nutritional treat) on residents meal trays. Dietary Manager #282 revealed there were times the facility ran out of supplements.
Observation on 02/20/24 at 4:40 P.M., revealed Resident #9 was sitting in the dining room eating her dinner. Resident #9's meal ticket had (frozen nutritional treat) on the ticket. Resident #9 did not have the magic cup (frozen nutritional treat) on her tray.
Interview with Licensed Practical Nurse #259, at the time of the observation, verified Resident #9 did not receive her magic cup (frozen nutritional treat) as ordered by the physician.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error when medications were not administered per the physicians order. This affected one (#37) of three residents reviewed for medication administration. The facility census was 40.
Findings include:
Review for Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included unspecified psychosis and dementia.
Review of the progress note dated 12/29/23 at 12:52 P.M., completed by Licensed Practical Nurse (LPN) #201 included the nurse was notified by the physician that Resident #37 was hard to arouse and diaphoretic. The physician ordered a stat (immediate) laboratory test (labs).
Review of the physician orders revealed on 12/29/23 an order for Resident #37 was received for STAT Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential (Diff) and a Urinalysis (UA) culture and sensitivity (C&S).
Review of the progress note for Resident #37 dated 01/01/24 at 6:10 P.M., completed by Registered Nurse (RN) #292, revealed the lab results were received for Resident #37 and the potassium level was 5.8; (Certified Nurse Practitioner) CNP was notified, and new orders were received.
Review of the untimed physician order for Resident #37 dated 01/01/24 revealed an order for Lokelma oral packet 10 grams one packet two times a day for three administrations for hyperkalemia.
Review of the Medication Administration Record (MAR) for Resident #37 revealed Lokelma was not administered on 01/01/24 due to not being available. Review of the MAR revealed on 01/02/24 one dose of Lokelma was administered at 9:00 A.M.; further review of the MAR revealed no further doses of Lokelma was administered.
Review of the progress notes and medication administration notes for Resident #37 revealed no documentation was completed to determine why Lokelma was not administered for the three doses.
Interview on 02/22/24 at 3:01 P.M., with CNP #290 revealed a high and low potassium levels could cause cardiac arrhythmia's and if the potassium level got critically high, it could cause cardiac arrest. CNP #290 confirmed after she was made aware of the high potassium level, she ordered Lokelma 10 grams for three doses, (decreases the potassium level). CNP #290 confirmed she was not made aware Resident #37 only received one of the three doses ordered.
Interview on 02/22/24 at 4:43 P.M., with Director of Nursing (DON) confirmed Resident #37 only received one of the three doses of Lokelma ordered. DON also confirmed the physician nor CNP were notified of the missed doses of Lokelma for Resident #37. DON revealed she was not sure what happened, either the pharmacy did not deliver the medication, or the medication was input into the Electronic medical record incorrectly. DON revealed she would have expected the nurse to notify CNP/MD immediately if the medication was not available. DON confirmed the resident did not have any significant side effects from not receiving the medication as ordered.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure medications were stored in a secure manner. This affected one (#7) and had the potential to affect 10 (#6, #13, #17, #18, #20, #24, #28, #34, #90 and #92) additional residents residing in the Memory Care Unit. The facility census was 40.
Findings include:
1. Review of Resident #7 revealed an admission date of 06/22/15. Diagnoses included unspecified dementia moderate with psychotic disturbance, restlessness and agitation, delirium, noncompliance with other medical treatment, and wandering.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 had no impairment to upper or lower extremities and was independent with ambulation.
Review of the care plan for Resident #7 dated 01/12/24 revealed Resident #7 had a behavior problem of refusing medication. Interventions included anticipating and meeting the resident's needs.
Review of the Medication Administration Record (MAR) revealed Resident #7 received cetirizine HCL 10 milligrams (mg), Depakote sprinkles 250 mg, fluphenazine hcl concentrate five mg, tamsulosin 0.4 mg capsule, and Zoloft 50 mg, during the morning medication pass on 02/20/24. Orders also included may put medicine in food/drinks every shift.
Interview on 02/20/24 at 10:18 A.M., with Licensed Practical Nurse (LPN) #225 revealed LPN #225 was at her medication cart located in the hall in the Memory Care Unit. LPN #225 revealed Resident #7 had an order to put his medication in his drink or food. LPN #225 revealed Resident #7 liked coffee so the nurses put his medication in his coffee. LPN #225 revealed she already put all Resident #7's morning medication in his coffee (confirmed listed as above), and he was in the activity room drinking it. LPN #225 confirmed she left the coffee with the medications in it with Resident #7 to drink and confirmed she was unable to see Resident #7 to confirm he was consuming all his medication.
Observation on 02/20/24 at 10:21 A.M., with LPN #225 revealed Resident #7 was sitting in the activity room of the Memory Care Unit with Resident #6. No staff were in the area. Resident #7 had a Styrofoam cup sitting in front of him with a lid. Observation revealed there was no more coffee in the cup. In the bottom of the cup and along the sides were reminiscences of crushed medications that did not dissolve. LPN #225 stated most of the medication was the tamsulosin because it does not dissolve but she would leave it with him until he took it all. LPN #225 verified she routinely left Resident #7's coffee and medications with him unsupervised.
Review of the census revealed there were 10 additional residents (#6, #13, #17, #18, #20, #24, #28, #34, #90 and #92) residing on the Memory Care unit.
2. Observation on 02/20/24 at 1:00 P.M. revealed State Tested Nursing Assistant (STNA) #204 pushed the code on the door to the nurses station in the memory care unit and entered the nurses station. Observation revealed inside the nurses station was two large plastic bags sitting on the counter behind the nurses station. LPN #225 revealed the bags had medications inside. LPN #225 verified the medications on the counter were to be returned to pharmacy and confirmed a medication refrigerator was present that did not have a lock on it. Observation revealed inside the refrigerator were four unopened vials of insulin and one partial bottle of tuberculin. Interview at the time of the observation, with LPN #225 confirmed all STNA's had the code to the door to enter the nurses station and confirmed they would have access to the unsecured medications behind the nurses station.
Observation and interview on 02/20/24 at 1:05 P.M., LPN #225 then left the nurses station, no staff were present in the nurses station, LPN #225 walked up the hall turning the corner to the next hall when the surveyor requested her to return. Observation revealed when LPN #225 exited the nurses station, she closed the door, but the door did not latch allowing the residents residing in the memory care unit access to enter the nurses station where medications were not secured, and staff were not present. LPN #225 returned to the nurses station and verified the door was not secured revealing sometimes it does that. Observation revealed Resident #7 was ambulating near the nurses station. LPN #225 confirmed there were 11 residents residing in the Memory Care Unit who would have the ability to enter the area (Resident #6, #7, #13, #17, #18, #20, #24, #28, #34, #90 and #92).
Interview on 02/20/24 at 1:25 P.M., with Director of Nursing (DON) confirmed medications unsecured in the Memory Care Units nurses station were one full bottle of phenytoin oral suspension, one full bottle of lactulose, buspirone hcl tablets and one fluticasone propionate nasal spray. DON confirmed STNA's knew the code to the nurses station and had access to unsecured medications.
Review of the policy titled, Medication Storage dated 05/01/22, included the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses station or other secured location.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

