Wickliffe Country Place

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility staff and pharmacy staff interview, medical record review, review of Self- Reported Incident (SRI) #264042 and facility policy review the facility failed to thoroughly investigate a missing controlled medication for one resident. This affected one (#181) of one resident reviewed for misappropriation of medications. The facility census was 114. Findings include: Record review for Resident #181 revealed an admission date of 06/04/25 and a discharge date of 09/03/25. Diagnoses included bipolar disorder and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 had little interest or pleasure in doing things and was feeling down, depressed or hopeless. Resident #181 used a wheelchair for mobility and was independent for eating and personal hygiene. Resident #181 had non-traumatic brain dysfunction, bipolar disorder and schizophrenia. Review of the physician order for Resident #181 dated 07/19/25 revealed an order for clonazepam (classified as a Schedule IV prescription benzodiazepine) oral table disintegrating 0.25 milligrams (mg), give one tablet by mouth two times a day for bipolar disorder. The scheduled times to be administered were morning and evening. Review of the Resident #181's Medication Administration Record (MAR) for August 2025 revealed from 08/01/25 through 08/09/25 Resident #181 received 15 of the 18 ordered doses of clonazepam. On 08/04/25 the MAR revealed the evening dose had an R documented with initials. Review of the chart code on the MAR revealed the R indicated the resident refused the medication. Additionally, on 08/05/25 and 08/06/25 the morning dose had an R documented. On 08/10/25 the morning dose and the evening dose, had OT documented on the MAR. The chart code indicated OT indicated Other; On 08/11/25 the evening dose had an OT documented; 08/12/25, 08/13/25, and 08/14/24 the morning dose had an OT documented. An R was documented 08/12/25 and 08/13/25 for the evening dose. Review of the MAR indicated Clonazepam was administered from 08/14/25 evening dose as ordered through 08/24/25 when Resident #181 was admitted to the hospital. Review of the med pass note for Resident #181 dated 08/10/25 at 7:57 A.M. completed by Licensed Practical Nurse (LPN) #275 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar (disorder) - medication on order. Review of the med pass note for Resident #181 dated 08/10/25 at 6:36 P.M. completed by LPN #346 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar - on order. Review of the med pass note for Resident #181 dated 08/11/25 at 9:29 A.M. completed by LPN #347 revealed clonazepam oral tablet disintegrating 0.25 mg give 1 tablet by mouth two times a day for bipolar. The pharmacy has indicated that it is too soon to refill the requested medication supply below. Clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar. Patient has requested refill too soon. Order will be dispensed on 08/21/25. Review of the med pass note dated 08/11/25 at 6:27 P.M. completed by Nurse Manager Assistant Director of Nursing (ADON), Staff Development/Registered Nurse (RN) #355 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar (disorder). Medication unavailable however R (resident) refused all medications from this nurse. Review of the med pass note dated 08/14/25 at 8:59 A.M. completed by LPN #347 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar - waiting on pharmacy. Review of the Certified Nurse Practitioner (CNP) Note for Resident #181 dated 08/14/25 at 11:51 P.M. completed by CNP #390 revealed chief complaint: N/V (nausea and vomiting), anxiety, follow up chest pain, and (congestive heart failure) CHF. She is resting quietly in bed. Reports feeling ok. No chest pain endorsed at time of exam. Continue current meds and treatments. Monitor. Addendum- anxious this afternoon. Per nurse, family called 911, but (Resident #181) refused to go. Did not leave facility. Awaiting klonopin (trade name for Clonazepam) from pharmacy. Review of the Self-Reported Incident (SRI) Tracking #264042 dated 08/14/25 at 1:36 P.M. with a date of discovery 08/14/25 and a category of Misappropriation and a brief description of the staff nurse identified medication unavailable. When calling pharmacy for medication, pharmacy stated the medication was delivered to the facility. Staff unable to locate medication at the facility. Alleged/suspected perpetrator was facility staff or other care provider. Resident remained at the facility at baseline. The Narrative Summary of the incident included interviewed the nurse that signed for receiving the medication when delivered to the facility. The report indicated the facility replaced the medication at the facility cost. Resident #181 was interviewed when asked if she refused medication, which medication she refused and why. The report indicated like residents were interviewed with no negative findings and staff were educated. The facility conclusion indicated the allegation was unsubstantiated and indicated evidence of abuse, neglect or misappropriation did not occur. Resident denied abuse occurred. No witnessed abuse, staff educated. The report was completed by the facility Administrator. Review of the typed Controlled Packing Slip titled Pharmacy #391 Controlled, revealed delivered to (Facility Name and address) shipping date 08/08/25. (Resident #181) Tramadol HCL tab 50 mg four of four and clonazepam ODT tab 0.25 mg 30 of 30. Under the listed medications revealed By signing below you acknowledge that the items above have been received. Under the statement was hand written name (LPN #275) with a hand written signature (LPN #275) dated 08/09/25. Review of the handwritten statement dated 08/14/25 at 12:13 P.M. signed by LPN #275 revealed on 08/09/25 she did not receive the narcotic medication clonazepam. On this date she only received and signed for tramadol 50 mg, four tablets for (Resident #181). No other medications for this resident were received or signed for by me. Interview on 09/15/25 at 1:04 P.M. with Administrator and DON revealed on 08/14/25 the nurse was passing medication, Resident #181's medication clonazepam was not available. The pharmacy was called and stated they delivered the clonazepam for Resident #181 on 08/09/25. The nurse, LPN #275 signed the packing slip confirming she received it. Interview with LPN #285 revealed her statement that she did not receive it. Administrator revealed she saw LPN #275's signature on the packing slip and stated, She signed she received it, but we were unable to locate the medication, could not find the form (the signature/count log used by nurses to sign off the medication after each dose was given to assure no missing doses) or medication. The nurse was suspended during the investigation. The DON confirmed the allegation was unsubstantiated because the nurse said she did not receive the medication. The Administrator and DON confirmed LPN #275 signed the packing slip on 08/09/25 used to deliver and confirmed the medication was received. The DON confirmed LPN #275 was never requested to take a drug screen. Record review of Resident #181's MAR and progress notes for 08/10/25 through 08/14/25 with the DON confirmed Resident #181's clonazepam was not available for administration and was documented. Phone interview on 09/15/25 at 3:09 P.M. with Pharmacy Staff #391, Account Manager #392, and Director of Clinical Services Pharmacist #393 revealed the pharmacy had packing slips for the medications delivered to the facility. When the driver arrives at the facility to deliver the residents' medications, the nurse checks in and counts all the medications while the driver is still there, then signs they received the medications. Account Manager #392 revealed the pharmacy had packing slips and the signature the nurse (LPN #275) signed it and confirmed she received the clonazepam for (Resident #181). Director of Clinical Services Pharmacist #393 confirmed the clonazepam was delivered and signed received by the facility nurse. Interview and record review on 09/15/25 at 3:17 P.M. with LPN #275 of the Controlled Packing Slip dated 08/09/25 confirmed the controlled packing slip for Resident #181 was signed by her (LPN #275). LPN #275 revealed she did not see the clonazepam written directly under the tramadol on the packing slip when she signed for the medication. LPN #275 revealed she was never asked to do a drug screen and confirmed she did not receive any further education on the proper procedure of receiving medications from the pharmacy after receiving the initial education in April 2025. LPN #275 confirmed on 08/10/25 Resident #181 did not have the A.M. dose of clonazepam available for administration. LPN #275 revealed during the nurse to nurse report the nurse told her the medication was already on order so she did not have to call the pharmacy or get a prescription from the physician. Interview on 09/15/25 at 3:39 P.M. with the DON revealed due to the incident, nurses were in-serviced on controlled drugs. The DON confirmed the in-service log dated and initiated 08/13/25 titled Controlled Substance In-service was signed by 16 nurses. The DON confirmed LPN #275 did not sign the in-service. The DON stated, She was educated in April on controlled substances. On 09/15/25 at 4:40 P.M. the DON revealed on 08/21/25 LPN #275 was given a final written warning. Review with DON of the final written warning dated 08/21/25 revealed employee name (LPN #275) was not adequately following policies and procedures for accepting controlled substances from pharmacy. On the form Previous Warnings were marked yes with a check mark and dated 04/18/25. The DON revealed this was when all nurses received initial training for the policy and procedures on pharmacy deliveries. The DON also stated LPN #275 was re-trained on the correct procedure when given the form. The DON confirmed the form did not indicate the training. Interview with the DON on 09/17/25 at 3:00 P.M. confirmed she did not see the note dated 08/11/25 at 9:29 A.M. completed by LPN #347 revealing the pharmacy has indicated that it is too soon to refill the requested medication supply below. Clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar. Patient has requested refill too soon. Order will be dispensed on 08-21-2025. The DON confirmed the MAR and nursing notes were not in the investigation file provided to the surveyor. The DON confirmed no investigation was initiated at that time, 08/11/25 to determine where the medication was or why it was too soon to refill. The DON revealed she would have to look into it. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property reviewed 01/06/25 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The initial response included staff should report all incidents /allegations immediately to the Administrator or designee. The Administrator or his or her designee will notify the Ohio Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, and misappropriation of resident property as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. If the accused is an employee, then review his or her employment records. Evidence of the investigation should be documented. Complete staff training, if appropriate, as determined by the results of the investigation. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2612137.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy revealed the facility failed to ensure sufficient staff were available to timely serve meal trays for the 18 residents residing on the A unit and failed to provide timely incontinence care for three residents. This affected three (#80, #109, and #111) of three residents reviewed for incontinence care also residing on the A unit. This had the potential to affect all 18 residents (#80, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112, #113, #114, and #115) residing on the A Unit. The facility census was 114.Findings include: 1. Record review for Resident #80 revealed an admission date of 08/23/23. Diagnoses included multiple sclerosis, spinal stenosis, and muscle weakness. Review of the Annual Minimum Data Set (MDS) dated [DATE] for Resident #80 revealed Resident #80 had a Brief Interview of Mental Status (BIMS) score of 12 (moderately cognitively impaired). Resident #80 required set up or clean up assistance for eating, dependent for oral hygiene, toileting hygiene, and personal hygiene. Resident #80 was frequently incontinent with bowel and bladder. Review of the care plan for Resident #80 dated 08/26/23 revealed Resident #80's preferences have been identified. Resident #80 preferred showers two times a week. An additional care plan dated 07/28/24 revealed Resident #80 had an activity of daily living (ADL) self care performance deficit. Interventions included staff were to assist with completion of ADL's on a daily basis so needs were met. Review of the care plan for Resident #80 dated 08/29/23 revealed Resident #80 had bowel incontinence related to impaired mobility, physical limitations, and MS. Interventions included bladder toileting program, check for wetness before meals, after meals, every evening, and on rounds during the night. Check resident, if he or she is continent, offer to assist with toileting, if he/she is incontinent, provide incontinence care. Observation on 09/20/25 at 9:14 A.M. of the A Hall revealed Licensed Practical Nurse (LPN) #275 was passing medications. Certified Nursing Assistant (CNA) #374 was passing breakfast trays. Interview with LPN #275 revealed she was the only nurse on the hall for 18 residents and CNA #374 was the only aide. LPN #275 revealed CNA #374 was passing the breakfast trays by herself. LPN #275 stated, There's not enough staff, I am still passing medications so I can't help her much. Interview on 09/20/25 at 9:15 A.M. with CNA #374 confirmed the breakfast cart arrived about 7:40 A.M.; CNA #374 confirmed she was still passing breakfast trays. Observation revealed at 9:20 A.M. CNA #374 served the last tray on the cart, Resident #98's tray. CNA #374 did not heat the food on the tray before serving it. Observation revealed residents were served pancakes, sausage and oatmeal. Resident #98 stated, The food is cold, it's not even a little warm it's that way all time. Interview with Resident #114 stated, it is cold, its every meal. Resident #80 also confirmed his food was served cold. The facility identified the following residents resided on the A Unit and would be affected by the late meal trays, Residents #80, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112, #113, #114, and #115. Interview on 09/20/25 at 9:30 A.M. with CNA #374 revealed she did the best she could. CNA #374 stated, I have not even started checking and changing (residents for incontinence), there's not enough help over here, I still have to collect trays. CNA #374 confirmed her shift started at 7:00 A.M. and confirmed she will not start checking on her residents or initiating her first set of rounds for incontinence until about 10:30 A.M. because she had to answer call lights and collect (meal) trays. Observation on 09/20/25 at 10:25 A.M. with CNA #374 revealed the CNA provided incontinence care for Resident #80. At the time of the observation, it was revealed that Resident #80's fingernails were very long and embedded with a dark substance. Resident #80 had food in his beard and crumbs and pieces of food on his sheets. CNA #374 revealed that (the crumbs and pieces of food) was his pizza from the night before. Resident #80 revealed he was last changed sometime in the middle of the previous night. Resident #80's incontinence brief was saturated with urine. The brief tore apart when removing it. CNA #374 confirmed this was the first time her shift she checked Resident #80 for incontinence. Resident #80 confirmed he would not mind if his nails were trimmed and confirmed he would like them to be cleaned. CNA #374 confirmed Resident #80 did not have a history of refusing care and confirmed his nails were embedded with a dark substance. Observation revealed CNA #374 completed incontinence care for Resident #80 but did not provide nail care before confirming she completed his A.M. care. Interview on 09/20/25 at 10:52 A.M. with Dietary Manager (DM) #319 and [NAME] #340 revealed breakfast trays were delivered to the A Hall at 7:45 A.M.; DM #319 revealed she does get complaints of cold food but the staff can heat the food up in the microwave. Interview on 09/20/25 at 12:19 P.M. with Resident #115 revealed sometimes staff take two hours to answer a call light and stated, The food is cold when we get it, they will heat it up but it's not as good though when heated in a microwave. 2. Record review for Resident #111 revealed an admission date of 02/08/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly MDS for Resident #111 dated 06/19/25 revealed Resident #111 had a BIMS score of 15 (cognitively intact). Resident #111 was frequently incontinent of bowel and bladder, was dependent for toileting hygiene and chair/bed to chair transfers. Review of the care plan for Resident #111 dated 02/09/24 revealed bladder incontinence BPH, urinary retention, malignant neoplasm of prostate. Place urinal/bedpan within resident's reach. Interventions included to check resident if he is continent, offer to assist with toileting, if he/she is incontinent, remove wet or soiled clothing, briefs, provide incontinence care. Observation on 09/20/25 at 11:05 A.M. revealed LPN #275 had linen in her arms and walking into Resident #111's room. Resident #111 revealed he would talk to the surveyor after he was changed. LPN #275 revealed she would be changing him because he had not been checked or changed at all this shift and the CNA was with other residents. Interview on 09/20/25 at 11:32 A.M. with Resident #111 revealed he was also Resident Council President. Resident #111 stated, My whole bed was wet (with urine) when she changed me, not enough staff, I was last changed sometime on third shift, we bring it up in Resident Council, it don't matter. Resident #111 revealed his concerns were changing residents timely, cold food and not getting assistance at night to go to bed until 10:00 P.M. or 11:00 P.M. Interview on 09/20/25 at 11:37 A.M. with LPN #275 confirmed she changed Resident #111 and stated, I did change (Resident #111), he was saturated, the sheets were saturated, the bed was also wet with urine, we still have four more residents for first rounds. Resident #109 will be our last resident for first rounds. 3. Record review for Resident #109 revealed an admission date of 02/19/25. Diagnoses included chronic obstructive pulmonary disease and muscle weakness. Review of the quarterly MDS dated [DATE] revealed Resident #109 was severely cognitively impaired. Resident #109 was frequently incontinent of bowel and bladder, was dependent (on staff), for toileting hygiene, and chair/bed to chair transfers. Review of the care plan for Resident #109 dated 02/20/25 revealed Resident #109 had bladder incontinence related to impaired mobility. Interventions included to check resident if he/she is continent, offer to assist with toileting, if he is incontinent, remove wet or soiled clothing, briefs, provide incontinence care. Observation on 09/20/25 at 11:55 A.M. of incontinence care for Resident #109 provided by LPN #275 and CNA #374 revealed Resident #109's incontinence brief was saturated (with urine). The pad under the brief was wet. Observation revealed Resident #109's buttocks were red with a small area of light purple discoloration near the crease of both the right and left buttocks. LPN #275 confirmed the red buttocks with the discolored areas. Interview on 09/20/25 at 1:43 P.M. with the DON revealed CNA's should be doing rounds every two hours and as needed. CNA's start at 7:00 A.M.; as soon as they come in they get their report and start their rounds. The DON revealed that an hour to pass meal trays is definitely too long and revealed nail care should be done with showers and anytime personal care is needed. Review of the facility policy titled, Incontinence Care dated 01/06/25 revealed the purpose was to keep skin clean, dry, free of irritation and odor, to prevent skin breakdown and prevent infections. This deficiency represents non-compliance investigated under Complaint Number 2620100.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy revealed the facility failed to assure trach supplies were available and care and treatment was completed. This affected one (#52) of one resident reviewed for trach supplies and treatment. The facility census was 114.Findings include: Record review for Resident #52 revealed an admission date of 03/06/24. Diagnoses included encounter for attention to tracheostomy (a direct opening or stoma through the neck into the windpipe (trachea) allowing a tube to be inserted to provide an airway), dysphagia, weakness, unspecified psychosis, obsessive compulsive disorder, post-traumatic stress disorder and obstructive sleep apnea. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired. Resident #52 had no rejection of care and required set up or clean up assistants with eating and oral hygiene. Resident #52 had a tracheostomy and received tracheostomy care. Review of the care plan for Resident #52 dated 03/07/24 revealed Resident #52 has a trach (a common shorthand term for tracheostomy) and is at risk for ineffective breathing patterns as evidence by shortness of breath and labored respirations. Interventions included to administer medications and respiratory treatments as ordered; monitor for effectiveness and adverse reactions of medications/treatments. Review of the Physician orders for Resident #52 revealed an order dated 03/07/24 to change trach inner cannula daily and as needed every night shift. An additional order dated 03/07/24 revealed trach care BID (two times a day) and prn (as needed) every day and evening shift. Review of the Treatment Administration Record for 09/01/25 through 09/15/25 for Resident #52 revealed the treatments to Resident #52's trach (including to change trach inner cannula daily and trach care BID and prn every day and evening shift) were documented on the TAR by facility nurses as completed as ordered. Observation and interview on 09/15/25 at 10:30 A.M. with Resident #52 revealed Resident #52 was sitting up in bed. Observation revealed Resident #52 had a trach intact and secured with trach ties. Resident #52 revealed he ran out of trach ties for his trach about a month ago. Resident #52 revealed the staff were aware there were no trach ties available. Observation revealed Resident #52's trach ties were dingy in color and appeared to be soiled. Interview on 09/15/25 at 10:32 A.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #364 revealed the Respiratory Therapist (RT) ordered Resident #52's trach supplies. RN ADON #364 revealed there were trach supplies available including trach ties kept in Resident #52's room. Observation revealed RN ADON #364 went to Resident #52's room and searched the room for trach supplies. RN ADON #364 confirmed there were no trach supplies in Resident #52's room. RN ADON #364 then went to the nurses station and approached Licensed Practical Nurse (LPN) #266. LPN #266 confirmed she was Resident #52's primary nurse. LPN #266 stated when asked about trach ties, I think we have some. Observation revealed LPN #266 looked in the medication cart and treatment cart and confirmed she was unable to find trach ties. LPN #266 also confirmed she was unable to find inner cannulas or a spare trach. RN ADON #364 revealed she would text RT to find out where the supplies were kept. Observation revealed RN ADON #364 went back into Resident #52's room and again looked for trach supplies. Resident #52 confirmed there were no supplies in the room. Resident #52 then removed his inner cannula in front of RN ADON #364 and revealed the inner cannula had not been changed in weeks. Observation revealed the inner cannula was soiled and discolored. RN ADON #364 confirmed the inner cannula was more soiled than usual and confirmed the neck ties were also soiled. RN ADON #364 confirmed there were no trach supplies on the hall and revealed there was some in the supply room downstairs in the basement. RN ADON #364 revealed Resident #52 was the only resident with a trach. Observation at 10:45 A.M. revealed RN ADON #364 searched the central supply room and revealed she was not sure where the trach supplies were. RN ADON #364 then looked on the assessment and revealed Resident #52 was to have a Shiley 7.5 trach. Central Supply Personnel #367 then entered and directed where the trach supplies would be located. Observation revealed at 10:50 A.M. RN ADON #364 found where trach supplies were located. RN ADON #364 confirmed all the trach supplies were there that was needed for Resident #52 except trach ties and confirmed there were no trach ties available. RN ADON #364 took trach supplies to the nursing station. RN ADON #364 confirmed the amount of time taken to find the trach supplies could have been detrimental to the resident if the supplies were needed in an emergency. Interview on 09/15/25 at 10:55 A.M. with LPN #266 revealed Resident #52 did all of his own trach care and she did not have to do any of it. LPN #266 confirmed she did not monitor Resident #52 do his trach care. Interview on 09/15/25 at 11:00 A.M. with Resident #52 and RN ADON #364 present revealed Resident #52 revealed his inner cannula had not been changed for weeks. Resident #52 revealed he made the nursing staff aware. Interview on 09/15/25 at 11:35 A.M. with Infection Preventionist Corporate RN #389 and DON revealed if a resident had a trach, trach supplies should be readily available. Resident #52's trach cleaning supplies should be kept at the bedside. The trach ties should be changed weekly and when visibly soiled and should also be kept at the bedside. A spare trach can be kept at the bedside, but it may not be if he has behavior. The nurses should be aware where the spare trach is kept. The inner cannula needs to be cleaned or changed daily; nurses should be the ones doing it. The DON confirmed the nurses were signing the orders and revealed nurses should be completing the care per the physician orders. Phone interview on 09/15/25 at 11:58 A.M. with the RT confirmed she visited the facility two times a week and revealed she visited Resident #52 one of those two days. The RT revealed Resident #52 did not keep trach supplies in his room because he goes through them and would use them all. The RT revealed she did not provide any care for Resident #52 when she visited, Resident #52 did his own trach care and revealed the nursing should give him his supplies when his trach care is due. The RT revealed trach ties should be changed at least once a week, and as needed, the inner cannula is disposable and should be changed daily and confirmed the trach care should be done twice daily. The RT revealed she usually checked Resident #52's supplies and ordered them. The RT revealed a spare trach should be kept with the nurse. Interview on 09/15/25 at 4:44 P.M. with LPN #292 confirmed he worked with Resident #52. LPN #292 revealed Resident #52 kept all his trach supplies in his room and did his own trach care. Interview on 09/15/25 at 5:11 P.M. with LPN #233 revealed Resident #52 liked to do his own trach care and she asks him if he did it then signs the orders confirming the treatment was completed. LPN #233 revealed the trach supplies were kept in the treatment or medication cart. Review of the facility policy titled, Tracheostomy Care revealed to verify the physicians order, gather the assembled supplies, assess the condition of the stoma, remove the inner cannula, cleanse around the stoma, place the new inner cannula inside tracheostomy tube, replace trach ties if soiled, document the date and time and the skin integrity around the stoma. This deficiency represents non-compliance investigated under Complaint Numbers 2616221, 2620100.