Based on record review, staff interview, and review of the policy, the facility failed to notify the physician/Certified Nurse Practitioner (CNP) timely of a high potassium level (lab value) for one resident. This affected one (#37) of three residents reviewed for physician notification of lab results. The facility census was 40.
Findings include:
Review for Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included unspecified psychosis and dementia.
Review of the progress note dated 12/29/23 at 12:52 P.M., completed by Licensed Practical Nurse (LPN) #201 included the nurse was notified by the physician that Resident #37 was hard to arouse and diaphoretic. The physician ordered a stat (immediate) laboratory test (labs).
Review of the physician orders revealed on 12/29/23 an order for Resident #37 was received for STAT Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential (Diff) and a Urinalysis (UA) culture and sensitivity (C&S).
Record review of the progress note dated 12/29/23 at 8:50 P.M. completed by LPN #274, Resident #37 refused the lab draw and a STAT lab work to be called in first thing in am for re-attempt.
Review of the resulting lab report for Resident #37 revealed the blood work was collected 12/30/23 at 1:20 P.M. The results were faxed to the nurse at the facility on 12/31/23 at 6:13 P.M. Results included the potassium level was 5.8 (High) normal range was 3.5 to 5.1
Review of the progress note for Resident #37 dated 01/01/24 at 6:10 P.M., completed by Registered Nurse (RN) #292 revealed the lab results were received for Resident #37 and the potassium level was 5.8; (Certified Nurse Practitioner) CNP was notified and new orders were received.
Review of the physician order for Resident #37 dated 01/01/24 revealed an order for Lokelma oral packet 10 grams one packet two times a day for hyperkalemia.
Interview on 02/22/24 at 3:01 P.M. with CNP #290 confirmed she, nor the physician, was notified of the high potassium level for Resident #37 until 01/01/24. CNP #290 revealed a high and low potassium levels could cause cardiac arrhythmia's and if the potassium level got critically high, it could cause cardiac arrest. CNP #290 confirmed after she was made aware of the high potassium level, she ordered Lokelma 10 grams for three doses, (decreases the potassium level).
Interview on 02/22/24 at 4:43 P.M., with Director of Nursing (DON) revealed she would have expected the nurse to notify CNP/MD immediately after receiving the lab result at the facility on 12/31/23 at 6:13 P.M.
Review of the policy titled, Change in Condition Monitoring dated 05/01/22, included our facility shell promptly notify the resident, his or her attending physician, and Family/ POA/Guardian of changes in the residents medical/mental condition and or status.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy, the facility failed to consistently document three residents controlled drug administration on their Medication Administration Record (MAR). This affected three (#1, #2 and #3) of four residents reviewed for accuracy of documentation on the medication administration record. The facility census was 40.
Findings include:
1. Review of Resident #1's medical record revealed an admission date of 05/07/15. Diagnoses included lumbago with sciatica, low back pain and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired.
Record review of the physician orders for February 2024 revealed resident had an order to receive oxycodone hcl tablet five mg by mouth every six hours as needed for pain.
Record review of the Controlled Drug Record compared to Resident #1's Medication Administration Record (MAR) for February 2024 revealed Resident #1 received oxycodone hcl tablet five mg by mouth on 02/02/24 at 9:00 P.M., 02/03/24 at 1:00 A.M., 02/03/24 at 8:11 A.M., 02/08/24 at 2:00 P.M. and 10:00 P.M., 02/09/24 at 9:00 A.M., 02/13/24 at 2:30 P.M., 02/15/24 at 9:00 A.M., and 02/17/24 at 10:00 P.M. that was not documented in Resident #1's MAR.
2. Review for Resident #2's medical record revealed an admission date of 11/20/18. Diagnoses included traumatic brain injury, personal history of traumatic fracture, and presence of right artificial hip joint. Review of the quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact. Resident received as needed pain medication for frequent pain.
Record review of the physician orders dated 09/11/23 revealed Resident #2 was to receive oxycodone hcl oral tablet five mg one tablet by mouth every 12 hours as needed for moderate to severe pain.
Record review of the Controlled Drug Record compared to Resident #2's MAR for February 2024 revealed Resident #2 received oxycodone hcl oral tablet five mg one tablet by mouth on 02/01/24 9:00 A.M., 02/02/24 9:00 A.M., 02/03/24 t 5:00 A.M., 02/06/24 at 1045 P.M., 02/07/24 at 10:40 A.M. and 9:00 P.M., 02/08/24 at 9:00 A.M., 02/09/24 t 9:00 A.M., 02/10/24 at 9:00 P.M., 02/11/24 at 10:40 P.M., 02/12/24 at 9:00 A.M., 02/13/24 at 9:30 A.M. and 9:00 P.M., 02/15/24 at 10:00 A.M., 02/20/24 at 12:40 P.M., and 02/21/24 at 2:00 P.M. that was not documented in Resident #2's MAR.
3. Review for Resident #3's medical record revealed an admission date of 04/14/21. Diagnoses included Alzheimer's disease and anxiety disorder. Record review of the quarterly MDS dated [DATE] revealed Resident #3 received medication for anxiety.
Record review of the physician orders dated 02/07/24 revealed Resident #3 received ativan one mg by mouth every six hours as needed for anxiety.
Record review of the Controlled Drug Record compared to Resident #3's MAR for February 2024 revealed Resident #3 received the Ativan one mg on 02/02/24 at 12:40 P.M., 02/08/24 at 7:00 A.M., 02/09/24 at 10:00 A.M. and 10:00 P.M., 02/13/24 at 9:00 A.M. and 8:00 P.M., 02/16/24 and 02/20/24 at 6:17 P.M. that was not documented in Resident #3's MAR.
Interview on 02/22/24 at 2:28 P.M., with Director of Nursing (DON) confirmed nurses documented on the Controlled Drug Record when the pulled a controlled drug for a resident. The nurse then was required to document on the Resident's MAR when the resident received the medication for accuracy of administration. DON confirmed Resident #1, #2, and #3 did not have accurate documentation of controlled medications on the MAR.
Review of the policy titled, Medication Administration dated 05/01/22, included the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next one.
This deficiency represents non-compliance investigated under Complaint Number OH00150668.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to ensure routine ongoing skin assessments were completed to timely identify and/or prevent pressure ulcer development. This affected three residents (#7, #20 and #43) of four residents reviewed for skin assessments/pressure ulcer care and treatment.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of 08/28/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, heart failure, major depressive disorder, and vascular dementia.
Review of Resident #7's physician orders dated 07/31/20 revealed weekly skin checks by licensed nurse, every day shift, every Tuesday for weekly skin check.
Review of Resident #7's medical record including assessments dated 12/19/21 through 09/21/23 revealed on 12/19/21 Resident #7's Braden Scale for Predicting Pressure Ulcer Risk noted he was high risk for developing a pressure ulcer, injury. Further review did not reveal documented evidence Resident #7 had another Braden Scale assessment completed.
Review of Resident #7's care plan revised 04/07/23 included Resident #7 had an ADL (activity of daily living) self-care performance deficit related to diagnoses. Resident #7 would maintain his current level of function in self-care performance through the review date. Interventions included Resident #7 needed two staff members to be pulled up, centered on bed, and could make small changes in position using the half bed rails. Resident #7 needed weight bearing help with significant position changes. Resident #7 was totally dependent for incontinence care. Resident #7 needed weekly skin assessments by a registered nurse.
Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #7 was always incontinent of urine and bowel.
Review of Resident #7's medical record including progress notes and assessments dated 09/05/23 through 09/19/23 did not reveal documentation weekly skin checks were completed.
Interview on 09/21/23 at 3:01 P.M. with the Director of Nursing (DON) revealed weekly skin checks should be documented in the resident medical record under the assessment tab. The DON confirmed Resident #7 did not have weekly skin checks documented for 09/05/23, 09/12/23, or 09/19/23. The DON confirmed Resident #7 did not have a Braden Scale for Predicting Pressure Ulcer Risk completed since 12/19/21. The DON stated the facility had new ownership starting 07/2023 and when the systems merged some of the information might not have carried over.
Review of the facility policy titled Wound Care, dated 05/01/22, included the nursing staff and attending physician would assess and document an individual's significant risk factors for developing pressure sores, for example, immobility, recent weight loss and a history of pressure ulcers.
2. Review of the medical record for Resident #20 revealed an admission date of 06/30/23 with diagnoses including cellulitis of right and left lower limb, and chronic diastolic congestive heart failure.
Review of Resident #20's physician's orders revealed an order for head-to-toe skin check to be completed one time a day every Tuesday.
Review of Resident #20's assessments revealed no Braden Risk Assessment tool was completed since admission on [DATE] and only one weekly skin check was completed on 09/05/23.
Review of Resident #20's care plan dated 06/30/23 revealed Resident #20 had potential and actual impairment to skin integrity, 09/13/23 wound to left thigh treatment per physician orders. Interventions included to apply protective barrier cream after each incontinence and with A.M. and P.M. care, avoid friction and shearing, use turn sheet for repositioning, daily skin inspection during hands on care, follow facility protocols for treatment of injury, Resident #20 needed pressure relieving and reducing mattress, pillows, sheepskin padding to protect the skin while up in the chair, and to keep skin clean and dry.
Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #20 was at risk of developing pressure ulcer injuries and no formal assessment tool such as the Braden scale was used.
Observation of wound care for Resident #20 on 09/21/23 at 9:00 A.M. with Nurse Practitioner #322 revealed all prevention measures were in place at the time of the observation.
Interview with the DON on 09/21/23 at 3:45 P.M. confirmed that a Braden Risk Assessment tool was not completed and only one weekly skin check was completed on 09/05/23 for Resident #20. The DON further revealed that per company policy, residents were to have a Braden Risk Assessment completed quarterly and annually.
3. Review of the medical record for Resident #43 revealed and admission date of 01/29/22 with diagnoses including unspecified dementia severe with psychotic disturbance, paranoid schizophrenia, and chronic obstructive pulmonary disease.
Review of Resident #43's assessments revealed the most current Braden Risk Assessment was completed on 02/06/22.
Review of Resident #43's care plan dated 01/03/23 revealed Resident #43 had an actual alteration in skin integrity related to chronic vascular wound to the left lower leg, diabetic neuropathic foot ulcer to the left second toe, and frequently refused dressing changes and would remove completed dressings. Interventions included administering treatments as ordered, assessing, recording, and monitoring wound healing if wounds were present, encourage mobility, monitor nutritional status, and to provide incontinence care if soiled to reduce exposure to moisture.
Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #43 was at risk for developing pressure ulcers and no formal tool such as a Braden Risk Assessment was utilized.
Interview with the DON on 09/21/23 at 3:45 P.M. confirmed that a Braden Risk Assessment tool was not completed since 02/06/22 and further revealed that per company policy, residents were to have a Braden Risk Assessment completed quarterly and annually.
This deficiency represents non-compliance investigated under Complaint Numbers OH00146402, OH00146368 and OH00146399.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected seven of twelve rooms on the locked unit, the residents who used the East hallway, and had the potential to affect all 39 residents currently residing in the facility.
Findings include:
During the initial tour was conducted on 09/18/23 from 10:18 A.M. to 12:20 P.M. the following was observed.
•
room [ROOM NUMBER] had a sticky floor.
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room [ROOM NUMBER] floors needed cleaning, they had spills and sticky areas.
•
room [ROOM NUMBER] had sticky floors.
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room [ROOM NUMBER] had no paper towels. The floor and paper and crumbs.
•
room [ROOM NUMBER] had no soap in the in the soap dispenser.
•
room [ROOM NUMBER] had no soap in the in the soap dispenser.
•
room [ROOM NUMBER] the paper towel dispenser was not working and there was a spill on the floor.
The above observations were verified by State Tested Nurse Aide (STNA) #301 at the time of the observations.
Interviews on 09/18/23 from 11:09 A.M. through 4:02 P.M. and on 09/19/23 at 11:14 A.M. with five alert and oriented residents (#3, #7, #19, #23, #35) revealed they felt the facility was kept somewhat clean; some housekeepers were much more thorough than others.
Interview on 09/18/23 from 11:16 A.M. through 4:17 P.M. with staff revealed the facility had housekeeping issues. They stated there was often no soap and paper towels, the floors were sometimes dirty. At least one of the two housekeepers had called off that morning. The facility had been through a lot of cleaning staff. The cleaning people didn't show up sometimes.
Observation on 09/18/23 at 11:24 A.M. revealed the dining room on the locked unit had not been swept after breakfast. There were crumbs and other food debris under the tables. The dining room tables had not been wiped down. There were spills and liquids on the tables. This was verified by Licensed Practical Nurse (LPN) #302 who quickly began to sweep the floor and wipe the tables.
No housekeeping staff were observed on the East unit on 09/18/23.
Observations on 09/19/23 at 11:21 A.M. revealed the East hallway was sticky. It was observed that the staff's shoes would stick to the floor. If someone stood still for a minute their shoes stuck enough to almost pull them off. The floor was also dirty in areas. These observations were verified by STNA #303 at the time of the observation.
Observations on 09/21/23 at 10:38 A.M. with Maintenance/Housekeeping Director #310 revealed the following:
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The doors inside the locked unit entrance were peeling.
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room [ROOM NUMBER] wall at the doorway was peeling.
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The molding was peeling away at the entrance door to the locked unit from the East unit.
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room [ROOM NUMBER] didn't have paint above the lights and part of the wall appeared damaged.
Interview on 09/21/23 at 10:50 A.M. Maintenance/Housekeeping Director #310 verified the findings and revealed there had been issues with housekeeping. The facility lost some housekeeping staff and was working on getting good housekeeping staff. Rooms were to be deep cleaned after a resident left and before a new resident was moved into a room.
Interview on 9/21/23 at 5:03 with the Director of Nursing (DON) verified the facility was struggling with finding good reliable housekeepers.
This deficiency represents non-compliance investigated under Complaint Numbers OH00146402, OH00146399, and OH00146368.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #41 revealed an admission date of 07/03/23 with diagnoses including cerebral infarction, aphasia, hemiplegia, and hemiparesis right dominant side, bipolar disorder, paranoid schizophrenia, behavioral and emotional disorders, impulse disorder, restlessness, and agitation. The resident was transferred to the hospital 09/02/23 and had not returned.
Review of the admission MDS assessment dated [DATE] revealed Resident #41 had intact cognition. The assessment had not identified the resident to have behaviors of wandering. The resident was independent for ambulation.
Review of the elopement risk assessment dated [DATE] revealed Resident #41 was at low risk for elopement.
Review of the care plan dated 07/11/23 stated Resident #41 was an elopement risk. The intervention was to keep the resident's picture in the elopement book.
Review of the physician orders for September 2023 identified order that Resident #41 may go out on Leave of Absence (LOA), with medication, dated 07/10/2023. The resident was moved to the locked unit on 08/12/23.
Review of the Physician Progress Note dated 07/08/23 at 7:55 A.M. revealed Resident #41 occasionally signed and went out to eat with family.
Review of the nurses note dated 07/09/23 at 7:12 P.M. revealed Resident #41 was educated on making sure he signed out when he is going out on a LOA with his family or staff. The resident had an order for his supervised LOA with medications.
There was no note in the medical record regarding Resident #41 having left the faciity on his own without signing out.
Interview 09/19/23 at 4:01 P.M. with the Administrator and Chief Commercial Officer (CCO) #300 revealed the facility had a soft file on the incident of Resident #41 leaving the facility without signing out on 07/09/23. They felt the incident was not an elopement due to the fact that Resident #41 was cognitively intact and had an order for LOA that did not include supervision.
Review of the soft file included a summary of the incident dated 07/09/23. The summary stated Resident #41 was admitted [DATE], was [AGE] years old with a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. The resident had no Power of Attorney (POA) or guardian. The resident had diagnosis of aphasia and Moyamoya (a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain). The facility holds all smoking material and the resident thought he did not have any cigarettes. He walked to the gas station on Sunday, 07/09/23, to get a pack of cigarettes. He was educated to sign out and alert staff when he wanted to go out. The resident's mother agreed he could go out; however, also educated the resident to ask her or the staff when he wanted/needed something. He expressed understanding. A Quality Assurance and Performance Improvement (QAPI) was put in place covering new smoking assessments, smoking agreements, smoking care plans, LOA policy, LOA order, ensure LOA sign out book visible at each nurse's station and front desk.
Interview 09/19/23 at 4:01 P.M. with the Administrator and COO #300 verified there was no note in Resident #41's medical record regarding him leaving the facility on 07/09/23.
This deficiency represents non-compliance investigated under Complaint Number OH00146368.
Based on record review, interview, and observation the facility failed to ensure documentation was accurate for two residents (#20, and #41) out of four resident records reviewed for accurate documentation. The facility census was 39.
Findings include:
1. Review of the medical record for Resident #20 revealed an admission date of 06/30/23 with diagnoses including cellulitis of right and left lower limb, and chronic diastolic congestive heart failure.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 required extensive assistance of two or more staff members for bed mobility and dressing. Resident #20 required total dependance of two or more staff members for transfers, toilet use, and personal hygiene.
Review of physician orders for Resident #20 revealed an order dated 09/13/23 for left lower thigh posterior, medial area, to cleanse with normal saline, pat dry, pack wound with alginate silver, and cover with absorbent dressing to be completed one time a day and as needed.
Observation of wound care for Resident #20 on 09/21/23 at 9:00 A.M. with Nurse Practitioner (NP) #322 revealed soiled dressing that was removed had a date of 09/19/23.
Interview on 09/21/23 at 10:27 A.M. with NP #322 revealed soiled dressing that was removed during wound care observation was dated 09/19/23 and the current order was for dressing to be completed daily.
Review of Resident #20's Treatment Administration Record (TAR) for September 2023 revealed that on 09/20/23 the left lower thigh posterior medial area wound dressing was signed as completed.
Further review of Resident #20's TAR for August 2023 revealed an order for left lower thigh dressing to be completed twice a day at 9:00 A.M. and 9:00 P.M. Dressing changes were not signed as completed for 9:00 P.M. on 08/05/23 and 08/14/23 and 9:00 A.M. on 08/08/23 and 08/19/23.
Interview on 09/21/23 at 3:45 P.M. with the Director of Nursing (DON) confirmed dressings were not signed as completed on Resident #20's TAR for 08/05/23, 08/08/23, 08/14/23 and 08/19/23. The DON also confirmed that the dressing order was signed as completed on 09/20/23 even though soiled dressing that was removed during wound care observation was dated 09/19/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the failed to maintain Resident #7's padded electric wheelchair in a clean and sanitary condition. This affected one resident (#7) of 39 residents reviewed for environment.
Findings include:
Review of Resident #7's medical record revealed an admission date of 08/28/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, heart failure, major depressive disorder, and vascular dementia.
Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #7 was always incontinent of urine and bowel.
Review of Resident #7's care plan revised 04/07/23 included Resident #7 had an ADL (activity of daily living) self-care performance deficit related to diagnoses. Resident #7 would maintain his current level of function in self-care performance through the review date. Interventions included Resident #7 needed two staff members to be pulled up, centered on bed, and could make small changes in position using the half bed rails. Resident #7 needed weight bearing help with significant position changes. Resident #7 was totally dependent for incontinence care. Resident #7 used a wheelchair for mobility and needed staff assistance for locomotion at times.
Observation on 09/21/23 at 8:40 A.M. of State Tested Nursing Assistant's (STNA)'s #315 and #317 providing morning and incontinence care for Resident #7 revealed he was lying in bed. Observation of a padded electric wheelchair plugged into the electric outlet in Resident #7's room revealed the wheelchair was very dirty with flecks of food and a large amount of crusty brown material on the seat and down the front of the wheelchair reaching to the bilateral leg and footrests of the wheelchair. STNA #315 confirmed the presence of flecks of food and the large amount of crusty brown material, and stated the night shift aides were supposed to clean the wheelchair. STNA #315 stated day shift aides should also clean the wheelchair if they noticed it was dirty.
Interview on 09/21/23 at 8:45 A.M. of the Director of Nursing (DON) confirmed Resident #7's wheelchair was dirty and needed to be cleaned. The DON stated the night shift aides should have cleaned the wheelchair, but the day shift aides could clean it too.
This deficiency represents non-compliance investigated under Complaint Number OH99146420, OH00146399, and OH00146368.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy and procedure review and interview, the facility failed to timely identify, provide timely medical intervention and notify Resident #42's physician and power of attorney (POA) of an acute change in condition/altered mental status. This affected one resident (#42) of three residents reviewed for change of condition. The facility census was 39.
Actual Harm occurred beginning on 08/27/23 at 1:46 A.M. when facility staff failed to timely identify and provide medical intervention for an acute change in condition (including lethargy, pain, decreased oxygen level) for Resident #42. The resident was noted to have a change in condition with no evidence, from 08/27/23 through 08/31/23 the resident's physician or power of attorney (POA) were notified. On 08/31/23 at 9:36 P.M. per family request, 911 was called and Resident #42 was transported via Emergency Medical Services (EMS) to the local Emergency Department. Resident #42 was admitted to the hospital with a urinary tract infection and possible sepsis. The resident did not return to the facility.
Findings include:
Review of Resident #42's medical record revealed an admission date of 06/28/23 with diagnoses including malignant neoplasm of meninges, malignant neoplasm of prostate, and displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with malunion, and anemia in neoplastic disease. Resident #42 was transported to the hospital Emergency Department on 08/31/23, admitted to the hospital and was discharged from the hospital on [DATE] to a different Skilled Nursing Facility.
Review of Resident #42's Clinical admission Evaluation dated 06/29/23 included Resident #42 obeyed commands, and denied weakness, tremors, numbness, or tingling. Resident #42's mood was pleasant, and no unwanted behaviors were witnessed. Resident #42 was confused, speech was clear, had the ability to understand others, and made himself understood.
Review of Resident #42's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 required extensive assistance of two staff for bed mobility, transfers, and required total dependence of two staff for toilet use. Resident #42 was always incontinent of urine and bowel. Resident #42 required limited assistance of staff for eating.
Review of Resident #42's care plan dated 07/09/23 included Resident #42's power of attorney (POA) consented for all physician recommended medical or surgical treatments. Resident #42's POA's wishes would be honored through the next review date. Interventions included to communicate any change of condition with Resident #42 and his POA, explain any medical or surgical treatments being recommended by the physician and how they pertain to Resident #42's quality of life, report any change of condition to the nurse or social worker.
Review of Resident #42's progress notes dated 08/26/23 at 10:28 P.M. revealed Resident #42 was congested, had thick mucus coming from his nose, and had a moist cough. Vital signs included a temperature of 98.2 degrees Fahrenheit, respirations 22 per minute, blood pressure 111/54, pulse 70 beats per minute, and 93 percent oxygen saturation level on room air. Resident #42 was administered Levsin (gut antispasmodic) for secretions.
Review of Resident #42's progress noted dated 08/27/23 at 1:46 A.M. revealed hospice was notified and arrived at the facility to evaluate Resident #42. As a result of the visit, the facility nurse was told to monitor Resident #42 and if any changes took place to call hospice.
Review of Resident #42's Hospice Assessment notes dated 08/27/23 at 2:20 A.M. revealed an unidentified facility nurse called and reported Resident #42 was congested with a moist cough, thick mucus, and secretions. Respirations were 24 per minute with no shortness of breath or labored breathing. The medication Levsin used for secretions was effective. The facility nurse was advised to call the hospice agency if Resident #42 had a change in status.
Review of Resident #42's progress notes from 08/27/23 at 1:46 A.M. through 08/30/23 at 9:31 P.M. revealed no documented evidence Resident #42 was monitored for a change of condition. There was no documented evidence Resident #42's mental status or vital signs were checked during this time period. There was no documented evidence Resident #42's POA, the hospice nurse, or Resident #42's physician were notified of any issues for Resident #42's during this time period.
Review of Resident #42's progress notes dated 08/30/23 at 6:44 A.M. revealed the anti-anxiety medication, Ativan 0.5 milligrams (mg) (which could be administered every four hours as needed for anxiety) was administered.
Review of Resident #42's progress notes dated 08/30/23 at 6:48 A.M. revealed Morphine sulfate oral solution (opioid pain medication) 10 mg/5 milliliter (ml), 0.5 ml (which could be administered every two hours as needed for pain and shortness of breath) was administered for the resident crying and screaming.
Review of Resident #42's Hospice Assessment note dated 08/30/23 at 8:31 P.M. revealed an emergent visit for lethargy noted by family. Family stated this was not Resident #42's baseline and he was found by them freezing, cold, and unresponsive. Family stated Resident #42 was cold due to anemia and they encouraged the facility to put extra layers on him. At the time of the visit, Resident #42 was cool to touch, pulses were palpable, and skin was pale. Resident #42 was minimally responsive to verbal and painful stimuli. Per facility nurse Resident #42 was restless and crying out in pain and was medicated with Roxanol (Morphine) and Ativan at 6:50 A.M. and since then Resident #42 was minimally responsive. The plan was to hold pain medication and hope Resident #42's lethargy wore off and was due to poor excretion due to age and body. The facility nurses were instructed to hold nighttime antipsychotic medication and all as needed medications until morning and the hospice nurse could reassess Resident #42's level of consciousness. Family and facility nurses agreeable to the plan.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 10:21 A.M. revealed emergent visit for lethargy noted by family. Resident #42 was curled on his right side in bed. Resident #42 was oriented to self, was minimally verbal with garbled speech, and followed commands. Resident #42's skin was warm, dry, with no edema and not mottling. Resident #42 had left over food in his mouth which was gently removed. Resident #42 was changed to a pureed diet. The resident's lungs were clear to auscultation, respirations shallow from pain, no shortness of breath. Resident #42 was notably lethargic and had not been out of bed since 08/30/23. Coordinated care with facility staff, educated facility nurse to give as needed Morphine for pain. Resident #42 was to be a daily watch at this time.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 11:11 A.M. included Hospice Nurse (HN) #318 spoke with POA #340, and POA #340 was very upset regarding Resident #42's care at the facility. POA #340 stated she did not believe Resident #42 was declining, rather she believed there was something wrong that needs to be treated. POA #340 demanded a laboratory testing (a complete blood count (CBC) and Depakote level draw and wants everything to find out what's wrong. POA #340 was educated on limitations of treatment, tests when a resident was on hospice and Resident #42 could be discharged from hospice for seeking treatment. POA #340 stated she wanted hospitalization and treatment for Resident #42 until cardiac arrest. POA #340 verbalized understanding about possible discharge from hospice. CBC and Depakote draw requested from the hospice physician at this time.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:33 P.M. revealed POA #340 called HN #318 and expressed concern about Resident #42's hydration status. POA #340 stated Resident #42 got dehydrated and developed urinary tract infections (UTIs) frequently and wanted him tested for a UTI and specific gravity. Permission was given for a urine test for infection, but a specific gravity would not be covered. POA #340 verbalized understanding but still wanted a urine test for infection and a specific gravity. POA #340 and HN #318 discussed hospitalization for fluid resuscitation, and HN #318 reminded POA #340 hospice patients could not be admitted to the hospital for treatment or they would be discharged from services. POA #340 verbalized understanding.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:42 P.M. revealed the facility was called and Resident #42's lab order was placed with Licensed Practical Nurse (LPN) #309.
Review of Resident #42's progress notes dated 08/31/23 at 6:59 P.M. written by LPN #309 revealed new orders for STAT (immediate) labs from Hospice Nurse #318 for a CBC, Depakote level, urine culture and sensitivity and specific gravity would be passed onto oncoming nurse.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:15 P.M. included POA #340 called and was very upset and wished for Resident #42 to be sent to the hospital. POA #340 reported Resident #42's oxygen saturation level was 85 percent and he was pocketing food. POA #340 indicated she went to the facility on [DATE] and Resident #42 was sitting in his wheelchair underneath an air conditioner in the hall. POA #42 stated Resident #42 was very lethargic, his temperature was 95 degrees Fahrenheit, and she warmed him up with blankets. POA #340 stated she requested lab work and a urinalysis for culture and sensitivity earlier in the day (08/31/23) because she believed Resident #42 was anemic and possibly dehydrated with a UTI. POA #340 stated the facility left these labs for the night nurse and the results would not be back until next week due to the holiday weekend. POA #340 demanded Resident #42 to be transported via squad to the local hospital Emergency Department. Hospice Nurse (HN) #341 advised POA #340 she would contact the facility for more information.
Review of Resident #42's Pre-hospital Care Report Summary dated 08/31/23 included a call was received on 08/31/23 at 9:36 P.M. and Emergency Medical Services (EMS) were on scene at 9:40 P.M. The dispatch reason was respiratory distress. At 9:59 P.M. Resident #42's oxygen saturation level was 88 percent and oxygen was initiated at four liters nasal cannula. The POA told the facility to withhold all comfort care medications and to run diagnostic testing for illness. The POA requested transport to the Emergency Department for more diagnostic procedures. Patient contact was delayed due to fire department consultation with Med Control.
Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:39 P.M. included HN #341 spoke with the facility and was told POA #340 demanded Resident #42 be transported to the local hospital. HN #341 stated it was POA #340's wish that Resident #42 was transported to the local Emergency Department and the wishes must be followed.
Review of Resident #42's progress note dated 08/31/23 at 11:21 P.M. written by Licensed Practical Nurse (LPN) #313 included when LPN #313 arrived for work it was reported to her Resident #42 needed STAT (immediate) labs and a urine test completed. Lab work was ordered, and Resident #42 was catheterized to obtain a urine specimen. When LPN #313 entered Resident #42's room to administer bedtime medications she observed Resident #42 grimacing in pain and white thick secretions coming from his mouth. Resident #42's temperature was 98.7 degrees Fahrenheit, respirations were 16 per minute, pulse was 75, blood pressure was 148/55, and oxygen saturation level was 86 percent on room air. LPN #313 informed POA #340 of Resident #42's condition and that she would keep Resident #42 comfortable and administer oxygen to assist with his oxygen saturation level. POA #340 wanted Resident #42 to be sent to the Emergency Department to be evaluated. POA #340 stated she understood this could revoke Resident #42's hospice order. POA #340 wanted Resident #42 sent to the Emergency Department via 911 and Emergency Medical Services (EMS). LPN #313 called 911 and Resident #42 was transported to the local Emergency Department. Resident #42's POA, Director of Nursing, and the hospice nurse were updated.
Review of Resident #42's progress note dated 09/01/23 at 1:15 A.M. included Resident #42 was admitted to the local hospital with a diagnosis of UTI with possible sepsis. Resident #42 was removed from hospice status.
Interview on 09/20/23 at 11:29 A.M. with Resident #42's POA #340 revealed she wanted all life saving measures done for Resident #42 up until extreme measures would be implemented like intubation, chest compressions. POA #340 stated if Resident #42 needed medicine she wanted him to have it. POA #340 stated Resident #42 had a fractured right hip, surgery was not recommended due to his brain tumor, and he started receiving hospice services in 07/2023. POA #340 stated the main reason Resident #42 started receiving hospice services was because it was not known how fast his brain tumor would progress and communication with the facility was challenging due to new owners and administration. POA #340 stated she did not receive a call from the facility informing her Resident #42's mental status changed and when she came in for a visit on 08/30/23 and found him cold and freezing and not responding well. POA #340 stated the nurse and State Tested Nursing Assistant (STNA) #315 assigned to care for Resident #42 were regular facility staff, knew Resident #42 and should have known his baseline and realized something was off. POA #340 stated she told Hospice Nurse #318 that Resident #42 had a UTI, as she could almost guarantee it. POA #340 stated Resident #42 needed medicine to clear his infection, and she wanted him to have fluids and antibiotics. POA #340 stated she wanted Resident #42 to have blood work and a urine test, and Hospice Nurse (HN) #318 requested a urine test and blood work through the facility. POA #340 stated on 08/31/23 at 9:00 P.M. she received a call from the resident's facility nurse, she did not remember her name, and the nurse told her she was preparing to have Resident #42's urine test completed and blood work drawn. POA #340 stated she thought the facility nurse was calling to give her the results because the urine test and blood work should have been done in the morning. The nurse also told POA #340 Resident #42's oxygen saturation was 85 percent, and POA #340 indicated she insisted Resident #42 was sent to the hospital via a 911 call and transported by EMS. POA #340 stated Resident #42 laid in bed all day on 08/31/23 and was not responsive.
Interview on 09/20/23 at 3:31 P.M. of LPN #309 revealed she had just started working at the facility around 08/31/23 and did not remember Resident #42 or any details regarding his care.
Interview on 09/20/23 at 4:02 P.M. with LPN #313 revealed when she arrived for work on 08/31/23 at 6:30 P.M., LPN #309 reported to her Resident #42 needed a urine sample and blood work drawn STAT. LPN #313 stated Registered Nurse (RN) #316 assisted her, placed a Foley catheter to obtain the urine specimen, and checked Resident #42's vital signs. LPN #313 stated Resident #42 did not look well and was grimacing in pain. LPN #313 stated she called POA #340 and informed her of Resident #42's low oxygen level, and she could make Resident #42 comfortable with oxygen and pain medication. LPN #313 indicated POA #340 wanted Resident #42 sent to the hospital and asked if Resident #42's STAT labs and urine test were back because the order was written early in the day. LPN #313 indicated a urine specimen was collected and placed in the specimen area but would not be picked up until the morning. LPN #313 stated the urine specimen was not sent and blood work was not drawn because Resident #42 was transported to the Emergency Department.
Interview on 09/20/23 at 4:14 P.M. with RN #316 revealed on 08/31/23 Resident #42 was lethargic and she thought he was passing. RN #316 stated she obtained Resident #42's urine specimen via a Foley catheter, and it was supposed to be sent the next morning, but he was sent to the hospital and the urine was not sent. RN #316 stated Resident #42's urine was orange in color and was darker than it should have been. RN #316 stated she did not know why the urine and lab work were not done on the day shift. RN #316 stated Resident #42 was usually alert, but the day he was sent to the hospital he was lethargic, sleeping a lot, and it was a change from how he usually was.
Interview on 09/21/23 at 8:15 A.M. with STNA #315 revealed Resident #42 could answer questions and say things like good morning, and how are you, but could not carry-on long conversations. STNA #315 stated Resident #42's nurse told him the day before he went to the hospital that Resident #42 was in pain and trying to get out of his chair and she gave him something to calm down and help him relax. STNA #315 stated after Resident #42 received the medication he was less sleepy and talkative. STNA #315 stated the resident was a lot sleepy the day he went to the hospital, and STNA #315 thought it was because Resident #42 did not sleep well. The nurse told me Resident #42's family was concerned because he was not his normal self which was alert.
Interview on 09/21/23 at 8:29 A.M. with STNA #317 revealed Resident #42 was generally alert and not sleepy or lethargic.
Interview on 09/21/23 at 1:23 P.M. with Hospice Nurse (HN) #318 and Hospice Supervisor (HS) #320 revealed HN #318 visited Resident #42 once a week, but the last few days he was lethargic and he was visited two days in a row. Resident #42 received a hospice emergent visit for lethargy on 08/30/23 (Hospice Nurse #342) and 08/31/23. HN #318 stated on 08/31/23 Resident #42 was lethargic and POA #340 was concerned about the lethargy, concerned because Resident #42 was not eating and POA #340 was also worried the resident might have a UTI. HN #318 stated she had not visited Resident #42 since 08/23/23 but did not receive any calls 08/27/23 through 08/31/23 from the facility regarding Resident #42's status. HN #318 stated on 08/27/23 the facility called to let the hospice nurses know they were using Levsin for secretions. HS #320 stated they would expect to get a call if Resident #42 was lethargic or had a change in condition in case they needed to make a visit to make Resident #42 more comfortable. HN #318 stated she called LPN #309 on 08/31/23 at 2:42 P.M. and gave orders for lab work and a urine specimen to be completed for Resident #42. HN #318 stated Resident #42 had lethargy and increased pain on 08/31/23 and this was a change from 08/23/23.
Interview on 09/21/23 at 2:57 P.M. with the Director of Nursing (DON) revealed an actual physician order was not written on 08/31/23 for the urine specimen and lab work to be completed per hospice. The DON also stated even with the resident's advance directives for Do Not Resuscitate (regardless of a DNRCCA or DNR no intubation) would require staff to perform all life saving measures to be done for Resident #42 up until the point of cardiac respiratory arrest.
Review of the facility policy titled Change in Condition Monitoring, dated 05/01/22, revealed the facility should promptly notify the resident, his or her attending physician, and the family, guardian, POA of changes in the resident's medical, mental condition and, or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical, emotional, or mental condition. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status, and required interdisciplinary review and or revision to the care plan. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. Unless otherwise instructed by the resident a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications would be made within twenty-four hours of a change occurring in the resident's medical, mental, condition or status. The nurse would record in the resident's medical record information relative to changes in the resident's medical, mental condition or status.
This deficiency represents non-compliance investigated under Complaint Numbers OH00146368 and OH00146399.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure proper mouth care was provided for Resident #43. This affected one resident (#43) out of three residents reviewed for assistance with activities of daily living. The facility census was 39.
Findings include:
Review of the medical record for Resident #43 revealed and admission date of [DATE] with diagnoses including unspecified dementia severe with psychotic disturbance, paranoid schizophrenia, and chronic obstructive pulmonary disease.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 required extensive assistance of two or more staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene.
Review of the physician orders for Resident #43 revealed an order dated [DATE] to admit to hospice services.
Further review of physician orders for Resident #43 revealed no orders for mouth care.
Review of Plan of Care tasks for Resident #43 revealed assistance with personal hygiene tasks such as combing hair, brushing teeth, shaving, and washing face and hands was charted as completed on [DATE] at 6:32 P.M.
Review of hospice documentation revealed a progress note dated [DATE] 3:19 A.M. that stated that during inspection or Resident #43's mouth cavity revealed copious amounts of green debris with white spots and mouth care was immediately provided by Hospice Registered Nurse (RN).
Review of Plan of Care tasks for Resident #43 revealed assistance with personal hygiene tasks such as combing hair, brushing teeth, shaving, and washing face and hands was not documented as completed again until [DATE] at 6:26 P.M., more than 15 hours later.
Review of the progress notes for Resident #43 revealed a nurses note dated [DATE] at 10:49 P.M. that stated Resident #43 had expired at 7:24 P.M.
Interview on [DATE] at 3:20 P.M. with Licensed Practical Nurse (LPN) #309 revealed Resident #43 had a history of becoming combative with hands on care but prior to Resident #43's passing, he had become calm and hands on care was able to be given without resistance.
Review of the policy titled Resident Activity of Daily Living (ADL) Care, dated [DATE], revealed all residents were expected to maintain acceptable standards of oral hygiene and mouth care to be provided, when necessary, at intervals appropriate to resident's needs.
This deficiency represents non-compliance investigated under Complaint Number OH00146402.

Based on record review, observation and interviews, the facility did not ensure Resident #23 was treated with respect and dignity. This affected one resident (#23) of three residents reviewed for resident rights. The facility census was 44.
Findings include:
Review of Resident #23's medical record revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, schizophrenia, major depressive disorder, hearing loss, dementia severe with other behavioral disturbance, dependence on wheelchair, anxiety disorder, urgency of urination, agitation, and schizoaffective disorder. Resident #23 had a legal guardian.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/14/23, revealed the resident had severe impairment in cognition, no rejection of care, was always incontinent and required two-person extensive assistance with transfers.
Review of Resident #23's plan of care, date initiated 06/01/18 and revised on 06/15/23, revealed Resident #23 had intermittent behaviors including cursing, name calling/racial slurs, refusing care, throwing items, breaks furniture, spitting/hitting staff/other residents, repetitive verbalizations often centered around toileting needs saying she needed to go to the bathroom after just being toileted related to her cognitive impairment, poor impulse control, ineffective coping and mental illness.
Plan of care interventions included giving her as many choices as possible about care and activities, if she was angry and making negative statements, try to calm/comfort her. If she requested toileting immediately after staff take her, try to engage her in other things to take her mind off of the fixation. Provide positive feedback for good behavior. When resident became agitated, intervene by guiding away from source of distress, engage calmly in conversation and if response was aggressive, staff to walk away and approach later.
Review of a self-reported incident (SRI) dated 07/25/23 revealed the facility filed the SRI and opened an investigation in response to an allegation of abuse/neglect reported to the Director of Nursing by Resident #23's sister. Resident #23's sister referred to camera footage from the camera in Resident #23's room showing State Tested Nursing Assistant (STNA) #906 slamming doors, banging a wheelchair against the wall and yelling into the camera that the sister needed to tell Resident #23 to stop calling them names and Resident #23 was in the room while this was going on in the room. A second STNA #905 came into the room to provide care and gave a statement that Resident #23 told her STNA #906 was slamming doors. The facility requested the cameral footage which was noted on the follow- up investigation report as received at approximately 2:00 P.M. on 07/25/23. The facility unsubstantiated the allegation of neglect/abuse.
Review of camera video footage date marked 07/24/23, time marked 1:23 A.M. to 5:56 A.M. and submitted to the surveyor by Resident #23's guardian clearly showed Resident #23 at 2:22 A.M. sitting on the side of her bed. STNA #906 walked into the room, picked up Resident #23's legs, positioned her on the bed and clearly said I'm not pulling you up, you not about to break my back. STNA #906 also looked directly into the camera and said since you like to video tape everything, make sure you understand and uh, you better talk to your sister about calling people out of their name. STNA #906 was pointing back towards the resident, and she had an angry look on her face with an angry tone of voice.
Review of camera video footage date marked 07/24/23 at 5:56 A.M. revealed Resident #23 sitting on her bed while State Tested Nursing Assistant (STNA) #905 was putting pants on her. STNA #906 was also on the video in the room and took hold of a large object with handles resembling a wheelchair and pushed it into other objects in the room making a banging noise loud enough that STNA #905 stopped what she was doing to look at STNA #906. The STNAs proceeded to hook Resident #23's sling into a mechanical lift, then STNA #906 turned around, aggressively swung the room door open so hard it made a loud banging sound. Resident #23 called out an expletive towards STNA #906. STNA #905 told her you need to stop it and Resident #23 replied you heard her then said another expletive. STNA #906 came back into the room and again swung the door hard enough the door made a very loud banging sound. Neither of the STNA's tried to calm or comfort Resident #23. STNA #906 did not speak to the resident at all during this video footage while STNA #905 continued to lift her off the bed using the mechanical lift.
Review of the personnel file for STNA #906 revealed her employment with the facility was terminated on 08/02/23 due to a violation of resident rights and company policy.
Observation was conducted on 08/03/23 at 9:40 A.M. of Resident #23 in her room. She was alert, appropriately dressed and pleasantly confused. There was a ring camera in her room directed towards her bed.
Interview was conducted on 08/03/23 at 8:49 A.M. with the guardian of Resident #23 who verified she had sent the camera video footage into the facility and alleged neglect of Resident #23 who was her sister. The guardian said she believed Resident #23 was symptomatic for a urinary infection due to her behaviors and that she needed to be calmed which STNA #905 and #906 were not trying to calm her. The guardian expressed that by STNA #906 slamming the door in her sister's room that would cause fear in her sister which would have caused her to cuss more at the staff because cussing was her defense mechanism.
Interview was conducted on 08/03/23 at 12:12 P.M. with the Director of Nursing (DON) who verified the contents of the SRI dated 07/24/23 involving Resident #23, STNA #906 and STNA #905.
Interview was conducted on 08/03/23 at 1:55 P.M. with STNA #906 who stated since Resident #23 had a camera put in her room, the resident had become mean to staff. STNA #906 verified she cared for the resident and verified she yelled into the camera because the resident started calling her names around 5:00 A.M. She said the resident was in rare form that night and asked to go to the bathroom many times.
Interview was conducted on 08/03/23 at 2:09 P.M. with STNA #905 who verified she had worked with STNA #906 that evening of the referenced camera video footage. STNA #905 described STNA #906's behavior around Resident #23 as angry and unprofessional.
Interview was conducted on 08/03/23 at 4:44 P.M. with Corporate Operations Officer (COO) #910 who verified STNA #906 was terminated from her employment with the facility because of her conduct related to the incidents involving Resident #23.
This deficiency represents non-compliance investigated under Complaint Number OH00144905.