Based on observation, interview, record review and facility policy review, the facility failed to follow the renal diet menu. This affected two residents (#115 and #129) of three residents reviewed for nutrition, and affected ten additional residents (#3, #16, #22, #42, #46, #56, #64, #94, #99 and #105) who received a renal diet. The facility census was 129.
Findings include:
Review of the medical record for Resident #115 revealed an admission date of 11/18/24. Diagnoses included end stage renal disease, peripheral vascular disease, and non-pressure chronic ulcers to the right and left lower leg. Physician orders effective January 2025 specified a renal diet with regular texture and thin consistency.
Review of the medical record for Resident #129 revealed an admission date of 06/17/20. Diagnoses included severe chronic kidney disease, adult failure to thrive and severe protein calorie malnutrition. Physician orders effective January 2025 specified a renal diet, mechanical soft with pureed fruit texture and thin consistency with large portions.
Interview on 01/29/25 at 7:55 A.M. with Resident #115 revealed a complaint about not receiving alternative food items during a meal which were not included in the renal diet.
Observation on 01/29/25 at 8:20 A.M. revealed Certified Nursing Assistant (CNA) #337 entered the room for Residents #115 and #129 and delivered their breakfast trays. Resident #115's plate included scrambled eggs and one blueberry muffin. There were beverages included on the tray but no additional food items. Resident #129's plate included a large portion of scrambled eggs and one blueberry muffin. There were beverages included on the tray but no additional food items.
Review of the meal ticket left on Resident #115's breakfast tray revealed a renal regular diet with no additional information or listed dislikes.
Interview on 01/29/25 at 8:26 A.M. with CNA #337 verified both Residents #115 and #129 received only scrambled eggs and one blueberry muffin on their plate with no additional food items on the tray.
Review of the facility menu for the week of 01/26/25 revealed the breakfast for 01/29/25 included the following food items: choice of hot or cold cereal, scrambled eggs with cheese, hash browns and a blueberry muffin.
Interview on 01/29/25 at 8:29 A.M. with Dietary Manager (DM) #402 confirmed the breakfast menu included the following food items: a choice of hot or cold cereal, scrambled eggs with cheese, hash browns and a blueberry muffin. DM #402 indicated Residents #115 and #129 both had renal diets and therefore would not receive food items such as hash browns, stating the cook followed the spreadsheet for renal diets.
Review of the breakfast menu spreadsheet for 01/29/25 revealed the following food items for residents who had a renal diet: scrambled eggs, one half cup of pineapple in place of the hash browns and no blueberry muffin.
Interview on 01/29/25 at 9:07 A.M. with DM #402 and [NAME] #222 verified the spreadsheet was not followed for all residents who required a renal diet during breakfast service which required omitting the blueberry muffin and adding a serving of pineapple.
Review of the facility provided list of residents who received renal diets printed 01/29/25 included twelve residents (#3, #16, #22, #42, #46, #56, #64, #94, #99, #105, #115 and #129).
Review of the undated facility policy, Therapeutic Diets revealed the facility will provide therapeutic diets to meet the clinical nutrition needs of residents.
This deficiency represents non-compliance investigated under Complaint Number OH00161451.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received bathing as planned and/or as requested. This affected one resident (#180) of five residents reviewed for showers. The facility census was 126.
Findings include:
Review of the medical record for Resident #180 revealed an admission date of 09/04/24. Diagnoses included but were not limited to type II diabetes mellitus, stage III chronic kidney disease and history of transient ischemic attacks.
Review of the 09/04/24 admission Minimum Data Set (MDS) 3.0 for Resident #180 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #180 required set up assistance for bathing.
Review of the care plan dated 09/06/24 for Resident #180 revealed under preferences, preferred showers.
Review of the facility shower schedule revealed Resident #180 was to receive showers on Wednesdays and Saturdays during the 3:00 P.M. to 11:00 P.M. shift.
Review of the facility Recreation admission assessment dated [DATE] for Resident #180 revealed under other preferences Resident #180 indicated it was very important choose between a shower or bed bath and preferred showers.
Review of the shower sheets for Resident #180 revealed refusals on 09/06/24 and 09/13/24 and showers provided on 09/10/24, 09/17/24, and 09/20/24. No noted reattempts for the shower refusals were indicated. No shower sheet was provided after 09/20/24.
Review of the nursing progress notes from 09/04/24 to 09/26/24 for Resident #180 did not indicate any shower refusals.
Interview on 09/23/24 at 11:05 A.M. with Resident #180 revealed he was admitted three weeks ago and has never been offered a shower and stated staff have just offered him a washcloth to wash up.
Interview on 09/25/24 at 11:02 A.M. with Licensed Practical Nurse (LPN #72) revealed Resident #180 is very cooperative and does not refuse care.
Interview on 09/26/24 at 8:06 A.M. with Resident #180 confirmed he was offered a washcloth to clean up yesterday but was not offered a shower. Resident #180 confirmed he has never been offered a shower since admission and has not refused bathing. Resident #180 stated he left a previous facility due to not getting consistent showers and had hoped moving to this facility would be better.
Interview on 09/26/24 at 8:11 A.M. with Unit Manager #139 confirmed shower sheets provided by the facility indicated a refusal on 09/06/24 and 09/13/24 and did not indicate if resident had been re-approached more than once. Unit Manager confirmed there was no shower sheet for 09/20/24 and the care plan did not indicate shower refusals. Unit Manager #139 confirmed Resident #180 was being offered a shower today.
Review of the revised facility policy (dated 06/30/22) titled; Bed Bath/Shower revealed residents will be scheduled to accommodate their preferences as facility is able and will be scheduled at least weekly. Staff will complete the bath/shower as scheduled or to accommodate resident preference. The staff will document when the bath/shower was completed per facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and review of facility policy revealed the facility failed to ensure enhanced barrier precautions were utilized for a resident during high contact resident care. This affected one resident (#108) of two residents observed for enhanced barrier precautions.
Findings included:
Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition.
Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included enhanced barrier precautions with high contact care including using a gown and gloves for dressing change and tube feeding care, check placement of feeding tube, keep head of bed elevated and monitor for complications.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #108 was rarely or never understood due to impaired cognition. She required substantial to maximum assistance of staff rolling left and right and was dependent on staff with most all her other activities of daily living. She had a feeding tube.
Review of September 2024 physician orders revealed Resident #108 had an order dated 06/02/24 that she was to be on enhanced barrier precautions. The order included use gown and gloves for high contact resident care including dressing, bathing, showering, transfers, hygiene care, linen changes, changing of briefs, and care of any device including tube feeding.
Observation on 09/24/24 at 8:09 A.M. upon entrance to Resident #108's room revealed Resident #108 had signage on the door to be on enhanced barrier precautions. Licensed Practical Nurse (LPN) #75 proceeded into her room only donning gloves and no gown and placed Resident #108's tube feeding on hold. LPN #75 provided high contact care for Resident #108 including repositioned her in bed, pulled her up in bed, obtained blood pressure, obtained oxygen saturation rate, auscultated placement of her tube feeding with her stethoscope, and proceeded to administer her medications and water flushes through her feeding tube.
Interview on 09/24/24 at 8:54 A.M. with LPN #75 verified she did not wear a gown when she provided Resident #108's high contact care. She verified Resident #108 was on enhanced barriers but stated I believe that is for people with like C-Diff (Clostridium difficile) or highly contagious things like that and Resident #108 does not have anything like that. She revealed she was not trained and/ or educated to wear precautions including a gown for high contact resident care when a resident was on enhanced barrier precautions.
Interview on 09/24/24 at 9:13 A.M. with the Director of Nursing revealed she had talked to LPN #75 after the observation and revealed all staff including LPN #75 had been educated over and over regarding enhanced barriers. She verified LPN #75 was to wear a gown during the care she provided Resident #108 including when she repositioned her, pulled her up in bed, obtained her blood pressure, obtained her oxygen saturation rate, auscultated her placement of her tube feeding with her stethoscope, and administered her medications and water flushes through her feeding tube.
Review of facility policy labeled; Enhanced Barrier Precautions (EBP) (dated 11/30/23) revealed enhanced barrier precautions (EBP) were an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs). EBP were to be used for residents with wounds, indwelling medical devices including central line, urinary catheter, and feeding tube. The policy revealed gowns and gloves were to be used for high-contact resident care activities for those at increased risk of MDRO acquisition including residents with wounds or indwelling medical devices. The policy revealed examples of high contact care activities included device care or use including feeding tube.
Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, (dated 03/20/24), by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24.

Based on interview, record review and review of facility policy revealed the facility did not ensure Resident #32's advanced directives were accurate per the physician orders on her electronic medical record. This affected one resident (#32) out of 43 residents reviewed for advanced directives. The facility census was 126.
Findings included:
Review of the medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension.
Review of the Do Not Resuscitate (DNR) Comfort Care form dated 08/02/23 and completed by Nurse Practitioner (NP) #500 revealed Resident #32 was to be a DNR Comfort Care- Arrest.
Review of the care plan dated 08/24/23 revealed Resident #32 and/ or family had chosen to have an advanced directive: DNR Comfort Care- Arrest. Interventions included the facility would review code status when significant change in condition occurred, monitor for appropriateness of a hospice consult, and review advance directive status with plan of care meetings.
Review of September 2024 physician orders per Resident #32's electronic medical record revealed under the code status section at the top of the orders Resident #32 was to be a full code. The physician orders also included an order dated 09/06/24 that revealed Resident #32 was to be a full code.
Interview on 09/23/24 at 3:56 P.M. with Licensed Practical Nurse (LPN) #78 was asked if a resident was found unresponsive without vitals where would she check to see what the resident's advanced directives were. LPN #78 revealed she would check the physician orders per the electronic medical record. LPN #78 verified Resident #32's advance directives were conflicting as the physician order stated she was a full code but in the hard chart there was a DNR Comfort Care form that identified Resident #32 was a DNR Comfort Care- Arrest.
Interview on 09/23/24 at 3:59 P.M. with the Director of Nursing revealed Resident #32's order in her electronic medical record stated that she was to be a full code but the DNR Comfort Care form in her medical record indicated she was to be a DNR Comfort Care- Arrest. She verified the order in the electronic medical record was not accurate.
Review of facility policy labeled; Advanced Care Planning dated 11/30/23 revealed upon admission the attending physician would help identify the prognosis for each resident. The physician and staff would identify individuals who desire or are likely candidates for palliative care. There was nothing identified in the policy regarding ensuring advanced directives were accurate in the electronic medical record and matched what advance directives were per the DNR Comfort Care form. There was also nothing in the policy regarding where a nurse should look if a resident was found unresponsive regarding what code status to utilize in the physician orders per the electronic medical record and/ or the DNR Comfort Care form in the hard medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policies the facility failed to ensure the resident, physician, legal guardian and/ or responsible party was notified regarding significant weight changes. This affected two residents (#16 and #32) out of seven residents reviewed for proper notifications of significant weight change. The facility census was 126.
Findings included:
1. Review of the medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia. She had a legal guardian. There was no documentation in the medical record regarding the physician, and legal guardian being notified of Resident #32's significant weight loss of 17.1 percent from 02/01/24 to 05/08/24.
Review of the weight record for Resident #32 from 01/08/24 to 09/24/24 revealed she had the following weights: 01/08/24 her weight was 197.6 pounds, 01/30/24 her weight was 202.3 pounds, 02/01/24 her weight was 193 pounds, and 05/08/24 her weight was 160 pounds which indicated a 17.1 percent significant weight loss. The weight record also revealed on 06/05/24 her weight was 171 pounds, 07/22/24 her weight was 173.1 pounds, 07/24/24 her weight was 166.6 pounds, and on 08/08/24 her weight was 162.4 pounds. There was no recorded weight from 02/01/24 until 05/08/24 (over three months) and there was no recorded weight for September 2024 as of the time of the review (09/24/24).
Review of quarterly Nutrition assessment dated [DATE] and completed by Dietician #171 revealed Resident #32's weight was 171 pounds. The assessment revealed Resident #32 had a 10.2 percent weight loss in six months. She continued a regular pureed diet with cup with handles for meals. The dietician recommended to continue to monitor the resident's weight and meal intakes.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively impaired. She was dependent on staff for eating. Her weight was 167 pounds, and she was identified with weight loss that was not prescribed.
Review of care plan last revised 08/06/24 revealed Resident #32 had nutritional needs as she had a significant weight loss in the last 180 days due to dysphagia, schizophrenia, and cerebral vascular accident. Interventions included diet as ordered, monitor and evaluate any significant weight loss, review weights and notify physician and responsible party regarding any significant weight change.
Interview on 09/24/24 at 3:37 P.M. with Dietician #169 revealed the facility did not have a dietician at this time and that other dieticians from other facilities had been filling in until a dietician was hired. She verified on review of the medical record that Resident #32's weight on 02/01/24 was 193 pounds, and then there was no weight recorded until 05/08/24 which was 160 pounds indicating a 17.1 percent weight loss. She verified she had gone for three months without a weight completed and upon her review there was no indication of a reason such as being in the hospital and/ or refusal as her weight should have been completed at least monthly. She verified she did not see per her medical record that the physician or legal guardian was notified of her significant weight loss and believed the nurses were to do this but was unsure.
Interview on 09/24/24 at 3:51 P.M. with the Director of Nursing verified Resident #32's weight was not completed for over three months as her weight on 02/01/24 was 193 pounds, and then there was no weight again until 05/08/24 which was 160 pounds indicating a 17.1 percent weight loss. She stated, to be honest the weight did not get done.
Interview on 09/24/24 at 2:10 P.M. with the Director of Nursing verified there was no evidence in the medical record the physician and/ or legal guardian was notified of Resident #32's significant weight loss of 17.1 percent. She verified any significant weight loss the nurses were to notify the physician, resident, legal guardian and/ or responsible party.
2. Review of the medical record for Resident #16 revealed an admission date of 01/04/24 and diagnoses included dementia, emphysema, mild protein calorie malnutrition, and dysphagia. There was nothing in the medical record regarding the resident, responsible party and physician being notified of Resident #16's 21 percent significant weight loss.
Review of weight record from 01/04/24 to 09/24/24 revealed Resident #16's admission weight was 131.6 pounds. His weight appeared stable until 07/24/24 his weight was 135 pounds and on 08/06/24 his weight was 106.6 indicating a 21 percent significant weight loss. There were no other weights recorded following the 08/06/24 weight.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had impaired cognition. His weight was 139 pounds indicating no weight loss and he was on a mechanically altered diet.
Review of care plan dated 07/16/24 revealed Resident #16 had nutritional needs related to advanced age, significant weight changes, dementia, dysphagia, and mild protein malnutrition. Interventions included diet as ordered, encourage oral intake, monitor weight every week for one month and then monthly thereafter, review weights and notify physician and responsible party of significant weight changes.
Review of Nutritional progress note dated 08/07/24 and completed by Dietician #170 revealed Resident #16 had a significant weight loss of 21 percent as his weight was 106.6 pounds indicating he was underweight. Dietician #170 questioned the validity of the weight and requested a reweigh. There was nothing in the progress note the physician and/ or responsible party was notified regarding the significant weight loss.
Review of Nutritional progress note dated 08/20/24 and completed by Dietician #170 revealed Resident #16 had a 21 percent significant weight loss over the last two weeks and Dietician #170 questioned the validity of the weight and requested a reweigh. She recommended to liberalize his diet and continue the magic cup supplement twice a day. There was nothing in the progress note the physician and/ or responsible party was notified regarding the significant weight loss.
Interview on 09/24/24 at 4:27 P.M. with Dietician #169 verified the last recorded weight per the electronic medical record was on 08/06/24 and was 106 pounds indicating a significant weight loss of 21 percent in one month. She verified upon review of the medical record the Dietician #170 had requested a re-weight to be completed on 08/07/24 and 08/20/24 as she questioned the validity of the weight. Dietician #169 revealed upon her review it did not appear a re-weight was completed as she goes by what is in the electronic medical record. She revealed she was unsure if the weight was accurate or not without a re-weight. She verified she did not see per his medical record that the resident, responsible party or physician was notified of his significant weight loss and believed the nurses were to do this but was unsure.
Interview on 09/25/24 at 9:51 A.M. with the Director of Nursing revealed a re-weight had been completed on 09/05/24 and the weight was 119.2 pounds (11.7 weight loss) but had not been entered into the electronic medical record instead it was in a weight book. She verified she was unsure if the dieticians knew about the weight book instead of just going by what was in the electronic medical record. She verified the nurses were to put the weights in the electronic medical record for the dietician to review.
Interview on 09/25/24 at 10:39 A.M. with the Director of Nursing verified there was nothing in the medical record that indicated the resident, responsible party and/ or physician was notified regarding Resident #16's significant weight loss.