Based on observations, interview and record review, the facility failed to ensure the food was prepared, stored and served in a clean and sanitary manner. This had the potential to affect all 44 residents in the facility receiving meals from the kitchen, as there were no residents identified by the facility as nothing by mouth (NPO). The facility census was 44.
Findings include:
Observations during the initial tour of the kitchen on 11/14/22 from 8:15 A.M. to 8:30 A.M. revealed the walk-in freezer had a heavy ice build on the floor and reaching onto the bottom of the wire shelf and onto boxes of grilled chicken breasts, two cases of ground beef and one case of breaded fish sticks. Food splatter was on the wall behind the stove and wall near dishmachine. The microwave had dried food residue on the inside of the microwave. These observations were verified by Dietary Manager (DM) #275 at time of observation and DM #275 stated the dietary department had been short staffed recently as an explanation of the findings.
Review of the facility policies and procedures dated 1/22/09 with a revision date of 08/08/22, titled, Dietary/Food Handling revealed guidelines for the safe food preparation, handling, and storage of perishable food included a clean kitchen environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected two (Resident #2 and #4) of two residents reviewed for respiratory care. The facility had a census of 44 residents.
Findings include:
1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement and anxiety.
Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and utilized oxygen.
Review of Resident #2's care plan dated 01/10/19 revealed he had respiratory impairment related to chronic obstructive pulmonary disease and experienced shortness of breath while lying flat. He was noted to use oxygen frequently. Interventions included to administer medications as ordered.
Review of the physician's order dated 11/07/19 revealed Resident #2's nasal cannula and oxygen tubing was to be replaced, initialed and dated weekly on night shift. Review of the physician's order dated 02/09/22 revealed Resident #2 was to have distilled water to humidify oxygen for nasal dryness every shift.
Observation and interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed he had oxygen on at two liters via a nasal cannula. Oxygen tubing and distilled water were noted to be undated. He stated he was unsure when the oxygen tubing and distilled water were changed last.
Interview on 11/14/22 at 9:38 A.M. with Licensed Practical Nurse (LPN) #256 verified Resident #2's oxygen tubing and humidification bottle were undated.
Review of the facility policy titled, Medication Administration, dated November 2021, revealed medications are to be administered in accordance with written orders of the prescriber.
2. Review of the medical record for Resident #4 revealed an admission date of 11/20/18 with diagnoses including Alzheimer's disease, emphysema, anxiety and a traumatic brain injury.
Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition and utilized oxygen.
Review of Resident #4's care plan dated 12/30/19 revealed he had altered respiratory status and difficulty breathing related to chronic obstructive pulmonary disease and experienced shortness of breath while lying flat and on exertion. He was noted to use supplemental oxygen. Interventions included to administer medications as ordered.
Review of the physician's order dated 04/28/22 revealed Resident #4's oxygen was to be maintained at four liters to maintain oxygen level above 92%. There were no physician's orders for staff to change the nasal cannula and oxygen tubing. There was also no order for distilled water humidification to the oxygen concentrator.
Review of the November 2022 Medication Administration Record and Treatment Administration Record for Resident #4 revealed nursing had administered oxygen daily at four liters on dayshift and nightshift.
Observation and interview on 11/14/22 at 9:32 A.M. with Resident #4 revealed he had oxygen on at four liters via a nasal cannula. The oxygen tubing was noted to be undated. The oxygen concentrator had distilled water attached that was dated 10/06/22. He stated he did not know when the tubing or distilled water bottle were scheduled to be changed.
Interview on 11/14/22 at 9:38 A.M. with Licensed Practical Nurse (LPN) #256 verified Resident #4's oxygen tubing was undated and the distilled water humidification bottle was dated 10/06/22. She verified there were no orders to change the oxygen tubing weekly or for him to have distilled water humidification to the oxygen concentrator.

Based on record review and interview, the facility failed to ensure Resident #2's pain medication was administered as ordered. This affected one (Resident #2) of three residents reviewed for timely reordering of pain medications. The facility had a census of 44 residents.
Findings include:
Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement.
Review of the physician's orders for Resident #2, revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19.
Review of the October 2022 Medication Administration Record, revealed Resident #2's Methadone was not administered at 9:00 A.M. and 9:00 P.M. on 10/24/22 and 10/29/22.
Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/24/22 and 10/29/22.
Interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed there were times he did not receive his pain medications because the facility had not reordered the medication timely. He stated he was in pain when he did not receive the medication as ordered.
Interview on 11/15/22 at 3:00 P.M. with the Administrator verified Resident #2's Methadone was not administered on the dates listed above.
Review of the facility policy titled, Controlled Substance Prescriptions, dated November 2021, revealed re-orders for controlled medications should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assurance an adequate supply is on hand.
This deficiency represents non-compliance investigated under Complaint Number OH00133336.

Based on review of facility staffing schedules and staff interviews, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 44 residents currently residing in the facility.
Findings include:
Review of the nursing staff information and staff schedule for 11/5/22 revealed no RNs were present and working in the facility.
Interview on 11/17/22 at 11:10 A.M. with Business Office Manager (BOM) #255 confirmed there was not an RN in the building on 11/5/22, the Director of Nursing (DON) #223 was scheduled on call.
Interview on 11/17/22 at 11:22 A.M. with the Director of Nursing (DON) #223 confirmed she was on call but did not work in the facility on 11/5/22 and there was not an RN working.

Based on observation, interview and record review, the facility failed to serve food in the proper portions to meet the nutritional needs of all residents in the facility ordered regular and therapeutic diets. This affected all 44 residents receiving meals from the kitchen, as no residents were identified by the facility as nothing by mouth (NPO). The facility census was 44.
Findings include:
Review of the facility's diet list revealed all residents received a variety of diet types including carbohydrate controlled diet (a therapeutic diet used to help control blood sugar levels in residents with diabetes), no added salt (NAS) diet, mechanically altered diet and regular diets with no restrictions.
Review of the posted lunch menu for 11/15/22 revealed the meal being served to the residents included beef pot pie, broccoli, choice of bread and apricot crisp.
Review of Resident Council meeting minutes for 04/27/22 revealed concerns with diet orders not being followed and the minutes for 10/19/22 revealed a concern with meal tickets not being followed and residents receiving the wrong foods.
Review of the beef pot pie recipe revealed the following main ingredients should be included in the recipie: diced beef, sliced carrots and frozen peas. The serving size was eight ounces (oz). This was verified by DM #275 on 11/15/22 at 3:00 P.M.
Observation on 11/15/22 at 11:25 A.M. of the lunch tray line meal service revealed beef pot pie, broccoli, and biscuits were being served for the resident meal. The beef pot pie did not have any vegetables in it, the beef appeared to be shredded not diced and the portion being served on the meal plates was one, four-ounce (oz.) spoodle. The broccoli portion being served was one, four oz. spoodle. The pureed beef pot pie had a green, #12 scoop to serve (which is equivalent to 3 oz), and pureed vegetables had a #16 scoop to serve (which is equivalent to two oz.). Dietary Manager (DM) #275 verified the portion sizes being served.
Interview on 11/15/22 at 11:25 A.M. with DM #275 revealed a spreadsheet to guide the cooks on proper portions for each diet type could not be found for the lunch meal on 11/15/22 so no spreadsheet had been used as a guide for proper portion sizes for the meal. When the surveyor asked DM#275 to see the spreadsheet for the meal DM #275 pulled out a spreadsheet dated 06/06/21 and said to use this one. The menu on the spreadsheet for lunch was turkey pot roast 3.5 oz., one baked potato, 4 oz. carrots, choice of roll, one dessert choice and was dated Sunday 06/06/21. DM #275 verified the spreadsheet did not match the meal being served at lunch.
Interview on 11/15/22 at 11:35 A.M. with DA #257 revealed DA #257 did not use spreadsheets to prepare desserts for the carbohydrate controlled diets. DA #257 stated a spreadsheet was not needed because the carbohydrate controlled diets always got the same foods as a regular diet. DA #257 said the dessert for the meal was gelatin cake, and the cake was made with diet gelatin.
Interview on 11/16/22 at 10:00 A.M. with Registered Dietician (RD) #243 revealed he only did a tray line audit as needed, did not have access to the tray card system and did not sign off on any menus or spreadsheets to certify the menus or spreadsheets met the nutritional requirements for all diet types for all residents in the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00136004 and OH00133336.