Review of undated facility policy labeled, Nutrition Intervention for Significant Weight Change revealed the registered dietician would assess monthly and weekly weight changes and recommended interventions intended to reverse the weight loss. The dietician would calculate and assess for significant weight changes: five percent in one month, 7.5 percent over three months and ten percent over six months would be considered significant. The policy revealed based on resident preferences and/ or discussions with the resident and/ or responsible party the dietician may recommended nutritional interventions to attempt to stabilize or reverse weight loss. There was nothing in the policy regarding notification to physician, responsible party and/ or resident of significant weight loss.
Review of facility policy labeled, Change in a Resident's Condition dated 11/30/23 revealed the facility shall notify the resident, physician, and representative of changes in the resident's medical condition. The nurse would document in the resident's medical record information relative to changes in the resident's medical condition or status.
This deficiency represents non-compliance investigated under Master Complaint Number OH00157866.

Based on observations and interviews the facility failed to maintain a sanitary environment surrounding the dumpster area. This had to potential to affect all 126 residents residing in the facility.
Findings include:
Observations on 09/23/24 at 8:54 A.M. revealed plastic garbage bags filled with food and other miscellaneous items, soiled adult briefs, latex gloves, plastic forks/spoons, Styrofoam cups surrounding three dumpsters located in the parking lot.
Interview during the observations, Food Service Director #166 verified the observations stating the garbage would be cleaned up immediately.
No facility policy was provided related to maintaining a clean and sanitary area surrounding the dumpsters.

Based on record review, observation, and interview the facility failed to provide assistance to maintain personal hygiene. This affected one (Resident #69) of five residents reviewed for activities of daily living. The census was 126
Findings include:
Review of medical record for Resident #69 revealed an admission date of 11/04/21. Diagnoses included depression, unspecified and type two diabetes. The resident had impaired cognition.
Review of the annual Minimum Data Set (MDS) assessment, dated 09/06/24, revealed Resident #69 had intact cognition. The resident required maximum assistance for personal hygiene.
Review of the plan of care dated 09/10/24 revealed Resident #69 had a activity of daily living (ADL) self-care performance deficit related to impaired mobility and generalized weakness. Interventions included for staff to provide total oral care, provide extensive assistance with personal hygiene; and encourage to start task and finish if the resident becomes tired or unable to complete.
Observation on 09/23/24 at 10:22 A.M., Resident #69 was observed to have facial hair covering her chin measuring approximately an eighth of an inch. Interview during the observation Resident #69 stated she would love to have the hair shaved off.
Interview on 09/23/24 at 10:23 A.M., State Tested Nurse Assistant (STNA) #39 stated yeah her hair is pretty long, I will shave it.
Observation on 09/25/24 at 10:49 A.M., Resident #69 was lying in bed, her chin was still not shaven.
Interview and observation on 09/25/24 at 10:56 A.M. Licensed Practical Nurse (LPN) #75 verified the observation and stated she would take of it immediately.
Review of the facility policy titled Activities of Daily Living, dated 2023 noted staff were to maintain personal hygiene including combing and/or styling hair, washing hands and face, brushing teeth, and shaving when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and review of facility policy revealed the facility failed to implement fall interventions as identified in the resident's plan of care. This affected one resident (#32) of four residents reviewed for falls and/ or accidents. The facility census was 126.
Findings included:
Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension.
Review of care plan dated 07/08/24 revealed Resident #32 was at risk for falls due to impaired mobility, generalized weakness, Schizophrenia, and neuropathy. Interventions included assist with transfers, locomotion and mobility, grab bar to bed, commonly used items within easy reach, and protective floor mat next to bed that was added on 08/29/24.
Review of the care plan dated 07/08/24 revealed Resident #32 had a self-care performance deficit related to impaired mobility, generalized weakness, and neuropathy. Interventions included grab bar on both sides of bed to assist with turning and repositioning, staff to anticipate needs daily, assist resident in proper body alignment while in bed, and use positioning devices as needed.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively impaired. She was dependent on staff assist with rolling left and right, toileting, dressing and showers. The MDS revealed transfers had not been attempted during the assessment period due to medical condition.
Review of quarterly fall review dated 08/06/24 and completed by Licensed practical Nurse (LPN) #139 revealed Resident #32 was at high risk for falls as she needed assistance with toileting, was confined to a chair, unable to stand, had diagnoses that placed her at high risk for falls as well as was on medications that increased her risk of falls.
Review of Fall Review- V3 dated 08/27/24 and completed by Registered Nurse (RN) #67 revealed Resident #32 continued to be at high risk for falls. The review revealed a certified nursing assistant (CNA) notified RN #67 that Resident #32 was on the floor. The nurse entered the room and Resident #32 was laying on the floor on her left side close to the bed. Resident #32 was unable to provide information regarding the fall. Resident #32 was lying in bed prior to the fall. There was no fall intervention added per the review.
Review of nursing note dated 08/27/24 at 11:09 P.M. and completed by RN #67 revealed a CNA had notified him that Resident #32 was on the floor on her left side close to the bed. He completed an assessment including neurological that revealed no injuries.
Review of nursing note dated 08/29/24 at 8:35 A.M. and completed by Assistant Director of Nursing (ADON)/ RN #31 revealed the interdisciplinary team met and discussed Resident #32's recent fall on 08/27/24. An intervention was implemented to have a floor mat to the side of her bed and her care plan was updated.
Observation on 09/23/24 at 1:25 P.M. revealed Resident #32 did not have a floor mat on either side of her bed.
Observation on 09/24/24 at 11:39 A.M. revealed Resident #32 did not have a floor mat on either side of her bed.
Interview on 09/24/24 at 12:58 P.M. with CNA #25 revealed she was Resident #32's CNA and that she did not have a floor mat to the side of her bed. CNA #25 revealed she had never seen her with a floor mat as she does not have one in her room and stated, I do not think she is supposed to have any.
Interview on 09/24/24 at 1:05 P.M. with LPN #95 revealed this was the first day working on Resident #32's unit but verified in Resident #32's care plan listed as a fall intervention she was to have a floor mat but that there was not a floor mat in her room. He stated, I will make sure she has a floor mat by the end of today.
Observation on 09/25/24 at 7:58 A.M. revealed Resident #32 was laying in bed and there was not a floor mat to the side of her bed.
Interview on 09/25/24 at 8:02 A.M. with LPN/ Unit Manager #134 verified there was not a floor mat to the side of Resident #32's bed. She also verified there was an intervention listed in the care plan that she was to have a floor mat due to her recent fall out of bed on 08/27/24. She revealed she would contact central supply to get a floor mat and that she was not sure why a mat was not placed yesterday.
Review of facility policy labeled, Falls- Clinical Protocol (dated 11/30/23) revealed for a resident that had fallen staff would attempt to define possible causes. A fall assessment would be completed, and the care plan reviewed and revised as appropriate. The policy revealed based on the assessment the staff and physician would identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and review of facility policies the facility did not ensure weights were obtained and monitored timely. This affected two residents (#16 and #32) of seven residents reviewed for nutrition. The facility census was 126.
Findings included:
1. Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included Schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia. She had a legal guardian. There was no documentation in the medical record regarding the physician, and legal guardian was notified of Resident #32's significant weight loss of 17.1 percent from 02/01/24 to 05/08/24.
Review of weight record for Resident #32 from 01/08/24 to 09/24/24 revealed she had the following weights: 01/08/24 her weight was 197.6 pounds, 01/30/24 her weight was 202.3 pounds, 02/01/24 her weight was 193 pounds, and 05/08/24 her weight was 160 pounds which indicated a 17.1 percent significant weight loss. The weight record also revealed on 06/05/24 her weight was 171 pounds, 07/22/24 her weight was 173.1 pounds, 07/24/24 her weight was 166.6 pounds, and on 08/08/24 her weight was 162.4 pounds. There was no recorded weight from 02/01/24 till 05/08/24 (over three months) and there was no recorded weight for September 2024 as of the time of the review (09/24/24).
Review of quarterly Nutrition assessment dated [DATE] and completed by Dietician #171 revealed Resident #32's weight was 171 pounds. The assessment revealed Resident #32 had a 10.2 percent weight loss in six months. She continued a regular pureed diet with cup with handles for meals. She recommended to continue to monitor her weight and meal intakes.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively impaired. She was dependent on staff on eating. Her weight was 167 pounds, and she was identified with weight loss that was not prescribed.
Review of care plan last revised 08/06/24 revealed Resident #32 had nutritional needs as she had a significant weight loss in the last 180 days due to dysphagia, schizophrenia, and cerebral vascular accident. Interventions included diet as ordered, monitor and evaluate any significant weight loss, review weights and notify physician and responsible party regarding any significant weight change.
Review of September 2024 physician orders revealed Resident #32 had an order for a pureed diet with a two-handle spout cup with meals, pro-heal liquid protein 30 milliliters (ml) twice a day to promote wound healing, and weekly weight times four weeks then monthly.
Review of readmission Nutritional assessment dated [DATE] at 1:55 P.M. and completed by Dietician #170 revealed Resident #32's weight was 162 pounds. She recommended to liberalize her diet to regular pureed, add liquid pro-heal 30 ml twice a day to promote wound healing and continue to monitor.
Observation on 09/24/24 at 1:03 P.M. revealed Occupational Therapy Assistant (OTA) #102 was sitting next to Resident #32 trying to encourage her to eat but she was refusing most all her food. OTA #102 notified LPN #95 of her refusals.
Interview on 09/24/24 at 3:37 P.M. with Dietician #169 revealed the facility did not have a dietician at this time and that other dieticians from other facilities had been filling in until a dietician was hired. She revealed all newly admitted residents were to be weighed weekly times four weeks and if the weight was stable then each resident was to be weighed monthly. She verified on review of the medical record that Resident #32's weight on 02/01/24 was 193 pounds, and then there was no weight recorded until 05/08/24 which was 160 pounds indicating a 17.1 percent weight loss. She verified she had gone for three months without a weight completed and upon her review there was no indication of a reason such as being in the hospital and/ or refusal as her weight should have been completed at least monthly. She revealed so far, her September 2024 weight had not been completed as she goes by what is in the electronic medical record as she believed the unit managers on each unit puts the weights in for the dietician to review but that she was not aware of any other location the weights would be. She revealed at times she had found weights were not completed timely.
Interview on 09/24/24 at 3:51 P.M. with the Director of Nursing revealed all new admission were to be weighed weekly for four weeks and then transition to a monthly weight if there were no concerns. She verified there was no full-time dietician at the facility that a dietician had been coming from other facilities to fill in. She verified Resident #32's weight was not completed for over three months as her weight on 02/01/24 was 193 pounds, and then there was no weight again until 05/08/24 which was 160 pounds indicating a 17.1 percent weight loss. She stated, to be honest the weight did not get done. She revealed for September 2024 her weight also had not been completed per the electronic medical record as they try to get the weights done the first week of the month and the nurses input the weights into the medical record.
Observation on 09/25/24 at 12:46 P.M. revealed staff took her lunch tray in, and she refused her meal after several attempts.
Interview on 09/24/24 at 2:10 P.M. with the Director of Nursing verified there was no evidence in the medical record the physician and/ or legal guardian was notified of Resident #32's significant weight loss of 17.1 percent. She verified any significant weight loss the nurses were to notify the physician, resident and responsible party.
2. Review of medical record for Resident #16 revealed an admission date of 01/04/24 and diagnoses included dementia, emphysema, mild protein calorie malnutrition, and dysphagia. There was nothing in the medical record regarding the resident, responsible party and physician notified of Resident #16's 21 percent significant weight loss.
Review of weight record from 01/04/24 to 09/24/24 revealed Resident #16's admission weight was 131.6. His weight appeared stable until 07/24/24 his weight was 135 pounds and on 08/06/24 his weight was 106.6 indicating a 21 percent significant weight loss. There were no other weights recorded following the 08/06/24 weight.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had impaired cognition. His weight was 139 pounds indicating no weight loss and he was on a mechanically altered diet.
Review of care plan dated 07/16/24 revealed Resident #16 had nutritional needs related to advanced age, significant weight changes, dementia, dysphagia, and mild protein malnutrition. Interventions included diet as ordered, encourage oral intake, monitor weight every week for one month and then monthly thereafter, review weights and notify physician and responsible party of significant weight changes.
Review of Nutritional progress note dated 08/07/24 and completed by Dietician #170 revealed Resident #16 had a significant weight loss of 21 percent as his weight was 106.6 pounds indicating he was underweight. Dietician #170 questioned the validity of the weight and requested a reweigh. There was nothing in the progress note the physician and/ or responsible party was notified regarding the significant weight loss.
Review of Nutritional progress note dated 08/20/24 and completed by Dietician #170 revealed Resident #16 had a 21 percent significant weight loss over the last two weeks and Dietician #170 questioned the validity of the weight and requested a reweigh. She recommended to liberalize his diet and continue the magic cup supplement twice a day. There was nothing in the progress note the physician and/ or responsible party was notified regarding the significant weight loss.
Review of September 2024 physician orders revealed Resident #16 had an order for weekly weights times four weeks and then monthly, mechanical soft regular diet, magic cup supplement two times a day, and encourage extra fluids.
Observation on 09/24/24 at 1:00 P.M. revealed Resident #16 was sitting in the lounge with his wife eating his lunch independently. He had a good appetite and no issues were noted.
Interview on 09/24/24 at 4:27 P.M. with Dietician #169 verified the last recorded weight per the electronic medical record was on 08/06/24 and was 106 indicating a significant weight loss of 21 percent in one month. She verified upon review of the medical record the Dietician #170 had requested a re-weight to be completed on 08/07/24 and 08/20/24 as she questioned the validity of the weight. Dietician #169 revealed upon her review it did not appear a re-weight was completed as she goes by what is in the electronic medical record. She revealed she was unsure if the weight was accurate or not without a re-weight.
Interview on 09/25/24 at 9:51 A.M. with the Director of Nursing revealed a re-weight had been completed on 09/05/24 and the weight was 119.2 pounds (11.7 weight loss) but had not been inputted into the electronic medical record instead it was in a weight book. She verified she was unsure if the dieticians knew about the weight book instead of just going by what was in the electronic medical record. She verified the nurses were to put the weights in the electronic medical record for the dietician to review.
Interview on 09/25/24 at 10:39 A.M. with the Director of Nursing verified there was nothing the medical record that indicated the responsible party and/ or physician was notified regarding Resident #16's significant weight loss.
Observation on 09/25/24 at 12:44 P.M. revealed Resident #16 was sitting in the lounge with his wife eating his lunch independently. He had a good appetite with no issues.
Review of undated facility policy labeled, Nutrition Intervention for Significant Weight Change revealed the registered dietician would assess monthly and weekly weight changes and recommended interventions intended to reverse the weight loss. The dietician would calculate and assess for significant weight changes: five percent in one month, 7.5 percent over three months and ten percent over six months would be considered significant. The policy revealed based on resident preferences and/ or discussions with the resident and/ or responsible party the dietician may recommended nutritional interventions to attempt to stabilize or reverse weight loss. There was nothing in the policy regarding notification to physician, responsible party and/ or resident of significant weight loss.
Review of facility policy labeled, Change in a Resident's Condition dated 11/30/23 revealed the facility shall notify the resident, physician, and representative of changes in the resident's medical condition. The nurse would document in the resident's medical record information relative to changes in the resident's medical condition or status.
This deficiency represents non-compliance investigated under Master Complaint Number OH00157866.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and review of facility policy the facility failed to ensure Resident #108's enteral tube feeding (a method of providing nutrition to patients who are unable to eat or drink safely by mouth) was infusing at the correct rate per physician order. This affected one resident (#108) of two residents reviewed for tube feeding.
Findings included:
Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition.
Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included tube feeding per dietary recommendation and physician order, check placement of feeding tube, keep head of bed elevated and monitor for complications.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #108 was rarely or never understood due to impaired cognition. She had a feeding tube.
Review of nursing note dated 08/20/24 at 2:05 P.M. and completed by Dietician #172 revealed Resident #108 tolerated her enteral tube feeding at a lower volume at a continues rate than the increased rate at a shorter time. Dietician #172 recommended Diabetisource at 50 milliliter (ml) per hour continuous.
Review of September 2024 physician order dated 08/20/24 revealed Resident #108 was to receive Diabetisource 50 ml per hour continuous.
Observation on 09/24/24 at 8:09 A.M. upon entrance to Resident #108's room revealed her tube feeding of Diabetisource was running at 65 ml per hour. Licensed Practical Nurse (LPN) #75 placed her tube feeding on hold while she administered Resident #108 her medications through her feeding tube. LPN #75 then proceeded to re-start the tube feeding at 65 ml per hour after completion of administering her medication, proceeded out the room and documented the administration of the medications per the electronic medical record.
Interview on 09/24/24 at 8:54 A.M. with LPN #75 verified Resident #108's tube feeding per the physician order was to be running at 50 ml per hour not 65 ml per hour. She revealed the previous nurse must have set the tube feeding at the wrong rate and that she had just continued the same setting without verifying the order when she restarted the tube feeding.
Review of facility policy labeled, Enteral Tube Feeding- Bolus and Continuous (dated 11/30/23) revealed to assure safe and effective administration of enteral tube feeding. The policy revealed check physician order, explain procedure, position in bed with head of bed 30 degrees throughout feeding, and program pump per order.

Based on interview, observation, policy review and review of the medical record revealed the facility failed to ensure enteral feedings were labeled and dated appropriately. This affected one resident (#93) of two residents reviewed for enteral feedings. The facility census was 126.
Findings include:
Review of the medical record for Resident #93 revealed an admission date of 10/06/22. Diagnoses included but were not limited to encephalopathy, gastrostomy, dysphagia, and history of transient ischemia attack (TIAs).
Review of the 09/02/24 annual Minimum Data Set (MDS) 3.0 for Resident #93 revealed a Brief Interview for Mental Status (BIMS) revealed severe cognitive impairment. Resident #93 and was dependent for all Activities of daily living (ADLs) and received a tube feeding.
Review of physician orders dated 11/10/23 for Resident #93 revealed an order to change enteral feeding bag and syringe every night shift for routine care and label with date.
Review of physician orders dated 09/01/24 for Resident #93 revealed an order for Isosource 1.5 calorie enteral feed at 50 milliliters (mL) per hour for 24 hours to provide 1200 mL volume, 1800 calories, 82 grams protein and 917 mL of free water.
Review of physician orders dated 11/10/23 for Resident #93 revealed an order to change tube feeding bag and syringe daily every night shift. Label with date.
Observation on 09/23/24 at 10:50 A.M. with Licensed Practical Nurse (LPN) #95 revealed an unlabeled, undated enteral tube feeding bag running at 50 mL connected to Resident #93. LPN #95 confirmed there was no resident name, no product name, date or time on the enteral feeding bag and stated there should have been.
Interview on 09/24/24 at 7:18 A.M. with LPN #72 confirmed when checking a resident tube feeding, physician orders are to be followed when hanging a new bag including labeling the bag with the resident name, date and time as tube feeding products are only good for 24 hours.
Interview on 09/25/24 at 2:54 P.M. with the Director of Nursing (DON) confirmed when a new tube feeding bag if hung, the date, time, product name and nurse's initials hanging the bag should be on the bag.
Review of the 11/30/23 facility policy titled; Enteral Tube Feeding-Bolus and Continuous revealed the policy was to assure safe and effective administration of enteral feeding. The policy did not include any information regarding ensuring the tube feeding bag was labeled with the produce it contained and/or the date/time it was hung.

Based on observations and interview the facility failed to maintain a sanitary kitchen. This had the potential to affect all residents residing in the facility except for three residents (#9, #93, and #123) who did not receive nutrition by mouth. The census was 126.
Findings include:
Observations on 09/23/24 at 8:35 A.M. of the kitchen revealed two garbage cans lids covered with dust and food debris, a paper inspection tag for the ancillary alarm located on the wall was located on the floor by doorway, the tag was covered with brownish debris and difficult to read inspection dates.