Based on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures. This had the potential to affect 44 residents receiving meals from the kitchen. No residents were identified as nothing by mouth (NPO). The facility census was 44.
Finding include:
Observation on 11/15/22 at 11:25 A.M. of the lunch tray line revealed all hot food items on the steam table had temperatures over 165 degrees Fahrenheit (F) including beef and broccoli. There was no heat retention system being used in the kitchen to keep the food warm once it left the steam table besides thermal domes to cover the plates and enclosed meal delivery carts. The meal delivery cart carrying a test tray left the kitchen at 12:11 P.M. and arrived on the unit at 12:12 P.M. The test tray was the last tray served off the cart to Dietary Manager (DM) #275 who proceeded to take temperatures of the beef and broccoli on the test tray. The beef and broccoli did not reach 100 degrees Fahrenheit (F) as verified by DM #275 during the observation. DM #275 stated the food should be hotter.
Interview on 11/16/22 at 10:00 A.M. with Registered Dietician (RD) #243 revealed he only conducted tray line audits on an as needed basis.
Review of the resident Council minutes revealed cold food was a concern on 12/15/21, 01/19/22, 02/16/22, 03/23/22, and 10/19/22.
Review of the facility policies and procedures dated 1/22/09 with a revision date of 08/08/22, titled, Dietary/Food Handling revealed that temperatures must be maintained for hot food at 135 degrees F or above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve food at the proper consistency to Resident #35. This affected one resident (Resident #35) of 44 residents receiving meals from the kitchen. No residents were identified by the facility as nothing by mouth (NPO). The facility census was 44.
Findings include:
Record review revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease, vascular dementia with mood disturbance, dysphagia following cerebral infarction and aphasia.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was severely cognitively impaired and required extensive assistance of one staff for eating.
Review of the plan of care for Resident #35 dated 04/05/21 with a revision date of 10/14/22 revealed Resident #35 had a nutritional problem related to diagnoses and a history of difficulty chewing/swallowing. Interventions included but not limited to monitor, document and report to physician as needed for signs and symptoms of dysphagia to include pocketing, choking and several attempts of swallowing.
Review of the physician's orders for November 2022 revealed orders for a regular diet with mechanical soft texture and pureed vegetables and thin liquids.
Review of Resident #35's diet ticket revealed Resident #35 would receive a regular diet with mechanical soft texture and pureed vegetables at meals.
Observation on 11/15/22 from 11:25 A.M. to 12:10 P.M. of the lunch tray line revealed Resident #35 was given regular vegetables instead of pureed vegetables.
Interview on 11/15/22 at 11:45 A.M. with Dietary Aide #257 verified Resident #35 was given regular vegetables on her meal tray because Resident #35's boyfriend (another resident in the facility) feeds her and that made it ok to give her regular vegetables when the boyfriend feeds her. When asked by the surveyor where she got that information DA #257 stated that was what nursing told her.
Additional review of the physician orders and care plan for Resident #35 revealed there were no orders or care plan to indicate it was ok for Resident #35's boyfriend to feed her regular vegetables that were not pureed.

Based on record review and interviews, the facility failed to ensure all narcotic medication accounting logs were maintained. This affected one (Resident #2) of three residents reviewed for documentation and accounting of narcotic medications. The facility had a census of 44 residents.
Findings include:
Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement.
Review of the physician's orders for Resident #2 revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19.
Review of the October 2022 Medication Administration Record, revealed Resident #2 was administered Methadone 30 mg at 9:00 A.M. and 9:00 P.M. on 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and 10/28/22.
Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and 10/28/22.
Interview on 11/15/22 at 12:26 P.M. with the Administrator verified the controlled drug records for Resident #2's Methadone 10 mg tablets to be missing for the dates listed above.
Review of the facility policy titled, Controlled Substance, dated November 2021, revealed accurate accountability of the inventory of all controlled drugs was to be maintained at all times.

Based on record review, observation and staff and resident interviews, the facility failed to act promptly upon grievances voiced during Resident Council meetings concerning issues of resident care and life in the facility. This affected four residents (Resident #3, #10, #11, and #29) of six residents who attended the resident council meeting and voiced concerns. The facility census was 44.
Findings included:
Review of the Resident Council meeting minutes dated 11/17/21, 12/15/21, 01/19/22, 02/16/22, 03/23/22, 04/27/22, 05/25/22, 06/22/22, 07/20/22, 08/29/22, 09/21/22, and 10/19/22 revealed the residents voiced concerns about hot food not being hot, not receiving evening snacks, therapeutic diets not being followed, inconsistent meal delivery times, no weekend activities and showers not being provided as preferred. There was no documented evidence the facility acted promptly on these concerns.
Interviews were conducted on 11/15/22 at 10:00 A.M. with Residents #3, #10, #11 and #29 at the Resident Council meeting. Resident #3 stated when she raised concerns at the meeting those concerns did not get addressed by administration. Resident #10 stated she did not feel her concerns were being addressed by administration. Resident #11 stated his concerns were not addressed by administration. Resident #29 expressed he felt his concerns were not always taken seriously or addressed by administration. Resident #3, #10, #11 and #29 verified the concerns voiced in the meeting minutes from 11/17/21 to 10/19/22 were ongoing concerns.
Record review and interview on 11/15/22 at 2:33 P.M. with the Administrator revealed there she had four resident concern forms, dated 01/05/21, 01/07/21, 11/23/21 and 03/23/22, since starting her position in August 2022. The Administrator revealed she was the person responsible to fill out the concern forms and logs for any resident concerns, she had not been receiving the resident council meeting minutes since starting her position in August 2022, and would begin requesting the resident council meeting minutes so she could review and address the concerns.
Review of the 06/27/07 facility policy called, Grievance Committee Policy and Procedure revealed any issues or concerns regarding violation of Resident Rights that are discussed in Resident Council will be referred to the Grievance Committee. All actions taken by the Grievance Committee that directly affect the resident of the home will be followed up on and discussed in Resident Council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #299) of one resident reviewed for funds conveyance. The facility census was 44.
Findings Include:
Resident #299 was admitted to the facility on [DATE]. Resident #299 expired at the facility on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis right side, dysphagia, diabetes mellitus, depression, and cerebral infarction.
Review of the business records for Resident #299 revealed $974.48 were dispersed to the State Recovery of the United States on [DATE].
Interview on [DATE] at 9:46 A.M. with Human Resource Manager/Business Office Manager (HR/BOM) #255 revealed the corporate office sends her the check and then she sends it out right away. HR/BOM #255 verified that Resident #299's funds were conveyed outside of required timeframes (30 days).

Based on observations, interviews and record review, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #2) of one resident reviewed for improperly stored medications. The facility had a census of 44 residents.
Findings include:
Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement, anxiety and non-compliance with medications and treatment regimens.
Review of the care plan dated 01/10/19 revealed Resident #2 had respiratory impairment related to chronic obstructive pulmonary disease with interventions including to administer medications per order. It was not care planned the resident could have medications at bedside and self administer.
Review of the physician's orders for Resident #2 revealed an order for Advair Diskus Aeorosol Powder Breath Activated 250-50 micrograms (mcg) (medication for chronic obstructive pulmonary disease), one inhalation, orally every 12 hours for shortness of breath dated 06/26/22. There were no indications resident could keep the medication at bedside and self administer.
Review of the November 2022 Medication Administration Record, revealed Advair 250-50 mcg was last administered on 11/15/22 at 9:00 P.M.
Observation on 11/16/22 at 8:21 A.M. of Resident #2's room revealed Advair 250/50 mcg to be on the bedside tray table. Resident #2 stated when the nurse brought his inhaler to his room, he used it and then dropped it on the bed. Resident #2 stated he tried to find it on the bed but could not. He stated the nurse said she would come back later to retrieve the medication. Resident #2 could not state when the nurse had brought the Advair to the room or who the nurse was.
Interview on 11/16/22 at 8:25 A.M. with Licensed Practical Nurse (LPN) #225, verified the Advair should not be left in Resident #2's room and she would remove it.
Review of the facility policy titled, Medication Storage in the Facility, dated November 2021, revealed medications intended for internal use are to be stored in a medication cart or other designated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected three residents (Residents #3, #10 and #29) of six reviewed who attended the resident council meeting and voiced concerns. The facility census was 44.
Findings include:
1. Review of medical record for Resident #3 revealed an admission date of 10/22/21. Diagnoses included cerebral infarction, hemiplegia affecting the right dominant side, bipolar type schizoaffective disorder, and diabetes mellitus with stage three diabetic chronic kidney disease.
Review of the 10/16/22 Minimum Data Set (MDS) assessment revealed she was moderately cognitively impaired. Review of activities of daily living (ADLs) revealed Resident #3 required extensive assist of one staff for transfer, toileting, and personal hygiene.
Interview during the resident council meeting conducted on 11/15/22 at 10:00 A.M. revealed Resident #3 stated mail was not received on Saturdays.
2. Review of medical record for Resident #10 revealed an admission date of 06/13/18. Diagnoses included schizophrenia, hypertensive heart disease with heart failure, depression, type two diabetes mellitus with neuropathy, and morbid obesity.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Activities of daily living (ADLs) revealed Resident #10 required extensive assist of one staff for bed mobility, transfer, transfer on and off the unit and toileting. Resident #10 required extensive assist of two staff for dressing and personal hygiene.
Interview on 11/15/22 at 12:25 P.M. with Resident #10 revealed no mail was passed on the weekends.
3. Review of medical record for Resident #29 revealed an admission date of 08/25/22. Diagnoses included alcohol use with dementia, aortic aneurysm without rupture, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, type II diabetes mellitus with diabetic neuropathy, spondylolysis, hypothyroidism, chronic viral hepatitis C, post-traumatic stress disorder, and dementia with agitation.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29 required limited assistance of one staff for bed mobility, transfer, walking in room and toileting and supervision for bathing, dressing, and eating meals.
Interview on 11/15/22 at 12:15 P.M. with Res #29 confirmed he does not receive mail on Saturdays because the office was closed.
Interview on 11/15/22 at 12:41 P.M. with Activities Supervisor #283 revealed there was no activities staff on the weekends, the Business Office Manager (BOM) picks up the mail and gives it to activities director or the Social Worker designee (SSD) to deliver Monday through Friday.
Interview on 11/21/22 at 10:00 A.M. with the Administrator verified the facility does not have a policy and was not specifically mentioned in the admission packet regarding receiving mail on the weekends, it is just part of their rights as a resident while living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #39) of one resident reviewed for advanced directives. The facility census was 44.
Findings Include:
Resident #39 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, schizophrenia, bipolar and systemic lupus erythematosus. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderate cognitively impairment and was independent for activities of daily living.
Review of the physicians' orders for Resident #39 revealed an order dated [DATE] for do not resuscitate comfort care (DNRCC) a code status signifying cardiopulmonary resuscitative measures (CPR) was not to be conducted in case of cardiac or respiratory arrest.
Review of the care plan dated [DATE] revealed the resident was a do not resuscitate comfort care- arrest (DNRCC-A) code status signifying medical interventions to maintain life up to the point of the heart or lungs stopping and CPR would not be performed on Resident #39.
Review of the signed electronic documents section of Resident 39's medical record revealed no signed DNR was in the chart.
Record review and interview on [DATE] at 5:14 P.M. with Licensed Practical Nurse (LPN) #256 revealed Resident # 39 's electronic medical record stated she was a DNRCC per the doctor's orders. The hard chart had no signed DNRCC document and on the outside of the hard chart was a sticker that stated Full Code meaning all life sustaining measures including CPR would be performed on Resident #39. This was verified by LPN #256 at time of the record review and LPN #256 stated the codes status should be the same throughout the medical record.

Based on medical record review, staff and family representative interview, and review of the facility policy, the facility failed to ensure a resident's family was notified following a change in status. This affected one (Resident #33) of three residents reviewed for notification of change in condition. The facility census was 44.
Findings include:
Review of the medical record for Resident #33 revealed an admission date of 11/07/17. Diagnoses included unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic kidney disease stage three, hypertensive chronic kidney disease, type two diabetes mellitus, history of traumatic brain injury, schizoaffective disorder bipolar type, and chronic viral hepatitis C.
Review of the 08/31/22 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #33 revealed a brief interview of mental status score of two which indicated severe cognitive impairment. Resident #33 was noted to be totally dependent upon one staff for toileting and bathing, required extensive assist of one staff for locomotion on and off the unit, dressing, eating and personal hygiene. Resident #33 required extensive assist of two staff for bed mobility and transfer. Resident #33 was noted to be incontinent of bowel and bladder.
Review of facility self-reported incident (SRI) # 224007 dated 07/13/22 revealed Resident #33 called the local police with a concern of staff not taking care of him. The facility completed an investigation and was found to be unsubstantiated but failed to notify Resident #33's representative following the incident.
Interview on 11/14/22 at 12:45 P.M. with Resident #33's representative confirmed she was not aware of any incident on 07/11/22 and had not been notified by the facility.
Review of nursing progress note for Resident #33 dated 07/11/22 revealed Resident #33 called the police. Following the investigation by the police, Licensed Practical Nurse #277 notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON).
Interview on 11/17/22 at 9:17A.M. with MDS #273 verified there was no documentation evidence Resident #33's representative had been notified timely of the incident.
Review of undated facility policy called, Your Rights and Protections as a Nursing Home Resident revealed the facility must notify the doctor and legal representative or interested family member if your physical, mental, or psychosocial status starts to get worse.
Review of undated facility policy called, Condition Change Policy and Procedure revealed notify physician and family and document the name of the family member documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received showers as scheduled and per their preference. This affected three (Residents #2, #3, and #19) of three residents reviewed for showers. The facility had a census of 44 residents.
Findings include:
1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, and bed confinement.
Review of Resident #2's Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and required limited assistance of one staff member for hygiene. Bathing did not occur on this assessment.
Review of Resident #2's care plan, dated 01/10/19, revealed he had self-care performance deficit related to morbid obesity, weakness and degenerative disc disease of the lower spine. Interventions included staff to provide extensive assistance for showering and bathing.
Review of the shower log for Resident #2 revealed he was to receive his showers on Tuesdays and Fridays. Review of his shower sheets from 10/04/22 through 11/11/22, revealed he did not receive showers on 10/11/22, 10/15/22, 10/18/22, 10/25/22, 10/28/22, 11/01/22, 11/04/22, 11/08/22 and 11/11/22.
There were no shower sheets or documentation in the electronic chart for Resident #2 for October 2022 or November 2022.
Interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed he does not get his showers as scheduled. He stated staff will put that he refused showers even though he did not.
Interview on 11/15/22 at 03:00 P.M. Administrator confirmed nothing was documented under tasks in the electronic medical record for showers and confirmed no further shower sheets were available for this resident.
2. Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to acute cerebral infarction, type two diabetes, schizoaffective disorder, bipolar and chronic obstructive pulmonary disease.
Review of this residents Minimum Data Set Assessment (MDS) 3.0 assessment, dated 10/16/22, revealed this resident had moderately impaired cognition and required extensive assistance of one staff for transfers, toilet use and personal hygiene.
Review of this resident plan of care dated 07/21/21 revealed this resident had an Activities of Daily Living self-care performance deficit related to diagnoses. Interventions for this plan of care included to encourage a sponge bath when a full bath or shower cannot be tolerated.
Interview on 11/14/22 at 11:32 A.M. with Resident #3 says she was told that she couldn't get a shower yesterday. Resident #3 didn't know what days her shower days were but wanted one yesterday.
Review of October 2022 shower sheets for Resident #3 revealed she received showers on 10/02/22 and 10/09/22 but refused showers on 10/11/22 and 10/13/22.
There were no shower sheets or documentation in the electronic chart for Resident #3 for November 2022.
Interview on 11/15/22 at 03:00 P.M. Administrator confirmed nothing is documented under tasks in the electronic medical record for showers and confirmed no further shower sheets were available after 10/16/22.
3. Review of the medical record for Resident #19 revealed an admission date of 06/04/19. Diagnoses included end stage renal disease, dependence upon dialysis, chronic atrial fibrillation, anxiety disorder, type II diabetes mellitus without complications, major depressive disorder, morbid obesity, and schizoaffective disorder.
Review of the 10/02/22 Minimum Data Set (MDS) 3.0 assessment for Resident #19 revealed moderate cognitive impairment. Resident #19 required extensive assist of two for bed mobility, dressing, and toileting. Resident #19 required total dependence of two staff for transfer and bathing.
Review of the facility shower logbook revealed Resident #19 was to receive showers during night shift on Tuesdays and Fridays.
Review of shower sheets for Resident #19 revealed no showers given since 10/16/22 and no documentation since that date of refusals in the medical record.
Interview on 11/15/22 at 3:00 P.M. with the Administrator confirmed nothing was document under the task tab in the electronic medical record for showers and confirmed no additional shower sheets were available after 10/16/22 for Resident #19.
Review of 01/10/19 revised facility policy called Personal Care Needs revealed personal care and support provided to meet the needs of the residents includes bathing and showering to promote a healthy environment and prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, review of job description, review of facility activity calendars, and policy review the facility failed to ensure activities to meet resident preferences and interests were offered on Saturdays. This affected two residents (Residents #10 and #29) of six residents reviewed for activities. The facility census was 44.
Findings include:
1. Review of medical record for Resident #10 revealed an admission date of 06/13/18. Diagnoses included schizophrenia, hypertensive heart disease with heart failure, depression, type II diabetes mellitus with neuropathy, and morbid obesity.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Activities of daily living (ADLs) revealed Resident #10 required extensive assist of one staff for bed mobility, transfer, transfer on and off the unit and toileting. Resident #10 required extensive assist of two staff for dressing and personal hygiene.
Interview on 11/15/22 at 12:15 P.M. with Resident #10 confirmed there were no staff led activities on Saturdays to meet Resident #10's interests and preferences.
2. Review of medical record for Resident #29 revealed an admission date of 08/25/22. Diagnoses included alcohol use with dementia, aortic aneurysm without rupture, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, type two diabetes mellitus with diabetic neuropathy, spondylolysis, hypothyroidism, chronic viral hepatitis C, post-traumatic stress disorder, and dementia with agitation.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29 required limited assistance of one staff for bed mobility, transfer, walking in room and toileting and supervision for bathing, dressing, and eating meals.
Interview on 11/15/22 at 12:15 P.M. with Resident #29 confirmed there were no staff led activities on Saturdays to meet his interests and preferences.
Interview on 11/15/22 at 12:41 P.M. with Social Services Designee (SSD) #283 revealed there were no activity staff on the weekends so a current events paper was delivered to the table in the activities room and laid on the table in the community area for residents to have access to that events paper. Residents could also start movies for themselves on Saturdays. SSD #283 stated she had never worked weekends while she was the activities director for three years, never had an assistant but occasionally a volunteer would come in on the weekends to provide an activity.
Interview on 11/15/22 12:40 P.M. with Activities Director #202 confirmed there were no activity staff scheduled on the weekends and stated she was trying to make the residents more independent.
Review of September, October and November 2022 activities calendars revealed no staff led activities on Saturdays.
Review of undated facility Activity Director job description revealed the activity director will plan and implement evening and weekend functions as necessary.
Review of the undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, revealed residents have a right to be treated with respect, participate in activities, and make complaints without fear of punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review the facility failed to change an enteral tube feeding after 24 hours. This affected one resident (Resident #248) of two residents reviewed for tube feedings. The facility census was 44.
Findings include:
Review of medical record for Resident #248 revealed an admission date of 07/30/21. Diagnoses included severe dementia with agitation. chronic obstructive pulmonary disease, unspecified psychosis, pressure ulcer of left heel stage III, and unspecified severe protein-calorie malnutrition.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #248 was severely mentally impaired, required extensive assist for bed mobility, transfer, dressing and eating. Resident #248 was totally dependent upon staff for toileting, personal hygiene and bathing.
Review of physician order dated 11/10/22 for Resident #248 revealed an order for an enteral feeding of Osmolite 1.2 at a rate of 60 milliliters per hour 24 hours a day with 150 cubic centimeter flush every four hours related to a diagnosis of severe protein-calorie malnutrition.
Observation on 11/17/22 at 7:32 A.M. revealed Resident #248 sleeping in her bed, with the head of bed elevated. The Osmolite 1.2 container of enteral feeding hanging on the tube feeding pole was dated 11/15/22 with 04:00 ( 4:00 A.M.) written on the container underneath Resident #248's.
Interview on 11/17/22 at 7:35 A.M. with Licensed Practical Nurse (LPN) #225 confirmed the enteral feeding container was dated 11/15/22 04:00 hours. LPN #225 stated she was unsure why the enteral feeding had not been changed, and it was to be changed every 24 hours.
Review of January 2022 facility policy called, Enteral Feeding revealed tube feeding bag was to be changed every 24 hours.

Based on record review, interview and policy review the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected three (Residents #16, #32 and #40) of five residents reviewed for unnecessary medications. The facility census was 50.
Findings include:
1. Resident #16's medical record revealed an admission date of 11/07/17 with diagnoses including kidney disease, dementia, schizophrenia and bipolar disorder.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/30/19, revealed the resident had impaired cognition, and was taking antipsychotic, antidepressant and antianxiety medications.
Review of the monthly pharmacy recommendations dated 06/05/19, 07/11/19, 08/03/19 and 10/07/19 revealed the pharmacist made recommendations on these dates. Review of the medical record revealed no evidence of the physician responding to any of the pharmacy recommendations.
On 01/23/20 at 12:10 P.M. the Director of Nursing (DON) revealed their policy indicated the physician was to sign all pharmacy recommendations within 30 days. The DON verified there was no evidence the physician addressed the pharmacy recommendations on the above dates.
2. Resident #40's medical record revealed an admission date of 07/12/14 with diagnoses including schizophrenia, dementia and anxiety.
Review of the quarterly MDS assessment, dated 10/10/19, revealed the resident had impaired cognition and received antipsychotic and antianxiety medications.
Review of the monthly pharmacy recommendations dated 03/15/19, 05/08/19, 06/05/19, 07/11/19 and 09/04/19 revealed the pharmacist made recommendations on these dates. Review of the medical record revealed no evidence of the physician responding to any of the pharmacy recommendations.
On 01/23/20 at 12:10 P.M. the DON verified there was no evidence the physician addressed the pharmacy recommendations on the above dates within 30 days.
3. Resident's #32 medical record revealed an admission date of 07/20/16 with diagnoses including major depression disorder, schizoaffective disorder, anxiety, and bipolar disorder.
The comprehensive MDS 3.0 dated 11/24/19 revealed the resident was cognitively intact, and had moderate depression and behaviors directed towards others.
Review of the monthly pharmacy recommendation for Resident #32 revealed a recommendation dated 07/11/19 to decrease Humalog an insulin to three times a day before meals. A recommendation dated 09/04/19 included to consider gradual dose reductions (GDR) for Klonopin 0.5 milligrams (mg.) (to treat anxiety) lithium 300 mg (to treat bipolar disorder) Seroquel 100 mg and 400 mg doses (to treat schizophrenia) Zoloft 100 mg (to treat depression) Haldol 5 mg (to treat schizophrenia) and Remeron 15 mg (to treat depression). There was no evidence found in the record the physician had addressed the pharmacist's recommendations.
Interview on 01/23/20 at 4:30 P.M. with the DON revealed the facility had no procedure in place to track follow up of pharmacy recommendations.
Review of facility policy titled Drug Regimen Review/Medication Regimen Review, dated 10/01/18, revealed all non-urgent recommendation/irregularities must be addressed within 30 days of the consultant pharmacist monthly visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Medical Record for Resident #16 revealed an admission date of 11/07/17 with diagnoses including kidney disease, dementia, schizophrenia and bipolar disorder.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition and received antipsychotic, antidepressant and antianxiety medications.
Review of the care plan dated 09/11/19 revealed Resident #16 used psychotropic medication due to diagnoses of depression, schizophrenia and bipolar disorder. Interventions included performing an Abnormal Involuntary Movement Scale (AIMS) and reporting any abnormalities indicative of Tardive Dyskinesia (involuntary repetitive body movements).
Review of assessments in the medical record revealed no evidence of an AIMS assessment being completed.
Interview on 01/23/20 at 12:10 P.M. with the DON verified no evidence could be provided that an AIMS assessment had been completed.
3. Review of the Medical Record for Resident #40 revealed an admission date of 07/12/14 with diagnoses including schizophrenia, dementia and anxiety.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition and received antipsychotic and antianxiety medications.
Review of the Pharmacy Recommendation dated 06/05/19 revealed Resident #40's last AIMS assessment was in 05/2018 and the resident was due for another AIMS assessment.
Review of assessments in the medical record revealed no evidence of an AIMS assessment being completed since 05/2018.
Interview on 01/23/20 at 12:10 P.M. with the DON verified no evidence could be provided that an AIMS assessment had been completed for the resident since 05/2018.
Based on record review and staff interview the facility failed to ensure as needed medication orders for psychotropic drugs were limited to 14 days and failed to address pharmacy recommendations in a timely manner. This affected one (Resident #8) of five residents reviewed for unnecessary medications. The facility also failed to ensure residents were assessed for side effects of psychotropic medications. This affected two (Resident #16 and Resident #40) of five residents reviewed for unnecessary medications. The facility census was 50.
1. Review of Resident #8's medical record revealed an admission date of 10/04/19 with diagnoses including major depression, schizophrenia, and anxiety.
The comprehensive Minimum Data Set (MDS) 3.0 dated 10/15/19 revealed the resident was cognitively intact, had mild depression and had no behaviors.
Review of the physician order dated 11/26/19 revealed the resident was to receive Ativan one milligram (mg) every 24 hours as need (PRN) for anxiety. Thee was no stop date indicated.
Review of the monthly Pharmacy Recommendation to the Physician dated 01/13/20 revealed a recommendation to discontinue or reorder the PRN Ativan per guidelines.
Review of Medication Administration Record (MAR) revealed PRN Ativan was not administered in December of 2019 but was administered five times in January 2020.
Interview with the Director of Nursing (DON) on 01/23/20 at 2:00 P.M. verified the PRN Ativan order should be limited to 14 days and was not addressed by the physician. It was addressed today by the Nurse Practitioner (NP).