The entire floor of kitchen was covered with food debris and miscellaneous grime, the bottom of a shelving unit holding clean sheet pans was covered with dust and miscellaneous food debris. Observations on the walk-in refrigerator revealed a bag of green/brownish lettuce on the self, the bag was not dated.
There was a plastic container storing food scoops located under the serving table that had miscellaneous food debris surrounding the scoops. The outside including the handle of the microwave was covered with dust and miscellaneous food debris.
A floor area by the microwave had a large fork, straws and miscellaneous food debris lying on top of a mouse trap. Food Service Director (FSD) #166 stated, I don't know why the fork is on the floor. Another plastic container holding plastic lids located on a bottom shelf was covered with thickening powder, which FSD #166 stated, well those need to be washed.
Observations of the juice dispenser nozzles revealed the nozzles were covered with brown liquid, observations of the reach in cooler had a turkey sandwich in a baggie that was not dated, there were also containers of a thickening agent flavored cranberry and orange, and thickened milk that were opened and not dated.
There was also a white liquid substance approximately six inches by six inches on the bottom shelf of the cooler. The outside of the door of the small refrigerator had white miscellaneous debris on the door and door handle.
Observations of the dry storage area had revealed small packets of condiments on the floor with miscellaneous debris on the floor.
Interview during the observations, FSD #166 verified all findings and directed kitchen staff to clean areas noted.
Observations on 09/24/24 at 11:04 A.M. of the kitchen revealed an exhaust fan located in the ceiling just right of the tray line. The fan was covered with blackish, brownish dust. Interview during the observations, FSD #166 verified the finding.
Observations on 09/24/24 at 11:10 A.M. of tray line preparation revealed Regional District Manager (RDM) #168 sanitized the cutting board located on the heating cart holding the cooked foods. The Manager then placed two thawed turkey patties on the cutting board along with a clean knife. FSD #166 verified the finding and directed staff to remove the patties and knife due to cross contamination.
Review of the facility policy titled Food Preparation and Storage, (not dated) noted kitchen surfaces and equipment will be cleaned and sanitized as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, menu spreadsheet review, and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 117 residents receiving meals from the kitchen as two residents (#67 and #108) were ordered nothing-by-mouth (NPO). The facility census was 119.
Findings include:
Review of a menu for week two, Tuesday corresponding to 03/26/24 revealed the following for the lunch meal: barbeque pork shoulder, tater tots, coleslaw, biscuit, and a spiced pear bar.
Interview on 03/25/24 at 10:20 A.M. with Resident #116 revealed food was terrible, did not taste good, and was often cold.
Interview on 03/25/24 at 10:32 A.M. with Resident #68 revealed the food sometimes was not warm.
Interview on 03/25/24 at 10:42 A.M. with Resident #5 revealed the food was sometimes cold.
Observation of the lunch meal on 03/26/24 starting at 11:30 A.M. revealed [NAME] #414 took temperatures of the foods to be served with the facility's self-calibrating electronic thermometer as follows: pork 186 degrees Fahrenheit (F); tater tots 179 degrees F; and coleslaw 32 degrees F. Tray service began at 11:35 A.M. Staff utilized plates out of a plate warmer as well as heated dome bottoms. The staff plating food was not being attentive to the communication from the tray line staff, and the [NAME] continued to plate trays for regular diets despite the tray line staff saying they needed modified diet plates. The plates that were not needed immediately sat on the top of the servery until utilized, which was approximately ten minutes left uncovered. Towards the end of tray line, kitchen staff ran out of heated dome bottoms as well as dome lids. Seven trays were sent to the units with no heated dome bottoms and an addition 14 trays were sent to the units without heated dome bottoms as well as dome lids. The 14 trays that had no dome lids were covered with aluminum foil prior to leaving the kitchen. A test tray was requested for the C-unit cart which was started at 12:35 P.M. and was the last tray plated. The cart was taken immediately to the C-unit and dropped off at 12:36 P.M. All trays were passed, and test tray was sampled with Dietary Manager #384. Temperatures of the foods to be sampled were as follows: pork 118.1 degrees F; tater tots 106.5 degrees F; and coleslaw 51.7 degrees F. The pork and tater tots were lukewarm and did not taste palatable at this temperature. Dietary Manager #384 stated at the time of the observation that the sampled food was under minimum serving temperature. Dietary Manager #384 was informed during the test tray observation that the tater tots, pork, and coleslaw were not palatable at the temperatures they were served at and did not disagree.
Review of the facility list of resident diets revealed Residents #67 and #108 were NPO.
Review of the facility policy, Dining and Meal Service, dated 06/08/22, revealed individuals will be provided with nourishing, palatable, attractive meals and will support each individual's daily nutritional and special dietary needs.
This deficiency represents non-compliance investigated under Complaint Number OH00151785.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed ensure Resident #110 was appropriately discharged and failed to ensure Resident #110's durable medical equipment (DME) was delivered timely upon discharge. This finding affected one (Resident #110) of three residents reviewed for discharges.
Findings include:
Review of Resident #110's medical record revealed he was admitted on [DATE] and discharged on 06/27/23 with diagnoses including encounter for other orthopedic aftercare, charcot's joint right ankle and foot and diabetes.
Review of Resident #110's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition.
Review of Resident #110's Clinical Utilization Review form from the insurance company dated 06/26/23 at 12:00 P.M. stated the last covered day was 06/22/23 and clinical information was requested and due on 06/23/23.
Review of Resident #110's social worker progress note dated 06/27/23 at 4:19 P.M. indicated he was discharged home with home health care (HHC). Upon discharge home, Resident #110 needed a hospital bed, commode and wheelchair.
Interview on 07/10/23 at 10:41 A.M. with Licensed Social Worker #905 indicated on 06/26/23 she received an email which stated Resident #110 was cut from therapy services on 06/22/23. She stated when she received the email, she immediately started sending out referrals for home care which included skilled physical therapy (PT) and occupational therapy (OT) and she sent in a referral for durable medical equipment (DME) including a bariatric wheelchair, commode and hospital bed. She stated the DME was to be delivered on 06/30/23 and she was unable to find a HHC provider for PT and OT and she notified the resident.
Interview on 07/10/23 at 11:29 A.M. with Resident #110 indicated he did not receive his DME equipment until 07/03/23 and he felt his HHC was not setup satisfactorily.
Interview on 07/10/23 at 11:36 A.M. with the Medical Supply #980 indicated the facility sent over a referral for DME equipment but it required additional information.
Interview on 07/10/23 at 1:30 P.M. with Insurance #982 with the Administrator, the Director of Nursing (DON) and Admissions Director #841 in attendance revealed Resident #110 was not issued a cut letter from the insurance company. Insurance #982 stated the Clinical Review Form dated 06/26/23 was a request for additional information and the date generated on the form was automatic and not the actual date of discontinuation of therapy services. Insurance #982 stated Resident #110's therapy did not end until the insurance company received Resident #110's Discharge Summary form from the facility. Insurance #982 also stated Resident #110 could have stayed in the facility for custodial care which included wound care and the insurance company would paid for the stay. She clarified no staff members called her to ask about the cut letter or ask for information regarding Resident #110's payment for therapy services.
Interview on 07/10/23 at 3:30 P.M. with Medical Supply #984 indicated she received the consult for Resident #110's DME equipment on 06/27/23 but needed more information. Medical Supply #984 stated she called the facility on 06/27/23 and left a message on Licensed Social Worker (LSW) #905's email regarding the extra information required. Medical Supply #984 confirmed she did not receive the additional information until Friday 06/30/23 and the DME equipment was delivered the next business day which was Monday 07/03/23.
Review of the Resident Transfer and Discharge Policy dated 11/13/19 indicated the interdisciplinary team (IDT) would provide the resident with appropriate preparation prior to discharge to ensure a safe and orderly discharge in accordance wit the facility Discharge Planning Policy.
This deficiency represents non-compliance investigated under Complaint Number OH00144278.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #58's diazepam anti-anxiety medication was reordered and available for resident use and the facility failed to accurately document the administration or refusal of Resident #58's anti-anxiety medication administration. This finding affected one (Resident #58) of four residents reviewed for medication administration.
Findings include:
Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, hypothyroidism and diabetes.
Review of Resident #58's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition.
Review of Resident #58's physician orders revealed an order dated 03/20/23 for diazepam anti-anxiety medication 10 mg (milligrams) administer one tablet by mouth twice daily.
Review of Resident #58's administration records (MARS) from 06/01/23 to 07/10/23 revealed the diazepam anti-anxiety medication was due at 6:30 A.M. and 6:30 P.M. The MARS from 06/01/23 to 07/10/23 for the 6:30 A.M. shift revealed nursing staff documented the resident refused the anti-anxiety medication on 06/02/23, 06/03/23, 06/04/23, 06/05/23, 06/06/23, 06/07/23, 06/10/23, 06/13/23, 06/17/23, 06/18/23, 06/21/23, 06/22/23, 06/23/23, 06/24/23, 06/26/23, 06/27/23, 06/29/23, 07/02/23, 07/03/23, 07/05/23, 07/06/23, 07/08/23 and 07/09/23. The MARS from 06/01/23 to 07/10/23 for the 6:30 P.M. shift revealed nursing staff documented the resident refused the anti-anxiety medication on 06/01/23, 06/02/23, 06/06/23, 06/07/23, 06/08/23, 06/12/23, 06/14/23, 06/15/23, 06/16/23, 06/17/23, 06/18/23, 06/19/23, 06/21/23, 06/22/23, 06/23/23, 06/24/23, 06/25/23, 06/26/23, 06/27/23, 06/28/23 and 07/02/23. Staff also documented the anti-anxiety medication was administered on 07/05/23.
Review of Resident #58's medical record revealed no evidence the physician was notified of the resident's medications being persistently refused or the medication not being available for administration.
Interview on 07/10/23 at 1:49 P.M. with the Director of Nursing (DON) confirmed Resident #58 had not received the diazepam anti-anxiety medication since 05/28/23 because the physician did not clarify the order. The DON also confirmed Resident #58's diazepam anti-anxiety medication was not administered or refused because it was unavailable and staff were documenting in Resident #58's medical record on multiple dates that she refused the anti-anxiety medication.
Review of the undated Administration Procedures for all Medications policy indicated to notify the physician of persistent refusals, held medications and suspected drug interactions.

Based on observation and interviews, the facility failed to serve hot and palatable foods. This had the potential to affect all 132 residents receiving food from the facility kitchen. Five (Resident's #25, #48, #38, #50, and #127) did not receive food from the facility. The facility census was 137.
Findings include:
Interview with Resident #67 on 09/19/22 at 12:57 P.M. revealed the food was usually not hot. Sometimes the facility used plates and sometimes the facility used Styrofoam.
Interview with Resident #441 on 09/19/22 at 12:08 P.M. revealed the food was often cold, and there was not anything I would eat at home.
Interview with Resident #71 on 09/19/22 at 12:43 P.M. revealed the food was cold sometimes.
Interview with Resident #1 on 09/19/22 at 1:24 P.M. revealed the food was often cold.
Interview with Resident #72 on 09/19/22 at 3:11 P.M. revealed the food was cold.
Interview with Resident #27 on 09/19/22 at 4:51 P.M. revealed the food was terrible and never hot when it arrives to the 300-hall.
Interview with Resident #12 on 09/20/22 at 8:42 A.M. revealed the food was bad, often cold, and not seasoned. There were a lot of items taken off the menu. It used to be much better.
Interview with Resident #116 on 09/20/22 at 8:51 A.M. revealed the food was cold and terrible; and if you don't like something, you get a bologna sandwich.
Interview with Resident #82 on 09/20/22 at 11:02 A.M. revealed the food was terrible. It had no spices and was usually cold.
Interview with Resident 115 on 09/20/22 at 1:20 P.M. revealed sometimes they refuse to bring an alternative like peanut butter and jelly. The food was cold, especially the soup.
On 09/21/22 at 12:53 P.M. a test tray observation was completed with Dietary Manager #695 after the last lunch tray was passed. All trays on the unit were passed within 10 minutes. All food was served in Styrofoam containers. The Sloppy Joe's tested at 116 degrees Fahrenheit (F) at the time of service. The temperature was below what is considered a palatable temperature for hot foods. The temperature was verified by Dietary Manager #695.
This deficiency substantiates Master Complaint Number OH00135858 and Complaint Number OH00135562.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of Centers for Disease Prevention and Control (CDC) guidance, and review of the facility policy the facility failed to ensure two (Resident's #1 and #450) were placed on contact precautions timely. The facility failed to ensure appropriate hand hygiene during and after care the of one (Resident #1) who was on contact precautions. The facility failed to ensure tuberculin screening tests were administered and read within the required time frame for two (Resident's #3 and #453). This affected two (Resident's #1 and #450) of three residents reviewed for transmission-based precautions, one (Resident #1) of three residents reviewed for hand hygiene, and two (Resident's #3 and #453) of five reviewed for tuberculin screening. The facility census was 137.
Findings include:
1. Review of Resident #1's medical record revealed an admission date of 05/24/22 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent, vesicointestinal fistula (occurs between the bowel and the bladder), personal history of other infectious and parasitic diseases, and morbid obesity.
Review of Resident #1's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Review of Resident #1's Discharge Return Anticipated MDS 3.0 assessment dated [DATE] revealed Resident #1 was frequently incontinent of urine and bowel.
Review of Resident #1's physician orders dated 08/22/22 revealed check stool for C Diff PCR (Clostridium Difficile polymerase chain reaction).
Review of Resident #1's Laboratory Service Report revealed the stool specimen was collected on 08/23/22 at 6:35 A.M. and reported on 08/24/22 at 4:54 P.M. The report revealed Resident #1's specimen was positive for Clostridium Difficile toxin by PCR (polymerase chain reaction, the test detects the presence of a virus). The positive predictive value of this test for C. Difficile infection was highest for patients with clinically significant diarrhea (greater that three unformed stools in 24 hours) who do not have an alternative explanation.
Review of Resident #1's progress notes on 08/25/22 at 7:19 A.M. revealed Resident #1 was admitted to the local hospital with severe sepsis, urosepsis.
Review of Resident #1's hospital records revealed Vancomycin 125 milligrams (mg) oral liquid (vancocin) was administered four times daily from 08/25/22 through 09/04/22.
Review of Resident #1's progress notes on 09/08/22 revealed Resident #1 returned from the hospital on [DATE] at 11:30 P.M.
Review of Resident #1's care plan dated 09/09/22 through 09/20/22 did not reveal a care plan or interventions for contact precautions related to Clostridium Difficile.
Review of Resident #1's medical record from 09/08/22 through 09/20/22 revealed from 09/10/22 through 09/11/22 Resident #1 had three watery diarrhea stools, from 09/14/22 through 09/15/22 Resident #1 had three watery diarrhea stools, on 09/16/22 Resident #1 had three watery diarrhea stools, from 09/17/22 through 09/18/22 Resident #1 had three watery diarrhea stools, from 09/18/22 through 09/19/22 Resident #1 had three watery diarrhea stools, from 09/19/22 through 09/20/22 Resident #1 had three watery diarrhea stools. Further review revealed on 09/08/22 and 09/12/22 Resident #1 had one or two watery diarrhea stools documented.
Review of Resident #1's progress notes on 09/16/2022 at 2:08 P.M. included Resident #1 refused care due to stomach cramping.
Observation on 09/19/22 at 1:13 P.M. of Resident #1's room revealed Resident #1 was not on contact precautions, there was no sign outside her room for contact precautions, and no plastic cart with PPE (Personal Protective Equipment) supplies were outside the room.
Observation on 09/19/22 at 1:13 P.M. of Resident #1 revealed she was lying in her bed, her hair was disheveled, tangled, and matted on the back of her head. Resident #1 stated there was not enough help in the facility; she waited as long as five hours for help, her average wait time was two hours. Resident #1 stated she laid in in feces and urine for hours. Resident #1 stated she required staff assistance for her care, and she had sores and wounds because her care was not provided timely. Resident #1 stated she had sores on both legs, her rear end, thighs, and sores on her side where her creases were. Resident #1 indicated when staff cleaned her, they finished and left the room immediately, and did not ask her if she needed anything else. Resident #1 stated the staff just walked out of the room and didn't come back. Resident #1 stated she was miserable, her legs jerk, and no one comes to help. Resident #1 stated she yelled out and staff did not come. Resident #1 stated staff will tell her they will come back to help her, and no one returns to provide care. Resident #1 stated she had a lot of bowel movements and the poop just runs out of me, as soon as they change me I have another bowel movement.
Interview on 09/19/22 at 1:30 P.M. with State Tested Nursing Assistant (STNA) #755 confirmed Resident #1 had large diarrhea watery bowel movements and she told the nurses about them.
Observations on 09/20/22 at 8:00 A.M. and 9:00 A.M. of Resident #1's room revealed Resident #1 was not on contact precautions.
Review of Resident #1's physician orders dated 09/20/22 at 9:34 A.M revealed Vancomycin Hydrochloride Solution 25 mg per milliliters (ml), give five ml by mouth every six hours for Clostridium Difficile for ten days. Further review revealed contact precautions related to Clostridium Difficile: Post See Nurse Before Entering sign on the door. Provide personal blood pressure cuff, stethoscope, and thermometer. Wear gloves, mask, and gown as needed. Wash hands when touching environment and with direct patient care, every shift for ten days.
Observation on 09/20/22 at 11:00 A.M. of Resident #1's room revealed there was a sign posted outside the room for contact precautions, stating gloves and a gown were needed if the room was entered by staff members or visitors. A plastic cart was observed outside Resident #1's room stocked with PPE.
Interview on 09/20/22 at 4:09 P.M. with the Director of Nursing (DON) and Regulatory Compliance Nurse/Acting Infection Preventionist (RCN/AIP) #801 revealed Resident #1 had diarrhea and CNP #800 ordered Vancomycin to treat Clostridium Difficile.
Review of Resident #1's Medication Administration Record (MAR) revealed Resident #1's first dose of Vancomycin Hydrochloride Solution 25 mg per ml was administered on 09/20/22 at 6:00 P.M.
Interview on 09/21/22 at 8:51 A.M. with Certified Nurse Practitioner (CNP) #800 revealed Resident #1 returned to the facility from the hospital on [DATE]. CNP #800 stated Resident #1 had an ongoing problem with diarrhea and was positive for Clostridium Difficille on 08/24/2022. Resident #1 was tested for Clostridium Difficile; the results came back positive after Resident #1 was admitted to the hospital, and she was treated with Vancomycin at the hospital for Clostridium Difficile. CNP #800 stated another test for Clostridium Difficile was not indicated because Resident #1 had a positive test result on 08/24/22 and her stool would remain positive for Clostridium Difficile for six weeks. CNP #800 revealed on 09/08/22 Resident #1 told her she was not having diarrhea (Resident #1 had two documented watery diarrhea bowel movements on 09/08/22). CNP #800 stated on 09/12/22 Resident #1 stated sometimes she had loose stools, on 09/16/22 she was called by nursing staff and told Resident #1 had diarrhea, on 09/19/22 nursing staff told her again about Resident #1's diarrhea. CNP #800 stated she ordered vancomycin for Clostridium Difficile on 09/20/22.
Observation on 09/22/22 at 1:15 P.M. of STNA's #669 and #755 providing incontinence care for Resident #1 revealed a towel was placed in Resident #1's left groin area. The towel had a large amount of liquid brown mucous drainage. STNA #755 stated Resident #1 requested the towel be placed in her left groin area due to large amounts of stool she was having. Resident #1 stated the towel kept the stool from going all over the place. STNA #755 stated Resident #1 usually had large amounts of loose watery diarrhea stools and it would mound up in her perineal area and there would be a huge pool of stool underneath her as well. STNA #755 stated today Resident #1 did not have the large diarrhea bowel movement she had in previous days. STNA #755 did not doff the gloves she used to provide incontinence care and walked to Resident #1's dresser, opened the drawer, and rustled through the items until she found the barrier cream. STNA #755 proceeded to apply barrier cream to Resident #1's buttocks and upper posterior thighs without changing the gloves used for incontinence care. STNA #669 and #775 did not change their soiled gloves before adjusting Resident #1's blankets and pillow.
Observation on 09/22/22 at 2:30 P.M. of STNA's #669 and #755 providing incontinence care for Resident #1 revealed they walked to a hand sanitizer dispenser just inside Resident #1's door to her room and rubbed hand sanitizer on their arms and hands. STNA's #669 and #755 did not wash their hands with soap and water prior to using alcohol-based hand sanitizer.
Interview on 09/22/22 at 2:30 P.M. with STNA's #669 and #755 confirmed they did not wash their hands with soap and water before using the hand sanitizer. STNA's #669 and #755 stated they were not aware they should have washed their hands with soap and water and thought using alcohol-based hand sanitizer was sufficient.
Review of the facility policy titled Contact Precautions, dated 06/08/22, included during care, change gloves after having contact with infective material (for example, fecal material or wound drainage which may contain high concentrations of microorganisms). Change gloves when moving from one site to another. Wash hands immediately with soap and water or alcohol-based hand rub. If the organism being isolated was Clostridium Difficile, soap and water are recommended.
2. Review of Resident #450's hospital records dated 09/06/22 through 09/12/22 revealed his urine culture showed ESBL (extended spectrum beta lactamase (ESBL) resistance) E. Coli. (Escherichia coli), and Resident #450 was placed on Macrobid (antibiotic).
Review of Resident #450's hospital discharge instructions dated 09/16/22 revealed during his hospitalization Resident #450's urine culture was positive for ESBL E. Coli. Infectious disease was consulted and recommended Macrobid. Further review revealed Resident #450 was incontinent at times and used an incontinence brief. Resident #450 was continent of bowel and used the toilet with stand by assist. Resident #450 required supervision with ambulation.
Review of Resident #451's medical record revealed an admission date of 09/16/22 and medical diagnoses were not documented. Resident #451 was continent of bowel and bladder. There was no documentation in Resident #451's medical record of ESBL.
Review of Resident #451's admission assessment dated [DATE] included Resident #451 required supervision for toileting hygiene (ability to maintain perineal hygiene, adjust clothes before or after voiding or having a bowel movement).
Review of Resident #451's medical record from 09/16/22 through 09/25/22 revealed Resident #451 was independent for toilet use and was provided supervision on 09/20/22 for toilet use.
Review of Resident #450's medical record revealed an admission date of 09/17/22 and diagnoses were not documented in the medical record. After surveyor intervention on 09/19/22 Resident #450's medical diagnoses were documented in the medical record on 09/20/22.
Review of Resident #450's physician orders on 09/17/22 revealed Macrobid capsule 100 mg (nitrofurantoin), give 100 mg by mouth every twelve hours for antibiotic.
Review of the facility census reports from 09/17/22 through 09/19/22 at 6:45 P.M. revealed Resident's #450 and #451 shared the same room and bathroom.
Review of Resident #450's medical record STNA charting from 09/18/22 through 09/25/22 revealed Resident #450 required one to two staff assistance for toileting. Further review revealed Resident #450 was both continent and incontinent for bladder and bowel function.
Observation on 09/19/22 at 4:20 P.M. of Resident #450's room did not reveal Resident #450 was on contact precautions. There was no contact precaution sign outside of the room, and there were no PPE supplies outside the room. Resident #450 had a roommate (Resident #451).
Observation on 09/19/22 at 4:20 P.M. revealed Resident #450 was lying in bed by the window and his roommate (Resident #451) was sitting in a chair. Resident #450's visitor (did not have PPE donned) was sitting in a chair talking to Resident #450's daughter on a cell phone, the visitor handed the phone to the surveyor. Resident #450's daughter stated staff did not like to get Resident #450 out of bed and preferred to give him a bedpan or urinal because they told her there was not enough staff to assist him to the bathroom. Resident #450's daughter stated he had a urinary tract infection.
Review of Resident #450's baseline care plan dated 09/19/22 did not reveal a care plan or interventions for ESBL resistance.
Review of Resident #450's admission Assessment on 09/19/22 at 4:37 P.M. revealed it was not complete. After surveyor intervention, Resident #450's admission Assessment was completed on 09/19/22 at 6:51 P.M. Review of the assessment revealed Resident #450's short term memory had no memory problem, but his long-term memory was unable to be assessed. Resident #450 required the extensive assistance of two staff for bed mobility and transfers and was incontinent of bowel and bladder.
Interview on 09/19/22 at 4:40 P.M. with Assistant Director of Nursing (ADON) #727 confirmed Resident #450 did not have his medical diagnoses documented in the medical record and did not have an admission Assessment initiated and completed.
Review of Resident #450's physician orders dated 09/19/22 at 6:11 P.M. revealed contact precautions related to ESBL in the urine; post See Nurse before entering sign on door; provide personal blood pressure cuff, stethoscope, and thermometer; wear gloves, mask, and gown as needed; wash hands when touching environment and with direct patient care every shift for UTI ESBL Further review on 09/19/22 at 6:19 P.M. revealed Macrobid capsule 100 mg (nitrofurantoin), give 100 mg by mouth two times a day for ESBL.
Review of Resident #450's progress notes dated 09/19/22 revealed notification was given regarding Resident #450's transfer to a private room. The change was due to the resident's clinical needs.
Review of Resident #450's medical diagnoses dated 09/20/22 included ESBL resistance, pleural effusion, dependence on supplemental oxygen, and type two diabetes mellitus without complications.
Interview on 09/26/22 at 10:13 A.M. with the DON and RCN/AIP #801 confirmed Resident #450 had ESBL and he was not placed on precautions immediately and he had a roommate. The DON stated the hospital did not inform the facility Resident #450 had ESBL but confirmed the hospital discharge instructions documented Resident #450's urine was positive for ESBL.
Interview on 09/26/22 at 12:30 P.M. with RCN/AIP #801 confirmed Resident #450's hospital discharge instructions stated Resident #450 had ESBL and confirmed the discharge instructions stated Resident #450 could use the bathroom with supervision.
Interview on 09/26/22 at 12:40 P.M. with Licensed Practical Nurse (LPN) #647 revealed Resident #450 went to the bathroom all the time to relieve himself and stated he was doing very well.
Interview on 09/26/22 at 2:14 P.M. with STNA #627 revealed she was frequently assigned to care for Resident #451 (Resident #450's roommate) and stated Resident #451 used his urinal most of the time and would walk into the bathroom by himself to empty the urinal. STNA #627 stated sometimes she would empty the urinal but mostly Resident #451 emptied it.
Review of CDC guidance titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 05/2022, included multidrug-resistant organisms (MDROs), infection or colonization (for example MRSA, VRE, ESBLs recommended contact plus standard precautions. A single-patient room was preferred for patients who required contact precautions.
Review of CDC guidance titled Management of Multidrug-Resistant Organisms In Healthcare Settings 2006, updated 02/15/17, included MDRO's were defined as microorganisms, predominantly bacteria, that were resistant to one or more classes of antimicrobial agents (1). Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VRE), these pathogens were frequently resistant to most available antimicrobial agents. These highly resistant organisms deserve special attention in healthcare facilities (2). In addition to MRSA and VRE, certain GNB, including those producing extended spectrum beta-lactamases (ESBLs) and others that are resistant to multiple classes of antimicrobial agents, are of particular concern. Preventing infections would reduce the burden of MDROs in healthcare settings. Prevention of antimicrobial resistance depends on appropriate clinical practices that should be incorporated into all routine patient care. Health Care Personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens.
3. Review of Resident #3's medical record revealed an admission date of 05/28/22 with diagnoses including osteomyelitis of vertebra, lumbar region, pressure ulcers of left buttock, sacral region, stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) of the right heel, unstageable pressure-induced deep tissue damage (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) of other site, chronic osteomyelitis of the left ankle and foot, chronic kidney disease, and type two diabetes mellitus with diabetic chronic kidney disease.
Review of Resident #3's physician orders dated 05/28/22 revealed read Mantoux 48 hours after given. Record results in the immunization tab. Change start date to 48 hours after tuberculin start date.
Review of Resident #3's Medication Administration Record (MAR) dated 05/31/22 stated read Mantoux (tuberculin test) 48 hours after given. Record results in the immunization tab. Change start date to 48 hours after tuberculin start date. There was no documented evidence on 05/31/22 the Mantoux was administered to Resident #3 or results were read.
Review of Resident #3's MAR dated, 06/07/22, revealed read Mantoux 48 hours after given. Record results in immunization tab. Change start date to 48 hours after tuberculin start date. There was documentation on 06/07/22 but it did not specify if the Mantoux was administered or read on 06/07/22. There was no further documentation in 06/2022 for Mantoux.
4. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity.
Review of Resident #453's physician orders dated 09/06/22 revealed Tuberculin PPD Solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time a day every seven day(s) for PPD Test for two weeks. Read in 48 hours. Repeat in 7 days if no reaction. Read Mantoux 48 hours after given. Record results in Immunization tab.
Review of Resident #453's MAR dated, 09/13/22, revealed Tuberculin PPD Solution 5 units per 0.1 milliliter (ml), inject 0.1 ml intradermally one time a day every seven days for PPD for two weeks. Read in 48 hours. Repeat in seven days if no reaction. Further review revealed it was administered on 09/13/22.
Review of Resident #453's MAR dated 09/19/22, revealed read Mantoux after given. Record results in immunization tab. Adjust start date when ordering, one time only for one day. Documentation revealed the test was read on 09/19/22 and should have been read either 09/15/22 or 09/16/22.
Interview on 09/22/22 at 11:00 A.M. with the DON and RCN/AIP #801 confirmed Resident's #3 and Resident #453 did not have their Mantoux tests administered and read according to physician orders and facility policy.
Review of the facility policy titled Tuberculosis Infection Prevention Program, reviewed 06/08/22, included all newly admitted residents would receive tuberculosis screening within 48 hours of admission. The facility would use the two-step TST (Tuberculin Skin Test) method for infection with M. Tuberculosis (Mycobacterium Tuberculosis).

Based on interview, observation, record review, and facility policy review the facility failed to ensure water temperatures were maintained in a safe manner at or below 120 degrees Fahrenheit (F). This affected eight residents (Resident's #12, #15, #20, #45, #95 #109, #116 and #136) and had the potential to affect 101 residents who resided on the 100, 200, 300, and 500 halls (Resident's #1, #2, #3, #4, #5, #6, #7, #9 #12, #13, #15, #16, #17, #20, #21, #25, #27, #30, #31, #33, #35, #37, #38 #41, #43, #44, #45 #47, #48, #49, #51, #52, #54, #55, #57, #59, #60, #61, #62, #63, #65, #66, #67, #68, #89, #70 #71, #72, #73, #74, #75, #77, #79, #80, #82, #86, #87, #93, #95, #96, #97, #99, #102, #104, #106, #108, #109, #111, #114, #116, #117, #118, #119, #121, #123, #125, #127, #130, #131, #133, #134, #135, #136, #139, #140, #391, #392, #442, #443, #444, #445, #446, #447, #448, #449, #450, #451, #452, #453, #454 and #455) reviewed for physical environment. The facility census was 137.
Findings included:
Review of the facility form labeled Logbook Documentation: Water Temperature, dated from 01/03/22 to 09/16/22, revealed water temperatures were documented as being checked five days a week, Monday through Friday, on each unit per Maintenance Director #638 and were documented within normal limits of 105 to 120 degrees Fahrenheit.
Observation on 09/19/22 from 2:25 P.M. to 2:46 P.M. with Maintenance Director #638 revealed the following water temperatures:
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Resident #20's water from the bathroom sink faucet was 123.8 degrees F. (Resident #20 resided on the 100-hall)
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Resident #136's water from the bathroom sink faucet was 127.8 degrees F. (Resident #136 resided on the 100-hall)
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Resident #15 and Resident #45's water from the bathroom sink faucet was 122 degrees F. (Resident #15 and Resident #45 resided on the 200-hall)
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Resident #12 and #116's water from the bathroom sink was 132.8 degrees F. (Resident #12 and #116 resided on the 300-hall)
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Resident #109's water from the bathroom sink was 140 degrees F. (Resident #109 resided on the 300-hall)
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Resident #95's water from the bathroom sink was 122 degrees F. (Resident #95 resided on the 500-hall)
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Resident #88 and Resident #101 who resided on the 400-hall as well as the 400-hall shower room recorded water temperatures at a safe temperature.
Interview on 09/19/22 at 2:46 P.M. with Maintenance Director #638 verified the above water temperatures and revealed they were at an unsafe temperature as four of the five halls were above 120 degrees F. He revealed he checked each unit five times a week, Monday through Friday, and had not had any previous concerns with water temperatures being above 120 degrees F. He revealed each unit had their own hot water tank, and the hot water tank was recently replaced on the 400-hall on 09/02/22. He revealed he felt this was why the water temperatures most likely were within normal limits on the 400-hall. He revealed the 100, 200, 300, and 500 halls hot water tanks were old and in need of being replaced. He revealed he was contacting Plumber #950.
Observation on 09/19/22 from 4:48 P.M. to 5:42 P.M. and 09/20/22 from 8:07 A.M. to 8:15 A.M. with Maintenance Director #638 revealed water temperatures were within normal limits on all the units including Resident's #12, #15, #20, #45, #88, #95, #101 #109, #116 and #136's rooms.
Interview on 09/19/22 at 4:50 P.M. with Plumber #950 revealed he felt the cause of the increased water temperatures on the 100, 200, 300 and 500 halls was from corrosion build up inside the water tanks that caused the screens in the tempering valves to become clogged. He revealed this caused the tempering valve not to work correctly and caused the water to be over 120 degrees F. He revealed he cleaned the screens to prevent the unsafe water temperatures but stated he felt the old water heaters on the 100, 200, 300, and 500 halls needed replaced as eventually the screens would become clogged again.
Interview on 09/26/22 at 1:46 P.M. with the Director of Nursing revealed the facility only had a policy regarding maintaining safe water temperatures as what was included in the Waterborne Pathogen Plan for preventing Legionnaires disease. She revealed she did not have any other policy regarding maintaining safe water temperatures in the facility.
Review of the facility policy labeled Waterborne Pathogen Plan, dated 06/08/22, revealed as a part of the infection control program the following would become an intricate part of ensuring the water within the facility was maintained for residents use in preventing growth and outbreak of Legionnaires disease. The policy revealed routine water temperatures would be taken to ensure the ideal range was maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip.
Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. Resident #116 was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating.
Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she wasn't contracted when she came to the facility in 2017. It happened when they stopped therapy.
Review of the Restorative Program Care Plan dated 01/29/18 revealed Resident #116 was at risk of impaired functional range of motion related to limitation to leg, limited range of motion, potential for contractures, refused to move extremities independently and weakness. The goal was for Resident #116 to maintain functional Range of Motion (ROM) status as evidenced by no decline through review date. Interventions included: Resident will participate in passive/active ROM to neck, shoulders, arms, elbows, wrists, fingers, hips, legs, knees, ankles, and toes 15 repetitions times two. Do over 15 minutes up to seven days a week. Passive ROM to bilateral lower extremities (BLE) emphasis on extension of bilateral hips/knees. Active ROM bilateral upper extremities and bilateral hip abduction 15 repetitions times two. Monitor for fatigue, offer rest as needed. Date Initiated: 01/29/18. Revision on: 09/29/20. Cue and prompt resident to perform exercises to extremities. Initiated 01/29/18.
Review of the Restorative Task Sheet revealed Resident #116 will participate in passive/active ROM to neck, shoulders, arms, elbows, wrists, fingers, hips, legs, knees, ankles, and toes 15 repetitions times two. Do over 15 minutes up to seven days a week. Passive ROM to BLE emphasis on extension of bilateral hips/knees. Active ROM to bilateral upper extremities and bilateral hip abduction 15 repetitions times two. Monitor for fatigue, offer rest as needed. To be completed by the STNA's on days and evenings.
Interviews on 09/26/22 from 9:09 A.M. through 9:15 A.M. with STNA #613, STNA #724, and STNA #804 revealed the STNAs did not do any ROM with Resident #116; however, Resident #116's contractures have been present for several years.
Interview on 09/26/22 at 9:29 A.M. with Restorative Nurse/ RN #746 revealed the facility was trying to get the restorative program back going again. The facility didn't have any dedicated restorative aides now. The STNAs were to complete the restorative programs on the floor as part of resident care. Resident #116 was resistant and declined splints. She had received therapy back in May 2022. RN #746 verified the restorative programs were only completed four times in the last 30 days.
Interview on 09/26/22 at 11:29 A.M. the Director of Nursing verified ROM Task sheets revealed the task had not been done regularly.
This deficiency substantiates Master Complaint Number OH00135858 and Complaint Number OH00135562.
Based on interview, observation, record review, and facility policy review the facility did not ensure Resident's #10 and #116 received their restorative programs per recommendation. This affected two (Resident's #10 and #116) of two (Resident's #10, and #116) reviewed for restorative nursing programs. This had the potential to affect 38 (Resident's #5, #10, #12, #14, #15, #16, #22, #23, #25, #28, #32, #35, #39, #40, #42, #43, #45, #51, #52, #53, #56, #59, #60, #64, #65, #70, #80, #87, #89, #99, #104, #106, #112, #116, #117, #121, #122, and #126) who received a restorative nursing programs. The facility census was 137.
Findings included:
1. Review of the medical record for Resident #10 revealed an admission date of 11/23/20 with diagnoses including chronic kidney disease, diabetes, dementia, asthma, and major depression.
Review of the care plan dated 02/12/21 revealed Resident #10 had a restorative nursing program due to impaired physical mobility in locomotion related to activity intolerance and weakness. Interventions included restorative ambulation program that included encourage resident to ambulate with wheeled walker with minimal assistance of one staff and follow with wheelchair, wear right knee soft knee brace when ambulating, ambulate 200 feet as tolerated with rest periods, completed for at least 15 minutes up to seven days a week and cease program if Resident #10 complains of pain.
Review of the Physical Therapy Discharge summary dated [DATE] and completed by Physical Therapist (PT) #610 revealed Resident #10 received physical therapy from 03/23/22 to 05/17/22. The discharge summary revealed Resident #10 was discharged on a restorative nursing ambulation program.
Review of the facility form labeled, Restorative/ Functional Maintenance Program dated 5/17/22 and completed by PT #610 revealed she recommended a restorative ambulation nursing program that included to ambulate 200 feet with wheeled walker and follow with a wheelchair. The recommendation included the goal for Resident #10 was to ambulate 300 feet with a wheeled walker.
Review of the Restorative Ambulation assessment dated [DATE] and completed by Restorative Nurse/ Registered Nurse (RN) #746 revealed Resident #10 had a restorative ambulation program that included to encourage Resident #10 to ambulate with his wheeled walker with minimal assist of one staff and to follow with a wheelchair. The assessment revealed Resident #10 was to ambulate 200 feet as tolerated with rest periods for at least 15 minutes up to seven days a week. The assessment revealed his goal was to ambulate 300 feet.
Review of the restorative documentation per the electronic record task bar dated from 08/22/22 to 09/20/22 revealed Resident #10 received the restorative ambulation program only three days during this time on 08/22/22, 08/31/22, and 09/09/22. The documentation revealed Resident #10 refused the restorative program on 09/09/22. There was no other documented evidence regarding Resident #10 receiving the restorative ambulation program or that he was offered/refused the program.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had impaired cognition with no behaviors. Resident #10 required extensive assist of one staff with bed mobility and transfers. He required one-staff physical assist with ambulation but that the activity had only occurred once or twice during the seven-day assessment reference period. Resident #10 had not received therapy or restorative nursing programs including ambulation during the assessment reference period.
Interview on 09/19/22 at 1:15 P.M. with Resident #10 revealed he did not receive his restorative nursing program and stated, I wish I could walk daily as he revealed he used to walk in therapy but now he only walks maybe once a week.
Interview and observation on 09/20/22 at 3:31 P.M. revealed Resident #10 had not ambulated. He revealed he did not walk today, 09/20/22 as no staff came by to assist with walking him.