Based on observation, interview, record review and meal ticket review the facility failed to ensure residents' food preferences we met. This affected one (Resident #15) of one resident reviewed for food preferences. The facility census was 50.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 10/12/19. The resident did not speak English very well and her daughter would assist with interpretation.
Interview on 01/21/20 at 10:30 A.M. with Resident #15 and her daughter (via phone) revealed the resident did not eat meat, fish or eggs due to her religious beliefs. Resident #15 showed her meal ticket for lunch on 01/19/20 that revealed she received Salisbury steak with beef gravy for lunch. Resident #15's daughter stated the facility was told about the resident's preferences, but kitchen continued to send her these items on her tray. Resident #15 then said no meat.
On 01/21/20 at 1:30 P.M. an observation of Resident #15's meal tray revealed she was served single servings of fish, rice and mixed vegetables.
Review of Resident #15's meal ticket dated 01/21/20 revealed the resident was to be served fish, rice and vegetables. In the comment area it was noted no meat, fish or eggs and double portions of vegetables for lunch and dinner.
On 01/21/20 at 1:47 P.M. the Director of Clinical Operation (DCO) #620 verified Resident #15's lunch tray had fish on it and she did not receive a double portion of vegetables.
On 01/21/20 at 3:26 P.M. interview with Dietitian #533 revealed Resident #15 was a vegetarian. Dietitian #533 verified Resident #15 was not to be served meat, fish or eggs, and should be served double portions of vegetables for lunch and dinner.
On 01/23/20 at 8:33 A.M. observation of Resident #15's breakfast tray revealed Resident #15 was served eggs for breakfast.

Based on observation and interview the facility failed to properly label and date food items. This had the potential to affect all 50 resident currently residing in the faciliy.
Findings include:
Observation on 01/21/20 at 12:15 P.M. of the unit refrigerator revealed the following
1. One unlabeled and undated opened half-filled bottle of ginger ale.
2. One unlabeled and undated McDonalds bag that continued food items.
3. One unlabeled and undated covered plate of food.
Observation on 01/21/20 at 12:20 P.M. of the snack drawer revealed the following.
1. Five unlabeled and undated bags of potato chips in a plastic folding sandwich bag.
2. One unlabeled and undated bag of potato chips in a plastic bag that was open to air.
3. One unlabeled and undated bag of Cheetos in a plastic folding baggie.
4. Twenty undated individually prepackaged packaged cookies.
5. Ten undated individually prepackaged fruit bars.
Interview with License Practical Nurse (LPN) #544 verified the above findings at the time of observation.
Interview 01/21/20 at 3:22 P.M. with the Dietitian revealed he was aware of the bulk snack and would check into the labeling.
Interview on 01/23/20 at 2:30 P.M. with the Dietary [NAME] #584 revealed she placed potatoes chips and Cheetos in clear plastic folding sandwich baggies then sealed them with scotch tape.

Based on observation, interview, record review and policy review the facility failed to ensure proper infection control procedures were followed regarding proper cleaning of a glucometer for Residents #38 and #16. This affected two residents observed for glucometer checks of eight residents ordered glucometer checks residing on the [NAME] hallway. The facility failed to ensure an indwelling urinary catheter drainage bag was properly secured for Resident #152. This affected one of one resident reviewed for the use of an indwelling urinary catheter. The facility failed to ensure proper storage of an oxygen mask for Resident #13. This affected one of one resident reviewed for oxygen use. The facility also failed to ensure a comprehensive Legionella management program was in place which had the potential to affect all 50 residents currently residing in the facility.
Findings include:
1. Review of the facility's Legionella management program revealed no risk assessment was completed and no routine water monitoring for services for hot, cold or chlorination levels. There was no monitoring of eye wash stations, ice machines or any flushing of the systems with hot and cold water.
Interview on 01/22/20 at 2:30 P.M. with Maintenance Director #548 verified there was no evidence of a Legionella risk assessment being completed or any water management program implemented.
Review of the facility policy titled, Legionnaire's Disease Surveillance (dated 08/11/17) revealed maintenance will perform routine water monitoring services for hot, cold and proper chlorination levels to be documented in electronic surveillance system.
2. Review of the medical record for Resident #152 revealed an admission dated of 01/20/20. Diagnoses including heart failure, traumatic brain injury and end stage renal failure.
Review of physician orders dated 01/20/20 revealed an order for indwelling urinary catheter (Foley catheter) care every shift and as needed with soap and water.
On 01/21/20 at 12:08 P.M. observation revealed Resident #152's Foley catheter drainage bag was laying on floor under the resident's bed.
On 01/21/20 at 12:12 P.M. interview with Licensed Practical Nurse (LPN) #542 verified Resident #152's Foley catheter drainage bag was laying on the floor under the bed, and it should have been hanging on the bed frame suspended off the floor.
Review of the facility policy titled, Foley Catheter Care (undated) revealed catheter drainage bags should be placed below the level of bladder and the bag should not be in contact with the floor.
3. Review of medical record for Resident #38 revealed and admission date of 09/10/19 with diagnoses including type 2 diabetes, pressure ulcer, anxiety and depression.
Review of January 2020 physicians orders revealed a glucose (blood sugar) level was to be obtained two times a day for diabetes.
Observation on 01/22/20 at 4:27 P.M. of Licensed Practical Nurse (LPN) #542 obtaining a glucose level for Resident #38 revealed she took the glucometer out of the medication cart, along with supplies and entered the resident's room. LPN #542 washed her hands, donned gloves, wiped the resident's index finger with an alcohol pad, pricked the finger with a lancet and placed the glucometer strip near the drop of blood and obtained a reading. LPN #542 washed her hands, walked back to medication room, cleaned the glucometer with an alcohol pad, and set it to dry on a paper towel. LPN #542 documented Resident #38's glucose level reading and reviewed Resident #16's order for a glucose reading. LPN #542 grabbed the glucometer off the paper towel and proceeded to Resident #16's room to obtain his glucose reading. LPN #542 walked back to the medication room, wiped the glucometer with an alcohol wipe and set it on a paper towel to dry. LPN #542 had no more residents who needed glucometer checks done at that time.
Interview on 01/22/20 at 4:55 P.M. with LPN #542 revealed the facility didn't have disinfecting wipes specifically for cleaning the glucometer and used alcohol instead.
Interview on 01/22/20 at 5:15 P.M. with Assistant Director of Nursing (ADON) #596 revealed the facility had germicidal wipes that killed blood borne pathogens for cleaning the glucometer. ADON #596 identified LPN #542 was an agency nurse. He verified she should have used the germicidal wipes for disinfecting the glucometer, not alcohol. LPN #542 would be instructed to use germicidal wipes to clean the glucometer. All regular staff were aware and used germicidal wipes to disinfect the glucometer with each use.
Review of the facility's titled Cleaning Glucometers Policy and Procedure (revised March 2017) revealed glucometers were to be cleaned with a disinfecting wipe.
4. Review of Resident's #13 medical record revealed an admit date of 02/07/06 with diagnoses of anxiety, asthma and contracture of the right ankle.
The comprehensive MDS 3.0 dated 10/16/19 revealed the resident was cognitively intact, had moderate depression and required total assistance with transferring and toileting.
Observation on 01/21/20 at 10:35 A.M. of Resident #13's room revealed a mobilizing (breathing) machine sitting on the foot of the bed with an uncovered face mask.
Interview on 01/21/20 at 10:40 A.M. with the State Tested Nursing Assistant (STNA) #599 revealed the nebulizer was always kept at the foot of bed and was never covered.
Observation on 01/21/20 at 5:25 P.M. of Resident #13's room revealed the nebulizer machine sitting on the dresser next to the bed with the mask uncovered.
Interview with 01/21/20 at 5:30 P.M. with Licensed Practical Nurse (LPN) #542 verified the finding and revealed the mask should with washed with soap and water, dried and covered after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure a safe functional environment for residents. This affected six (Residents #5, #31, #14, #49, #45 and #26) of 50 residents.
Findings include:
Observations during tour of the facility with the Director of Maintenance (DM) on 01/21/20 revealed the following light switches did not positively function and caused the lights to [NAME] or turn off when touched while in the on position.
1. At 9:30 A.M. in Resident #5's room the main light switch by the door.
2. At 9:42 A.M. in Resident #31's room all three light switches in the room.
3. At 9:45 A.M. in Resident #45's room the light switch by the sink.
4. At 10:46 A.M. in Resident #14's room the light switch by the sink.
5. At 10:47 A.M. in Resident #49's room the light switch by the door.
6. At 10:55 A.M. in Resident #26's room the light switch by the door.
Interview with the DM verified the above findings at the time of the observations.
This deficiency is an example of continued non-compliance from the complaint survey completed 01/06/20.

Based on observation, record review and interview the facility failed to ensure meals were delivered in a timely manner in accordance with the posted designated service times. This had the potential to affect all 50 residents currently residing in the facility.
Findings include:
Interview on 01/21/20 at 10:05 A.M. with Kitchen Manager #700 verified the meal times per the provided copy of the designated service times. Lunch meal times were as follows: East Hall trays to be delivered at 12:20 P.M., [NAME] Hall #1 at 12:30 P.M., [NAME] Hall #2 at 12:40 P.M. and the Dining Room at 12:50 P.M. Dinner meal times were as follows: East Hall trays to be delivered at 5:20 P.M., [NAME] Hall #1 at 5:30 P.M., [NAME] Hall #2 at 5:40 P.M. and the Dining Room at 5:50 P.M.
Observations on 01/21/20 from 12:05 P.M. through 2:00 P.M. of the lunch meal revealed lunch was delivered to the East Hall at 12:56 P.M., [NAME] Hall #1 was delivered at 1:07 P.M., [NAME] Hall #2 was delivered at 1:20 P.M., and the Dining Room was at 1:45 P.M.
Interview on 01/21/20 at 2:00 P.M. with Regional Nurse #620 verified lunch was delivered to East Hall at 12:56 P.M., [NAME] Hall #1 was delivered at 1:07 P.M., [NAME] Hall #2 was delivered at 1:20 P.M., and the Dining Room was delivered at 1:45 P.M.
Interview on 01/21/20 at 4:48 P.M. with Kitchen Manager #700 revealed the kitchen staff was cleaning stove burners before lunch and it took longer than anticipated.
Observations on 01/21/20 from 5:15 P.M. through 6:25 P.M. of the dinner meal revealed dinner was delivered to the East Hall at 5:27 P.M., [NAME] Hall #1 was delivered at 5:41 P.M., [NAME] Hall #2 was delivered at 6:00 P.M., and the Dining Room was delivered at 6:22 P.M.
Interview on 01/21/20 at 6:25 P.M. with Regional Nurse #620 verified dinner was delivered to East Hall at 5:27 P.M., [NAME] Hall #1 was delivered at 5:41 P.M., [NAME] Hall #2 was delivered at 6:00 P.M., and the Dining Room was delivered at 6:22 P.M.
Interview on 01/22/20 at 11:56 A.M. with the Administrator and Kitchen Manager #700 verified lunch and dinner meals on 01/21/20 were delivered late, and they indicated major cleaning such as the stove burners would take place after meal service times.