Interview on 09/21/22 at 2:35 P.M. with the Director of Nursing revealed Restorative Nurse/ RN #746 only now worked at the facility on an as needed basis until the facility found a replacement restorative nurse. She revealed they use to have three restorative aides but with staffing shortage they were all moved to other positions, and they no longer have a designated restorative aide that completed the restorative programs. She revealed the floor staff were to complete the restorative programs and document when they completed the program. The Director of Nursing verified from 08/22/22 to 09/20/22 Resident #10 only received his restorative ambulation program three times, on 08/22/22, 08/31/22, and 09/09/22. She revealed the expectation was that Resident #10 receive his restorative program daily and/or at least be offered his program.
Interview and observation on 09/21/22 at 3:26 P.M. revealed Resident #10 had not ambulated. He revealed he did not walk today, 09/21/22 as no staff came by to assist with walking.
Interview on 09/22/22 at 8:36 A.M. with PT #610 revealed when she discharged Resident #10 from physical therapy, she completed a referral for Resident #10 to be on an ambulation restorative program to ambulate with a wheeled walker with soft knee brace 125 feet to 200 feet. PT #610 revealed she does not recommend a frequency on the referral as she leaves that up to nursing but revealed she felt Resident #10 should receive his restorative ambulation program more than three times in the last 30 days to not decline with his ambulation ability.
Interview on 09/22/22 at 9:09 A.M. with State Tested Nursing Assistant (STNA) #644 revealed she routinely worked on the 400-hall where Resident #10 resided. She revealed that there was not sufficient staff to complete restorative programs and the care needs of the residents. She revealed she was unable to complete Resident #10's ambulation program when she worked due to there was not enough staff.
Interview on 09/22/22 at 8:45 A.M. and Restorative Nurse/ RN #746 revealed she used to oversee the restorative program on a full-time basis but now only worked at the facility on an as needed basis. She revealed she used to have three restorative aides and then because of staffing needs they were placed on the floor or in other positions. She revealed it was the expectation of the floor staff to complete the programs. She revealed Resident #10 was to receive his ambulation program seven days a week for at least 15 minutes but verified that he had only received his program three times, 08/22/22, 08/31/22, and 09/09/22 in the last 30 days. She revealed he most likely did not receive his restorative program because of lack of staffing as the floor staff was unable to get to the program or because the floor staff were not used to doing the programs and education was needed to educate the staff on the floor regarding the programs in place. She revealed since she only worked as need, she was not able to get around to educating the floor staff on the programs.
Interview on 09/26/22 at 9:27 A.M. with STNA #616 revealed she used to be a restorative aide at the facility and when COVID-19 started, the facility discontinued having the restorative aides and instead had the floor staff complete the programs. She revealed she was not able to complete the restorative programs including Resident #10's ambulation program as there was not enough staff to complete the care needs and complete the restorative programs on the floor.
Review of the facility policy labeled, Restorative Nursing Policy and Procedure dated 06/08/22 revealed a restorative nursing program was to promote each resident's ability to maintain or regain the highest degree of independence as safely possible. The policy revealed the facility would develop an individualized program based on the resident's restorative needs and include the restorative program on the care plan. The policy revealed all restorative and maintenance programs were initiated with the input from the resident and/or responsible party and reviewed at resident care conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to implement a care plan intervention after a fall for Resident #122. This affected one (Resident #122) of two Resident #62 and Resident #122) reviewed for accuracy of care plan fall interventions. The facility census was 137.
Findings include:
Review of the medical record for Resident #122 revealed an admission date of 09/05/18 with diagnoses including diabetes, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and history of falling.
Review of the care plan dated 11/3/21 revealed Resident #122 was a fall risk related to impaired mobility, unstable health conditions, unsteady gait, weakness from chronic obstructive pulmonary disease, and history of falls. Interventions included analyze previous resident falls to determine whether pattern, bariatric bed, bed in low position, and reinforce need to call for assistance. The care plan revealed on 08/10/22 the facility implemented an intervention for Resident #122 to have a therapy evaluation after a fall on 08/09/22.
Review of the quarterly fall risk assessment dated [DATE] revealed Resident #122 was at high risk for falls due to unsteady while standing without physical support, health conditions, and the medications that she was prescribed.
Review of the facility form labeled, C5 Fall Review- V3 dated 08/09/22 and completed by Licensed Practical Nurse (LPN) #773 revealed Resident #122 stated she was trying to reach her bedside table from the bed and slid from the bed to the floor. The review revealed Resident #122 stated she had hit her head, was bleeding from her left lower leg, and was sent to the hospital for evaluation.
Review of the nursing note dated 08/10/22 at 3:47 P.M. and completed by the Director of Nursing revealed the interdisciplinary team met to review the fall for Resident #122 that had occurred on 08/09/22. The nursing note revealed she was observed on the floor beside her bed, and Resident #122 stated that she was trying to reach her bedside table and slid off the bed. The nursing note revealed interventions already in place included: bariatric bed and reinforce need to ambulate with staff presence for safety. The nursing note revealed she was assessed for injury and sent to the emergency room for evaluation. The nursing note revealed the new intervention implemented for Resident #122 was to have a therapy evaluation completed.
Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #122 had intact cognition. She required extensive assist of two staff with bed mobility, transfers, and toileting. She required limited assist of one staff with ambulation and supervision with locomotion.
Interview on 09/20/22 at 3:36 P.M. with Resident #122 revealed about a month ago she went to roll over and fell out of bed when she tried to grab something off the table. She revealed she fell and cut her leg on the bedside table and hurt her shoulder. She revealed after her fall she was not seen by therapy.
Interview on 09/21/22 at 11:14 A.M. with Speech Therapist #806 revealed she was filling in as rehabilitation director as Former Director of Rehabilitation #805's last day was 09/20/22. She revealed when nursing sent a referral for a therapy evaluation to be completed, nursing filled out a form labeled, Therapy Referral. She revealed the referral form was placed in a book labeled, 2022 Therapy Screens that was divided by name alphabetically. Speech Therapist #806 revealed she looked through the book, and a therapy referral was never received for Resident #122 to have an evaluation and/ or an evaluation was never completed according to the therapy documentation.
Interview on 09/21/22 at 2:33 P.M. with the Director of Nursing revealed she did not send a formal therapy referral form to therapy for Resident #122 that she had communicated the need for the referral by email to Former Director of Rehabilitation #805. She revealed she was not aware the therapy evaluation was not completed and verified that Resident #122 had a therapy evaluation listed as a fall intervention per her care plan after she fell on [DATE].
Review of the blank undated form labeled, Therapy Referral revealed the form included resident name, room number, request for screen or evaluation, reason of the referral, comments, and a signature of who was requesting the therapy referral.
Review of the facility policy labeled, Falls- Clinical Protocol dated 06/08/22 revealed based on the proceeding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure neglect did not occur. This affected two (Resident's #452 and #453) of three residents reviewed for neglect. The facility census was 137.
Findings include:
1. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity.
Review of Resident #453's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #453 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #453 was always incontinent of urine and frequently incontinent of bowel.
Review of Resident #453's care plan dated 09/07/22 included Resident #453 was a fall risk characterized by impaired balance, impaired mobility, incontinence,
and cellulitis to lower extremities. The goal was to prevent, minimize fall related injuries through the review date. Analyze previous resident falls to determine whether pattern or trend can be addressed. Interventions include to assist with all transfers, locomotion, and mobility; offer assist with toileting in advance of need; and reinforce need to call for assistance.
2. Review of Resident #452's medical record revealed an admission date of 09/13/22 with diagnoses including encephalopathy, bipolar disorder, and Parkinson's disease.
Review of Resident #452's admission MDS 3.0 assessment dated [DATE] revealed Resident #452 was cognitively intact and required limited assistance of one staff for bed mobility, transfers, and toilet use. Resident #452 required supervision for locomotion in her room. Resident #452 was frequently incontinent of urine and always continent of bowel.
Review of Resident #452's care plan dated 09/14/22 included Resident #452 was at risk for falls characterized by impaired balance and impaired mobility. The goals were Resident #452 would have no fall related injuries that require hospitalization through the review date, and prevent, minimize fall related injuries through the review date. Resident #452 would maintain highest level of independence with mobility and maintain safety, reducing falls occurrence and possibility of injury through staff intervention. Interventions included to assist with all transfers, locomotion, and mobility.
Interview on 09/20/22 at 9:40 A.M with Resident's #452 and #453 revealed they were told by an unidentified State Tested Nurse Aide (STNA) to put their call light on only if there was an emergency. The unidentified STNA told Resident's #452 and #453 they had a reputation for putting their call light on too much. Resident #453 stated the unidentified STNA told them she did not want to bring COVID-19 home to her family and wanted to enter the COVID-19 unit as little as possible. Resident #453 stated they hardly ever put their call light on and said the STNA hurt her feelings when she said they had a reputation. Resident #452 stated today the unidentified STNA told her she would come back to their room in about 20 to 40 minutes, and they better have their needs ready. Resident #452 stated she felt the STNA was telling her this was their chance for care, and she better get her needs met on this visit because no one was coming back for a long time or not at all.
Interview on 09/20/22 at 10:00 A.M. with Resident #452 revealed Resident #452 stated on either Saturday or Sunday a STNA told her to use her rollator to go to the bathroom because there was not have enough staff. Resident #452 stated she was told by therapy not to use the rollator with wheels but to use the walker with two wheels. Resident #452 stated therapy told her this because she was unsteady on her feet while walking. Resident #452 stated she was supposed to have assistance to go to the bathroom.
Observation on 09/20/22 at 10:00 A.M. of Resident #452's room revealed a rollator with wheels and a two wheeled walker located along the wall.
Interview on 09/20/22 at 10:24 A.M. with STNA #627 revealed there was not enough staff, and she told the Resident's #452 and #453 she would be back and for them to have their needs ready. STNA #627 stated her assignment included the residents in the COVID-19 unit and residents outside the COVID-19 unit. STNA #627 stated it was not good for the staff to work on the COVID-19 unit and also on the non-COVID-19 unit because that increased the chance the non-COVID-19 residents would become positive for COVID-19. STNA #627 stated she told Resident's #452 and #453 she did not want to take COVID-19 home to her family. STNA #627 stated she told Resident #452 to use her rollator to go to the bathroom and she told Resident's #452 and #453 they activate their call lights too often.
Interview on 09/20/22 at 11:05 A.M. with Director of Rehab (DOR) #805 revealed Physical Therapy was working with Resident #452 to use the most appropriate device for ambulation. Resident #452 was told not to use the rollator with wheels and recommended the two wheeled walker to increase steadiness to prepare for using the rollator. DOR #805 stated Resident #452 was not steady right now with the rollator and should not use the rollator because she could fall.
Interview on 09/22/22 at 7:17 A.M. with Resident #453 revealed last night she had an accident with urine and stool and laid in the urine and stool for two hours before she was cleaned up. Resident #453 stated she activated her call light and told an unidentified STNA she needed assistance to the bathroom. The STNA told Resident #453 there was not another staff member available to help her get Resident #453 to the bathroom and Resident #453 would have to use a bedpan. The STNA left the unit to find a bedpan and did not return for two hours and when she returned, she stated she could not find a bedpan. By that time Resident #453 had an accident of urine and bowel in her bed because she could not hold it any longer.
Interview on 09/22/22 at 7:33 A.M. with Resident #453 revealed she asked STNA #809 to assist her out of bed because her back hurt and she was unable to adjust her bed because her bed controller did not work. Resident #453 stated when she pressed the buttons nothing happened, and it had been like that for a couple days. Resident #453 stated she told the STNA's her remote did not work but nothing was done. Resident #453 stated an unidentified STNA told her she could not get her out of bed without the okay from therapy.
Observation on 09/22/22 at 7:33 A.M. of Resident #453's bed controller revealed when the buttons were pressed, they did not work, and Resident #453 was unable to adjust her bed position. After surveyor intervention STNA #809 confirmed the controller did not work and contacted the maintenance department to fix or replace the broken bed controller.
Interview on 09/22/22 at 8:18 A.M. with Registered Nurse (RN) #696 revealed Resident #453 could get out of bed and did not need the approval of the therapy department. RN #696 stated there was no physician order stating she could not get out of bed.
Review of Resident #453's physician orders did not reveal orders stating Resident #453 could not get out of bed without the approval of the therapy department.
Interview on 09/23/22 at 2:49 P.M. with Speech Therapist/Acting Director of Therapy (ST/ADT) #806 revealed Resident #452 was instructed to use the two-wheeled walker and not the rollator in the first seven days because she was unsteady. ST/ADT #806 stated the rollator wheels can go all different directions and turn the rollator causing Resident #452 to experience a fall.
Review of Resident #452's Physical Therapy Progress Notes dated 09/14/22 included Resident #452 was educated on the two-wheeled walker being more conducive to small spaces. Resident #452 required multiple cues due to unsafe turning in bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #45 had orders in place to receive appropriate indwelling catheter care. This affected one (Resident #45) of three residents reviewed for indwelling catheter care orders. The facility census was 137.
Findings include:
Review of the medical record for Resident #45 revealed an admission date of 11/04/21 wit diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dementia, benign prostatic hyperplasia, and neuromuscular dysfunction of bladder.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS revealed Resident #45 had an indwelling urinary catheter.
Review of the September 2022 physician orders for Resident #45 revealed there were no active orders for Resident #45's indwelling catheter care.
Review of the September 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no active orders for Resident #45's indwelling catheter care since 09/09/22.
Review of the September 2022 nursing progress notes revealed Resident #45 was admitted to the hospital from [DATE] through 09/08/22 and was readmitted back to the facility.
Interview on 09/22/22 at 2:06 P.M. with the Director of Nursing revealed Resident #45 was admitted to the hospital from [DATE] through 09/08/22 and when readmitted back to the facility somehow Resident #45's indwelling catheter care orders were not reordered at the time. The Director of Nursing verified Resident #45 did not have active indwelling catheter orders from 09/09/22 through 09/22/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure two (Resident's #136 and #450) were administered oxygen as ordered by the physician. This affected two (Resident's #136 and #450) of seven residents reviewed for oxygen administration. The facility census was 137.
Findings include:
1. Review of Resident #136's medical record revealed an admission date of 08/30/22 with diagnoses including acute respiratory failure with hypoxia, malignant neoplasm of ascending colon, and end stage renal disease.
Review of Resident #136's oxygen saturations summary in the medical record from 09/05/22 through 09/19/22 revealed Resident #136 had oxygen via nasal cannula, and her oxygen saturations ranged from 95 to 100 percent.
Review of Resident #136's physician orders from 09/05/22 through 09/19/22 did not reveal orders for oxygen administration.
Review of Resident #136's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #136 was cognitively intact and used oxygen.
Observation of Resident #136 on 09/19/22 at 3:31 P.M. revealed oxygen was being administered at two liters per minute per nasal cannula.
Interview on 09/19/22 at 3:40 P.M. with Licensed Practical Nurse (LPN) #735 confirmed Resident #136 did not have a physician order for oxygen administration and confirmed Resident #136 was receiving oxygen at two liters per minute per nasal cannula.
2. Review of Resident #450's medical record revealed an admission date of 09/17/22 with diagnoses including extended spectrum beta lactamase (ESBL) resistance, pleural effusion, dependence on supplemental oxygen, and type two diabetes mellitus without complications.
Review of Resident #450's admission assessment dated [DATE] revealed Resident #450 had oxygen administered at two liters per minute per nasal cannula.
Review of Resident #450's oxygen saturations summary in the medical record dated 09/17/22 at 3:07 P.M. revealed Resident #450 had an oxygen saturation of 100 percent on oxygen via nasal cannula.
Review of Resident #450's physician orders from 09/17/22 through 09/19/22 did not reveal orders for oxygen to be administered at two liters per minute per nasal cannula.
Interview on 09/19/22 at 4:20 P.M. with Resident #450's daughter stated Resident #450 should have oxygen administered at two liters per minute per nasal cannula due to chronic obstructive pulmonary disease.
Observation of Resident #450 on 09/19/22 at 4:20 P.M. revealed his oxygen was being administered at one liter per minute per nasal cannula.
Interview on 09/19/22 at 4:45 P.M. with LPN #647 confirmed Resident #450's oxygen was being administered at one liter per minute per nasal cannula, and Resident #450 did not have a physician order for oxygen in his medical record.
Review of the facility policy titled Oxygen Administration, reviewed 06/08/22, included to check physician's order for liter flow and method of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1's medical record revealed an admission date of 05/24/22 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent, vesicointestinal fistula (occurs between the bowel and the bladder), personal history of other infectious and parasitic diseases, and morbid obesity.
Review of Resident #1's admission assessment dated [DATE] revealed Resident #1 was at high risk for skin breakdown.
Review of Resident #1's admission MDS 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Review of Resident #1's discharge return anticipated MDS 3.0 assessment dated [DATE] revealed Resident #1 was frequently incontinent of urine and bowel.
Review of Resident #1's progress notes dated 08/25/22 at 7:19 A.M. revealed Resident #1 was admitted to the local hospital with severe sepsis, urosepsis.
Review of Resident #1's hospital records revealed Vancomycin 125 milligrams (mg), oral liquid Vancocin, (an antibiotic) was administered four times daily from 08/25/22 through 09/04/22 for clostridium difficile (a bacterium that causes diarrhea and colitis).
Review of Resident #1's readmission assessment dated [DATE] revealed Resident #1 was at severe risk for skin breakdown.
Review of Resident #1's progress notes dated 09/08/22 through 09/20/22 did not reveal Resident #1 refused to have care provided except for 09/16/22 due to stomach cramping.
Review of Resident #1's assessments from 09/08/22 through 09/20/22 revealed no documented evidence skin assessments (C1 Health Documentation) were completed.
Review of Resident #1's care plan dated 09/09/22 included Resident #1 had the potential for alteration in skin integrity related to immobility, incontinence, morbid obesity, moisture skin folds, and abdominal wound. Resident #1 liked to direct care despite staff attempting to provide care as ordered. Resident #1 denied frequent skin interventions stating that physicians have told her in the past not to do certain things although the physician told her otherwise. Resident #1 was followed by facility wound doctors and refused certain suggestions of care. The goal of the care plan included Resident #1 would not develop skin breakdown through the review date. Interventions included to keep bed linen clean, dry, and as free of wrinkles as possible.
Observation on 09/19/22 at 1:13 P.M. of Resident #1 revealed she was lying in her bed, her hair was disheveled, tangled, and matted on the back of her head. Resident #1 stated she laid in in poop and pee for hours. Resident #1 stated she required staff assistance for her care, and she had sores and wounds because her care was not provided timely. Resident #1 stated she had sores on both legs, her rear end, thighs, and sores on her side where her creases were. Resident #1 indicated when staff cleaned her, they finished and left the room immediately, and did not ask her if she needed anything else. Resident #1 stated the staff just walked out of the room and did not come back. Resident #1 stated she was miserable, her legs jerk, and no one comes to help. Resident #1 stated she yelled out and staff did not come. Resident #1 stated staff have told her they would come back to help her, and no one returns to provide care. Resident #1 stated she had a lot of bowel movements and the poop just runs out of me as soon as they change me, I have another bowel movement.
Review of Resident #1's physician orders dated 09/21/22 revealed orders to cleanse the wound (across gluteus) with normal saline or skin cleanser and pat dry with two nonsterile two by two gauze sponges; apply Medihoney (wound/burn gel that has antibacterial and bacteria resistant properties) followed by an abdominal (ABD) pad, and secure with tape; monitor for signs and symptoms of pain with dressing change; medicate with pain medication as needed and, or notify the physician if pain is present; every day shift for wound care and as needed.
Review of Resident #1's physician wound notes dated 09/20/22 included Resident #1 had new bilateral gluteal wounds found on 09/20/22. The location of the wound was bilateral glutei and was unstageable. The tissue bed was 75 percent necrotic and 25 percent epithelial. Slough type was yellow, soft, and wound edges were attached. The wound measured 5.0 cm in length by 12.0 cm in width, and the depth was unable to be determined. Description of the wound was irregular ovoid, linear-shaped, full-thickness wound crossing the right and left glutei and contiguous (touching along a boundary or at a point; adjacent), with a base comprised of 20 percent purple discolored epidermis laterally on the right gluteus, and 80 percent pale soft adherent eschar; unable to assess drainage or odor due to feces, edges were irregular, defined and attached; the periwound (tissue surrounding the wound) was moist and soiled.
Interview on 09/22/22 at 1:15 P.M. with STNA #755 revealed she was preparing to provide care for Resident #1, and this was the first time today she provided care for Resident #1 because she was very busy and did not have time previously.
Observation on 09/22/22 at 1:15 P.M. of STNAs #669 and #755 providing incontinence care for Resident #1 revealed a towel was placed in Resident #1's left groin area. The towel had a large amount of liquid brown mucous drainage. STNA #755 stated Resident #1 requested the towel be placed in her left groin area due to large amounts of stool she was having. Resident #1 stated the towel kept the stool from going all over the place. STNA #755 stated Resident #1 usually had large amounts of loose watery diarrhea stools and it would mound up in her perineal area and there would be a huge pool of stool underneath her as well. STNA #755 stated today Resident #1 did not have the large diarrhea bowel movement she had in previous days. During incontinence care Resident #1 was rolled onto her side and a soiled dressing across Resident #1's buttocks was noted. LPN #820 walked into Resident #1's room, stood by the bed for approximately 10 minutes, stated something (unclear) then walked out of Resident #1's room. STNA #755 stated LPN #820 left to gather supplies to change the soiled dressing across Resident #1's buttocks. The dressing had brownish drainage saturating it and the edges were raised from the skin due to moisture. LPN #820 did not return to Resident #1's room for approximately 15 minutes and STNA #755 walked out of the room to find her. Resident #1 stated often staff say they are going to do something and do not follow through. STNA #755 walked back in the room and stated LPN #820 was on her way to the room. At 1:54 P.M. LPN #820 poked her head in the room and stated Wound Nurse (WN)/LPN #629 was on the way to change the dressing. STNAs #669 and #755 stood with Resident #1 lying on her right side waiting for WN/LPN #629 to arrive.
Observation on 09/22/22 at 2:03 P.M. revealed WN/LPN #629 arrived for the dressing change and STNA's #669 and #755 positioned Resident #1 on her side. WN/LPN #629 stated she was notified by LPN #820 about the dressing change seven minutes ago, and LPN #820 could have changed the dressing. Resident #1's bottom was reddened and when the dressing was removed, a long red wound could be seen extending across Resident #1's bilateral buttocks. The wound was approximately eight inches long, about a half inch wide, and the wound tissue was red with streaks of white throughout. The drainage was reddish colored. WN/LPN #629 stated this was a new wound found on wound rounds with the wound physician on 09/20/22. WN/LPN #629 stated she ordered a low air loss mattress on 09/20/22, but Resident #1 refused the mattress. Resident #1 confirmed she did not want a low air loss mattress due to dizziness. Resident #1 currently was on a pressure reducing bariatric mattress. WN/LPN #629 stated the wound physician thought the pressure injury was due to Resident #1 lying on wrinkled sheets.
Based on observation, record review, interview, and policy review the facility failed to ensure appropriate interventions were implemented to timely identify pressure ulcers for Resident's #1 and #80. Actual Harm occurred on 09/08/22 when Resident #80, who required extensive assistance with two staff for bed mobility and transfers was observed to have a new unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) to the right gluteal fold when first observed by Licensed Practical Nurse (LPN)/Wound Nurse #629. In addition Actual Harm occurred on 09/20/22 when Resident #1, who required extensive assistance of two staff for bed mobility, transfers, and toilet use was observed during wound rounds to have a new unstageable pressure ulcer across the bilateral glutei. This affected two residents (Resident's #1 and #80) of three residents reviewed for pressure ulcers. The facility census was 137.
Findings include:
1. Review of the medical record for Resident #80 revealed an admission date of 12/09/21 with diagnoses including atrial fibrillation, dementia, schizoaffective disorder, type two diabetes mellitus with diabetic neuropathy, and muscle weakness.
Review of the plan of care dated 12/10/21 for Resident #80 revealed he was at risk for impaired skin integrity related to immobility. Interventions included Braden score quarterly and as needed, dry thoroughly between skin folds after cleansing, monitor between folds for redness, irritation, bleeding, malodor, etc., pressure redistribution cushion to chair, and pressure redistribution mattress to bed.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had impaired cognition. He required the assistance of two staff for bed mobility and transfers. He was frequently incontinent of bladder and always incontinent of bowel. He was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers at the time.
Review of the quarterly Braden scale skin assessment dated [DATE] revealed Resident #80 was at mild risk for developing a pressure area as his sensory perception was slightly limited, he was rarely moist, his mobility was very limited, and he had a problem with friction and shear requiring moderate to maximum assistance in moving.
Review of the form labeled, Weekly Ulcer/Wound Documentation - V6 dated 09/08/22 and completed by LPN/Wound Nurse #629 revealed Resident #80 had a new unstageable pressure ulcer to his right ischial tuberosity. Resident #80's pressure ulcer was unstageable as the area had slough in the base of the wound and a scant amount of thin green drainage with no foul odor. The unstageable pressure ulcer to Resident #80's right ischial tuberosity measured 2.0 centimeters (cm) in length by 1.5 cm in width. The wound base was covered with 100 percent (%) slough tissue.
Review of the nursing noted dated 09/08/22 at 7:12 A.M. revealed a new skin alteration was noted to Resident #80's right gluteal fold when assisting him to bed. Resident #80 denied he had any pain or discomfort to the area. The area was cleansed with normal saline and a border gauze dressing was applied. The physician was notified, and no new orders were given at the time.
Review of the nursing note dated 09/08/22 at 12:02 P.M. authored by LPN/Wound Nurse #629 revealed she was completing weekly wound tracking and assessment for Resident #80. Resident #80 was observed to have a pressure area to his right ischial tuberosity. LPN/Wound #629 indicated the pressure ulcer was unstageable related to slough being present.
Review of the physician orders for September 2022 revealed Resident #80 had an order to cleanse right ischium area with normal saline or skin cleanser and pat dry with nonsterile two-by-two gauze, apply normal saline moistened collagen powder and cover with a border foam dressing daily.
Review of the form labeled, Weekly Ulcer/Wound Documentation - V6 dated 09/13/22 and completed by LPN/Wound Nurse #629, revealed Resident #80's unstageable pressure ulcer to his right ischial tuberosity continued. The pressure ulcer measured 2.0 cm in length by 1.2 cm in width by 0.2 cm in depth. The whole wound base was visible with 100% granulated tissue, no slough, and a scant amount of thin straw-colored drainage.
Observation on 09/22/22 at 10:19 A.M. with LPN/Wound Nurse #629 revealed Resident #80 had a pressure ulcer to his right ischial tuberosity with all the wound base visible with 100% granulation tissue present and scant amount of thin, straw-colored drainage. LPN/Wound Nurse #629 cleansed area with normal saline and patted dry with nonsterile two-by-twos, applied normal saline moistened collagen powder to the wound base, and applied a border foam dressing.
Interview on 09/22/22 at 10:31 A.M. with LPN/Wound Nurse #629 stated on 09/08/22 staff told her Resident #80 had a new skin alteration and she assessed Resident #80. LPN/Wound Nurse #629 verified Resident #80's new skin alteration was found on his right ischial tuberosity and was classified as an unstageable pressure ulcer due to the presence of slough to the wound bed when first assessed.
Review of the facility policy titled, Pressure Ulcer Prevention Protocols/Risk Assessment, dated 06/08/22, revealed no evidence of interventions to identify pressure ulcers at an earlier stage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to provide consistent and timely assistance with activities of daily living (ADL) for incontinence care and showers. This affected four (Resident's #17, #116, #441 and #453) of eight residents reviewed for ADL. The facility census was 137.
Finding included:
1. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. The resident was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating.
Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she never got her showers. The resident said when there was only one aide on third shift she didn't get changed. One time it happened six nights in row.
Review of the care plan for preferences dated 04/10/20 and revised 09/13/22 revealed Resident #116 preferred a shower.
Review of the ADL care plan initiated on 10/24/17 and most recently revised 04/22/20, included the intervention dated 08/10/18, for staff to provide assistance as needed with bed mobility, transfers, locomotion, ambulation, dressing, meals, toileting, personal hygiene, and bathing.
Review of the Shower Schedule for the 300-hall revealed Resident #116 was to get a shower between 11:00 P.M. and 7:00 A.M. on Mondays and Thursdays.
Review of the Shower Task revealed Not Applicable (N/A) was marked five times, otherwise nothing was noted for the past 30 days, 08/22/22 through 09/20/22 with the exception of 09/12/22.
Review of Shower Sheets revealed Resident #116 received a bed bath 08/22/22, 08/25/22, 08/29/22, 09/03/22, 09/05/22, 09/08/22, 09/15/22, and 09/19/22. The resident received a shower on 09/12/22. The resident refused a shower on 09/05/22, 09/08/22, and 09/15/22.
Interview on 09/22/22 at 1:14 P.M. with State Tested Nurse Aide (STNA) #803 revealed that frequently when she came in for her morning shift almost all the residents were wet. She made sure everyone was clean but could not always give everyone a shower.
Interview on 09/22/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #802 stated she often received complaints about people not being changed.
Interview on 09/23/22 at 7:55 A.M. with STNA #690 asked the surveyor to come back at 9:00 A.M. to observe incontinence care because she needed the assistance of another staff member for Resident #116 due to the Resident's contractures and because she had to pass breakfast trays.
Observation on 09/23/22 at 9:02 A.M. of STNA's #690 and #721 providing incontinence care for Resident #116 revealed her incontinence brief was wet. STNA #690 removed Resident #116's soiled incontinence brief and long red marks could be seen on Resident #116's upper thighs and buttocks, and the marks extended around the legs and buttocks. The red marks were approximately twelve inches long and one-half inch wide on Resident #116's bilateral upper thighs and buttocks. STNA #690 stated the marks were caused from the incontinence brief rubbing against Resident #116's skin. Observation of Resident #116's revealed reddened areas on her bilateral buttocks and perineal area. STNA #690 and #721 confirmed Resident #116 had reddened areas on her buttocks and perineal area. Observation of the pink reusable draw sheet revealed it was very wet with urine, and the urine was dried around the edges. STNA's #690 and #721 confirmed the urine on the draw sheet was dried around the edges.
On 09/23/22 at 2:49 P.M. the Director of Nursing (DON) verified the shower sheets revealed Resident #116 usually received a bed bath.
2. Review of the medical record for Resident #17 revealed an admission date of 10/07/21 with diagnosis including chronic obstructive pulmonary disease (COPD), diabetes with diabetic neuropathy, spinal stenosis, and muscle weakness.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition. The resident required the extensive of two staff for bed mobility, dressing, toilet use, and personal hygiene. The resident was totally dependent for transfers and bathing. Resident #17 was independent for locomotion.
Interview on 09/19/22 at 1:00 P.M. Resident #17 stated staff did not change him often enough. The resident revealed staff sometimes did not get him out of bed until late and sometimes had not laid him back in bed until after midnight due to staffing. Resident #17 stated he had a sore on his thigh and scrotum from sitting in urine. When asked about showers he laughed and stated he had only received two showers in ages. He stated they gave him a bed bath, but he wanted showers.
Observation on 09/22/22 at 7:34 A.M. of incontinence care, revealed Resident #17's brief was noted to be slightly wet with urine, no bowel movement noted at the time. The skin was observed to be slightly red around the gluteal folds and a small red sore was noted to the scrotum.
Interview on 09/22/22 at 7:41 A.M. with Registered Nurse (RN) #727 and LPN #753 verified Resident #17 was wet, his buttocks were slightly red, and they verified the small red sore to his scrotum.
Interview on 09/22/22 at 1:14 P.M. with STNA #803 revealed that frequently when she came in for her morning shift almost all the residents were wet. She made sure everyone was clean but could not always give everyone a shower.
Interview on 09/22/22 at 1:41 P.M. LPN #802 stated she often received complaints about people not being changed.
3. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity.
Review of Resident #453's admission MDS 3.0 assessment dated [DATE] revealed Resident #453 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #453 was always incontinent of urine and frequently incontinent of bowel.
Review of Resident #453's care plan dated 09/07/22 included Resident #453 had a potential for alteration in skin integrity related to incontinence and obesity. Resident #453 would not develop skin breakdown through the review date. Interventions included to keep bed linen clean, dry, and free of wrinkles; to dry thoroughly between skin folds after cleansing, and monitor between folds for redness, irritation, bleeding, malodor.
Interview on 09/20/22 at 9:36 A.M. with Resident #453 revealed she always had to wait to get her incontinence brief changed. Resident #453 stated there was not enough staff and she waited long periods of time for an aide to change her brief. Resident #453 stated if a STNA did not check her for four hours she would activate her call light because it was not good to have a wet brief on that long.
Interview on 09/22/22 at 7:17 A.M. with Resident #453 revealed last night she had an accident with urine and stool and laid in the urine and stool for two hours before she was cleaned up. Resident #453 stated she activated her call light and told an unidentified STNA she needed assistance to the bathroom. The STNA told Resident #453 there was not another staff member available to help her get Resident #453 to the bathroom, and Resident #453 would have to use a bedpan. The STNA left the unit to find a bedpan and did not return for two hours and when she returned, she stated she could not find a bedpan. By that time Resident #453 had an accident of urine and bowel in her bed because she could not hold it any longer.
Interview on 09/22/22 at 7:33 A.M. with Resident #453 revealed her incontinence brief was wet now and had not been changed for three to four hours. Resident #453 stated she told an STNA at least two hours ago she needed changed, but the STNA did not change her. Resident #453 did not know the STNA's name.
Observation on 09/22/22 at 8:35 A.M. of STNA's #809 and #810 providing incontinence care for Resident #453 revealed her incontinence brief was soaked with urine, her draw sheet was soaked with urine, and her fitted sheet had a large wet area from urine with dried urine observed around the edges of the wet area. Resident #453's bilateral posterior thighs were reddened, and the resident stated the reddened areas were painful when touched. Resident #453's left buttock had an abrasion approximately the size of a quarter, and her right buttock had an approximately two-inch reddened area. STNA's #809 and #810 confirmed the presence of the abrasion on the left buttock and the two-inch reddened area on the right buttock.
Review of the facility policy titled Incontinence Care, reviewed 06/08/22, included the purpose was to keep skin clean, dry, free or irritation and odor; to identify skin problems as soon as possible so treatment can be started; to prevent skin breakdown; and to prevent infection.
4. Review of Resident #441's medical record revealed an admission date of 09/01/22 with diagnoses including metabolic encephalopathy, sepsis, type two diabetes mellitus, and end stage renal disease.
Review of Resident #441's admission MDS 3.0 assessment dated [DATE] revealed Resident #441 was cognitively intact and required extensive assistance of one staff for bed mobility, transfers, and personal hygiene.
Interview on 09/19/22 at 12:03 P.M. with Resident #441 revealed he does not get up when he wants to because he must wait for the STNA's to be available and that could be a long time. Resident #441 stated he did not get bathed on his scheduled days, wore the same clothes for three days, and had to insist yesterday (09/18/22) to get bathed multiple times. Resident #441 stated the STNA's did not come in until 12:30 A.M. for his bath.
Observation on 09/19/22 at 12:10 P.M. of Resident #441 revealed his fingernails were approximately a half an inch long, and he had beard stubble noted on his face. Resident #441 stated he would like to have his fingernails clipped shorter and he needed to be shaved. Resident #441 stated he would do it himself, but he could not get up without assistance and there was no mirror available for him to use.
Interview on 09/19/22 at 1:00 P.M. with STNA #755 confirmed Resident #755 had long fingernails and beard stubble on his face.
Review of Resident #441's STNA charting in the medical record revealed Resident #441's bath was completed on 09/19/22 at 12:44 A.M.
Review of the facility policy titled Bed Bath, Shower, reviewed 11/13/19, included the purpose was to cleanse, refresh, and soothe the resident, to stimulate circulation. The State Tested Nursing Assistant would complete the bath, shower as scheduled.
This deficiency substantiates Master Complaint Number OH00135858 and Complaint Number OH00135562.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to complete dialysis assessments before and after dialysis and send a dialysis communication form to dialysis. This affected one (Resident #93) of one resident reviewed for dialysis. This had the potential to affect 17 additional residents (Resident #2, #6, #26, #31, #35, #54, #74, #82, #84, #87, #111, #119, #133, #134, #139, #443, and #446) who received dialysis. The facility census was 137.
Findings include:
Review of the medical record for Resident #93 revealed an admission date of 08/05/22 with diagnoses including end stage renal failure, dependence on renal dialysis, spinal stenosis, major depression, and muscle weakness.
Review of the physician orders for August 2022 and September 2022 revealed Resident #93 received dialysis three times a week on Monday, Wednesday, and Friday in house, and had a physician order dated 08/10/22 to complete and lock dialysis assessment and dialysis communication forms before and after dialysis. The order included to print and send the dialysis communication form with Resident #93 to dialysis.
Review of the facility form labeled, Dialysis Communication Form- V3 from 08/05/22 to 09/19/22 revealed the communication forms were only completed on 08/26/22, 09/07/22, 09/14/22, and 09/15/22. There was not a Dialysis Communication Form completed on 08/08/22, 08/10/22, 08/12/22, 08/15/22, 08/17/22, 08/19/22, 08/22/22, 08/24/22, 08/29/22, 08/31/22, 09/02/22, 09/05/22, 09/09/22, 09/12/22, and 09/16/22. There were no assessments after dialysis completed.
Review of admission Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had impaired cognition. The assessment revealed he received dialysis.
Review of care plan dated 08/21/22 revealed Resident #93 had renal failure and required hemodialysis Monday, Wednesday, and Friday. Interventions included monitor and record vital signs per physician orders, monitor for signs of fluid deficit, monitor for signs of fluid excess, and monitor for signs of real failure including swelling, confusion, restlessness, and fatigue. The care plan did not include interventions regarding completing a dialysis assessment before and after dialysis and/or sending a dialysis communication form to dialysis.
Interview on 09/22/22 at 2:07 P.M. with Dialysis/Registered Nurse (RN) #807 and Dialysis Technician #808 revealed they felt the communication from the facility to the dialysis center was poor as the facility was supposed to send a dialysis communication form with the resident each time to a resident went to dialysis, and they rarely received the communication form, including for Resident #93. They revealed this caused a concern as they did not know if the resident had any medication changes and/or if the resident was having any health complications including abnormal vital signs prior to dialysis. They revealed they brought this concern up to the facility previously, including to the Director of Nursing, but they had not seen any improvement.
Interview on 09/22/22 at 2:24 P.M. with the Director of Nursing verified that dialysis had brought up the concern regarding the dialysis communication forms not being sent with the resident to dialysis. She revealed she added an order to all residents, including Resident #93, on the physician orders to remind the nurses to send the dialysis communication form to dialysis. She verified that a dialysis communication form was not completed and/or sent to dialysis on 08/08/22, 08/10/22, 08/12/22, 08/15/22, 08/17/22, 08/19/22, 08/22/22, 08/24/22, 08/29/22, 08/31/22, 09/02/22, 09/05/22, 09/09/22, 09/12/22, and 09/16/22. She also verified the physician order dated 08/10/22 revealed the nurse was also to complete a dialysis assessment before and after dialysis. She revealed she had no documented evidence an assessment was completed after dialysis on 08/08/22, 08/10/22, 08/12/22, 08/15/22, 08/17/22, 08/19/22, 08/22/22, 08/24/22, 08/26,22, 08/29/22, 08/31/22, 09/02/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/14/22, and 09/16/22.
Review of the facility policy labeled, Dialysis Communication, dated 06/08/22, revealed to ensure appropriate documentation was provided for the resident and to ensure communication between the facility and the dialysis center the following was to be completed including nursing would complete the dialysis communication form each time the resident received dialysis. The policy did not include anything in regard to the nurse completing an assessment after the resident returned from dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient staff to provide the necessary care and services including restorative nursing, getting assistance to bed per preference and timely manner, timely incontinence care, showers per schedule and preference, changing of clothing, and meeting the minimum daily staffing requirement of 2.50 hours per resident. This had the potential to affect all 137 residents residing in the facility.
Findings include:
1. Review of the staffing tool with Scheduler/ State Tested Nursing Assistant (STNA) #725 on 09/22/22 at 11:57 A.M. revealed the facility did not meet the minimum daily staffing requirement of 2.50. On 09/18/22 the facility had 2.42 hours of direct care staff per resident.
Interview on 09/22/22 at 11:57 A.M. with Scheduler/ STNA #725 verified on 09/18/22 there was 2.42 hours of direct care staff per resident. She revealed there were several call offs on 09/18/22, and they were unable to cover all the call offs to meet the daily staffing requirement of 2.50.
2. Review of the medical record for Resident #10 revealed he had an admission date of 11/23/20 with diagnoses including chronic kidney disease, diabetes, dementia, asthma, and major depression.
Review of the care plan dated 02/12/21 revealed Resident #10 required a restorative nursing program due to impaired physical mobility in locomotion related to activity intolerance and weakness. Interventions included restorative ambulation program that included encourage resident to ambulate with wheeled walker with minimal assistance of one staff and follow with a wheelchair, wear right knee soft knee brace when ambulating, ambulate 200 feet as tolerated with rest periods, completed for at least 15 minutes up to seven days a week and cease program if Resident #10 complains of pain.
Review of the facility form labeled Restorative/ Functional Maintenance Program, dated 05/17/22, and completed by Physical Therapist (PT) #610 revealed Resident #10 was to have a restorative ambulation nursing program that included to ambulate 200 feet with wheeled walker and follow with a wheelchair. The recommendation included the goal for Resident #10 was to ambulate 300 feet with a wheeled walker.
Review of the Restorative Ambulation assessment dated [DATE] and completed by Restorative Nurse/ Registered Nurse (RN) #746 revealed Resident #10 had a restorative ambulation program that included to encourage Resident #10 to ambulate with a wheeled walker with minimal assist of one staff and to follow with a wheelchair. The assessment revealed Resident #10 was to ambulate 200 feet as tolerated with rest periods for at least 15 minutes up to seven days a week. The assessment revealed his goal was to ambulate 300 feet.
Review of restorative documentation in the electronic medical record task bar dated from 08/22/22 to 09/20/22 revealed Resident #10 received the restorative ambulation program only three days during this time on 08/22/22, 08/31/22, and 09/09/22. The documentation revealed he refused his restorative program on 09/09/22. There was no other documentation regarding Resident #10 receiving the restorative ambulation program or that he was offered the program.
Review of the annual Minimum Data Set (MDS) 3.0 dated 09/02/22 revealed Resident #10 had impaired cognition with no behaviors. Resident #10 required extensive assist of one staff with bed mobility and transfers. He required one-staff physical assist with ambulation but that the activity had only occurred once or twice during the seven-day assessment reference period. Resident #10 had not received any therapy or restorative nursing including ambulation during the seven-day assessment reference period.
Interview on 09/19/22 at 1:15 P.M. with Resident #10 revealed he did not receive his restorative nursing program and stated, I wish I could walk daily as he revealed he used to walk in therapy but now only maybe once a week.
Interview and observation on 09/20/22 at 3:31 P.M. revealed Resident #10 had not ambulated. He revealed he did not walk today, 09/20/22, as no staff came by to assist with walking him.
Interview on 09/21/22 at 2:35 P.M. with the Director of Nursing revealed Restorative Nurse/ RN #746 only worked at the facility on an as needed basis until the facility found a replacement restorative nurse. She revealed they used to have three restorative aides but with staffing shortage they were all moved to other positions, and they no longer have designated restorative aides that completed the restorative programs. She revealed the floor staff were to complete the restorative programs and document when they completed the program. The Director of Nursing verified from 08/22/22 to 09/20/22 Resident #10 only received the restorative ambulation program three times, on 08/22/22, 08/31/22, and 09/09/22. She revealed the expectation was that Resident #10 receive his restorative program daily and/ or at least be offered his program.
Interview and observation on 09/21/22 at 3:26 P.M. revealed Resident #10 had not ambulated. He revealed he did not walk today, 09/21/22, as no staff came by to assist with walking.
Interview on 09/22/22 at 8:36 A.M. with PT #610 revealed when she discharged Resident #10 from physical therapy, she completed a referral for Resident #10 to be on a restorative ambulation program to ambulate with a wheeled walker with a soft knee brace 125 feet to 200 feet. PT #610 revealed she does not recommend a frequency on the referral as she leaves that up to nursing but revealed she felt Resident #10 should receive the restorative ambulation program more than three times in the last 30 days, so his ambulation ability did not decline.
Interview on 09/22/22 at 9:09 A.M. with STNA #644 revealed she routinely worked on the 400 hall where Resident #10 resided. She revealed that there was not sufficient staff to complete restorative programs and the care needs of the residents. She revealed she was unable to complete Resident #10's ambulation program when she worked because there was not enough staff.
Interview on 09/22/22 at 8:45 A.M. and Restorative Nurse/ RN #746 revealed she used to oversee the restorative program on a full-time basis but now only worked at the facility on an as needed basis. She revealed she used to have three restorative aides and then because of staffing needs they were placed on the floor or in other positions. She revealed it was the expectation of the floor staff to complete the programs. She revealed Resident #10 was to receive his ambulation program seven days a week for at least 15 minutes but verified that he had only received his program three times, 08/22/22, 08/31/22, and 09/09/22 in the last 30 days. She revealed he most likely did not receive his restorative program because of lack of staffing as the floor staff was unable to get to the program or because the floor staff were not used to doing the programs and education was needed to educate the staff on the floor regarding the programs in place. She revealed since she only worked as need, she was not able to get around to educating the floor staff on the programs.
Interview on 09/26/22 at 9:27 A.M. with STNA #616 revealed she used to be a restorative aide at the facility but when COVID-19 started, the facility discontinued having the restorative aides and instead had the floor staff complete the programs. She revealed she was not able to complete the restorative programs, including Resident #10's ambulation program, as there was not enough staff to complete the care needs and complete the restorative programs on the floor.
Review of the facility policy labeled Restorative Nursing Policy and Procedure, dated 06/08/22, revealed a restorative nursing program was to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. The policy revealed the facility would develop an individualized program based on the resident's restorative needs and include the restorative program on the care plan. The policy revealed all restorative and maintenance programs were initiated with the input from the resident and/ or responsible party and reviewed at resident care conferences.
3. Review of medical record for Resident #93 revealed an admission date of 08/05/22 and his diagnoses included end stage renal failure, dependence on renal dialysis, spinal stenosis, major depression, and muscle weakness.
Review of admission Minimum Date Set (MDS) dated [DATE] revealed Resident #93 had impaired cognition as his brief interview for mental status (BIMS) score was a 13. He required extensive assist of two people with bed mobility and was totally dependent of two people with transfers. He was unable to ambulate. The assessment revealed he received dialysis.
Review of care plan dated 08/21/22 revealed Resident #93 had an activities of daily living self-care performance related to end stage renal disease and spinal stenosis. Interventions included provide mechanical lift transfers with two people assist on dialysis days, monitor for fatigue, and provide rest periods as needed.
Review of physician orders for September 2022 revealed Resident #93 required a mechanical lift to always transfer with the assistance of two staff.
Interview on 09/19/22 from 12:50 P.M. to 1:13 P.M. with Resident #93 revealed he was frustrated as when he returned from dialysis he always asked to go back to bed right away as he stated dialysis took a lot out of him and he was in a lot of discomfort in his back and butt from sitting up the whole time in his wheelchair for dialysis. He revealed he always had to wait extended amounts of time to get back into bed as they always said there was not enough staff to assist. He revealed sometimes he had to wait over an hour to get to bed after dialysis.
Interview on 09/21/22 at 8:28 A.M. with LPN #735 revealed she was Resident #93's nurse, and she revealed most the time on the 100 hall there was only one nurse and one aide causing difficulty in meeting the residents needs in a timely manner. She revealed it was difficult as there were several residents on the 100-hall that required a mechanical lift to transfer, or they were a two person assist. She revealed Resident #93 always requested to go right back to bed when he returned from dialysis but at times he had to wait until they had enough staff to assist as he was a two person assist with a mechanical lift.
Observation and interview on 09/21/22 at 11:11 A.M. with Resident #93 revealed he returned from dialysis, and he stated he had asked STNA #755 to go to bed but that she had told him she needed to get another staff to assist him. He revealed this was a normal pattern at the facility as he knew he would have to wait to get back in bed as there was probably not enough staff to assist. He revealed he was tired from dialysis, and he was in discomfort from sitting up at dialysis.
Interview on 09/21/22 at 11:38 A.M. with STNA #755 revealed she was sitting behind the 100-hall nursing station on the computer. She verified that Resident #93 had asked her at approximately 11:00 A.M. to go to bed when he returned from his dialysis but that she had to wait for a second staff to come back to the floor to assist in transferring him.
Observation on 09/21/22 at 11:48 A.M. Resident #93 rang his call light. Observation on 09/21/22 at 11:49 A.M. revealed LPN #735 answered his light and Resident #93 had asked again to lay down and she had stated the staff was tied up in another room at the current time.
Observation on 09/21/22 at 12:09 P.M. revealed Resident #93 self-propelled himself out in the hallway and the Administrator walked by Resident #93. Resident #93 expressed to the Administrator that he was not having a good day as he was still waiting to get into bed after dialysis. Observation revealed the Administrator revealed he would find staff to assist Resident #93.
Observation and interview on 09/21/22 at 12:17 P.M. revealed Resident #93 gestured for the surveyor to come to his room, and he stated how he was frustrated as he had asked to go to bed at 11:00 A.M. and it was now 12:17 P.M. and he still was not in bed. He revealed he was weak, tired and that his back and butt was sore from being up but that he did not feel the staff at the facility understood. He revealed that the facility always just stated that he had to wait because of staffing.
Observation on 09/21/22 at 12:19 P.M. revealed the Director of Nursing and Assistant Director of Nursing #727 assisted Resident back in bed. They verified staff on the unit were with another resident.
Review of facility form labeled transfer status for the 100-hall revealed on 09/21/22 the 100 halls had a census of 13 residents and six (Resident #1, #44, #71, #93, #139, #241) of the 13 residents required either a two person assist and/ or mechanical lift.
4. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip.
Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. Resident #116 was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating.
Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she wasn't contracted when she came to the facility in 2017. It happened when they stopped therapy.
Review of the Restorative Program Care Plan dated 01/29/18 revealed Resident #116 was at risk of impaired functional range of motion related to limitation to leg, limited range of motion, potential for contractures, refused to move extremities independently and weakness. The goal was for Resident #116 to maintain functional Range of Motion (ROM) status as evidenced by no decline through review date. Interventions included: Resident will participate in passive/active ROM to neck, shoulders, arms, elbows, wrists, fingers, hips, legs, knees, ankles, and toes 15 repetitions times two. Do over 15 minutes up to seven days a week. Passive ROM to bilateral lower extremities (BLE) emphasis on extension of bilateral hips/knees. Active ROM bilateral upper extremities and bilateral hip abduction 15 repetitions times two. Monitor for fatigue, offer rest as needed. Date Initiated: 01/29/18. Revision on: 09/29/20. Cue and prompt resident to perform exercises to extremities. Initiated 01/29/18.
Review of the Restorative Task Sheet revealed Resident #116 will participate in passive/active ROM to neck, shoulders, arms, elbows, wrists, fingers, hips, legs, knees, ankles, and toes 15 repetitions times two. Do over 15 minutes up to seven days a week. Passive ROM to BLE emphasis on extension of bilateral hips/knees. Active ROM to bilateral upper extremities and bilateral hip abduction 15 repetitions times two. Monitor for fatigue, offer rest as needed. To be completed by the STNA's on days and evenings.
Interviews on 09/26/22 from 9:09 A.M. through 9:15 A.M. with STNA #613, STNA #724, and STNA #804 revealed the STNAs did not do any ROM with Resident #116; however, Resident #116's contractures have been present for several years.
Interview on 09/26/22 at 9:29 A.M. with Restorative Nurse/ RN #746 revealed the facility was trying to get the restorative program back going again. The facility didn't have any dedicated restorative aides now. The STNAs were to complete the restorative programs on the floor as part of resident care. Resident #116 was resistant and declined splints. She had received therapy back in May 2022. RN #746 verified the restorative programs were only completed four times in the last 30 days.
Interview on 09/26/22 at 11:29 A.M. the Director of Nursing verified ROM Task sheets revealed the task had not been done regularly.
5. Review of Resident #441's medical record revealed an admission date of 09/01/22 with diagnoses including metabolic encephalopathy, sepsis, type two diabetes mellitus, and end stage renal disease.
Review of Resident #441's admission MDS 3.0 assessment dated [DATE] revealed Resident #441 was cognitively intact and required extensive assistance of one staff for bed mobility, transfers, and personal hygiene.
Interview on 09/19/22 at 12:03 P.M. with Resident #441 revealed he does not get up when he wants to because he must wait for the STNA's to be available and that could be a long time. Resident #441 stated he did not get bathed on his scheduled days, wore the same clothes for three days, and had to insist yesterday (09/18/22) to get bathed multiple times. Resident #441 stated the STNA's did not come in until 12:30 A.M. for his bath.
Observation on 09/19/22 at 12:10 P.M. of Resident #441 revealed his fingernails were approximately a half an inch long, and he had beard stubble noted on his face. Resident #441 stated he would like to have his fingernails clipped shorter and he needed to be shaved. Resident #441 stated he would do it himself, but he could not get up without assistance and there was no mirror available for him to use.
Interview on 09/19/22 at 1:00 P.M. with STNA #755 confirmed Resident #755 had long fingernails and beard stubble on his face.
Review of Resident #441's STNA charting in the medical record revealed Resident #441's bath was completed on 09/19/22 at 12:44 A.M.
Review of the facility policy titled Bed Bath, Shower, reviewed 11/13/19, included the purpose was to cleanse, refresh, and soothe the resident, to stimulate circulation. The State Tested Nursing Assistant would complete the bath, shower as scheduled.
6. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip.
Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. The resident was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating.
Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she never got her showers. The resident said when there was only one aide on third shift she didn't get changed. One time it happened six nights in row.
Review of the care plan for preferences dated 04/10/20 and revised 09/13/22 revealed Resident #116 preferred a shower.
Review of the ADL care plan initiated on 10/24/17 and most recently revised 04/22/20, included the intervention dated 08/10/18, for staff to provide assistance as needed with bed mobility, transfers, locomotion, ambulation, dressing, meals, toileting, personal hygiene, and bathing.
Review of the Shower Schedule for the 300-hall revealed Resident #116 was to get a shower between 11:00 P.M. and 7:00 A.M. on Mondays and Thursdays.
Review of the Shower Task revealed Not Applicable (N/A) was marked five times, otherwise nothing was noted for the past 30 days, 08/22/22 through 09/20/22 with the exception of 09/12/22.
Review of Shower Sheets revealed Resident #116 received a bed bath 08/22/22, 08/25/22, 08/29/22, 09/03/22, 09/05/22, 09/08/22, 09/15/22, and 09/19/22. The resident received a shower on 09/12/22. The resident refused a shower on 09/05/22, 09/08/22, and 09/15/22.
Interview on 09/22/22 at 1:14 P.M. with STNA #803 revealed that frequently when she came in for her morning shift almost all the residents were wet. She made sure everyone was clean but could not always give everyone a shower.
Interview on 09/22/22 at 1:41 P.M. with LPN #802 stated she often received complaints about people not being changed.
Interview on 09/23/22 at 7:55 A.M. with STNA #690 asked the surveyor to come back at 9:00 A.M. to observe incontinence care because she needed the assistance of another staff member for Resident #116 due to the Resident's contractures and because she had to pass breakfast trays.
Observation on 09/23/22 at 9:02 A.M. of STNA's #690 and #721 providing incontinence care for Resident #116 revealed her incontinence brief was wet. STNA #690 removed Resident #116's soiled incontinence brief and long red marks could be seen on Resident #116's upper thighs and buttocks, and the marks extended around the legs and buttocks. The red marks were approximately twelve inches long and one-half inch wide on Resident #116's bilateral upper thighs and buttocks. STNA #690 stated the marks were caused from the incontinence brief rubbing against Resident #116's skin. Observation of Resident #116's revealed reddened areas on her bilateral buttocks and perineal area. STNA #690 and #721 confirmed Resident #116 had reddened areas on her buttocks and perineal area. Observation of the pink reusable draw sheet revealed it was very wet with urine, and the urine was dried around the edges. STNA's #690 and #721 confirmed the urine on the draw sheet was dried around the edges.
On 09/23/22 at 2:49 P.M. the Director of Nursing verified the shower sheets revealed Resident #116 usually received a bed bath.
7. Review of the medical record for Resident #17 revealed an admission date of 10/07/21 with diagnosis including chronic obstructive pulmonary disease (COPD), diabetes with diabetic neuropathy, spinal stenosis, and muscle weakness.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition. The resident required the extensive of two staff for bed mobility, dressing, toilet use, and personal hygiene. The resident was totally dependent for transfers and bathing. Resident #17 was independent for locomotion.
Interview on 09/19/22 at 1:00 P.M. Resident #17 stated staff did not change him often enough. The resident revealed staff sometimes did not get him out of bed until late and sometimes had not laid him back in bed until after midnight due to staffing. Resident #17 stated he had a sore on his thigh and scrotum from sitting in urine. When asked about showers he laughed and stated he had only received two showers in ages. He stated they gave him a bed bath, but he wanted showers.
Observation on 09/22/22 at 7:34 A.M. of incontinence care, revealed Resident #17's brief was noted to be slightly wet with urine, no bowel movement noted at the time. The skin was observed to be slightly red around the gluteal folds and a small red sore was noted to the scrotum.
Interview on 09/22/22 at 7:41 A.M. with Registered Nurse (RN) #727 and LPN #753 verified Resident #17 was wet, his buttocks were slightly red, and they verified the small red sore to his scrotum.
Interview on 09/22/22 at 1:14 P.M. with STNA #803 revealed that frequently when she came in for her morning shift almost all the residents were wet. She made sure everyone was clean but could not always give everyone a shower.
Interview on 09/22/22 at 1:41 P.M. LPN #802 stated she often received complaints about people not being changed.
8. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity.
Review of Resident #453's admission MDS 3.0 assessment dated [DATE] revealed Resident #453 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #453 was always incontinent of urine and frequently incontinent of bowel.
Review of Resident #453's care plan dated 09/07/22 included Resident #453 had a potential for alteration in skin integrity related to incontinence and obesity. Resident #453 would not develop skin breakdown through the review date. Interventions included to keep bed linen clean, dry, and free of wrinkles; to dry thoroughly between skin folds after cleansing, and monitor between folds for redness, irritation, bleeding, malodor.
Interview on 09/20/22 at 9:36 A.M. with Resident #453 revealed she always had to wait to get her incontinence brief changed. Resident #453 stated there was not enough staff and she waited long periods of time for an aide to change her brief. Resident #453 stated if a STNA did not check her for four hours she would activate her call light because it was not good to have a wet brief on that long.
Interview on 09/22/22 at 7:17 A.M. with Resident #453 revealed last night she had an accident with urine and stool and laid in the urine and stool for two hours before she was cleaned up. Resident #453 stated she activated her call light and told an unidentified STNA she needed assistance to the bathroom. The STNA told Resident #453 there was not another staff member available to help her get Resident #453 to the bathroom, and Resident #453 would have to use a bedpan. The STNA left the unit to find a bedpan and did not return for two hours and when she returned, she stated she could not find a bedpan. By that time Resident #453 had an accident of urine and bowel in her bed because she could not hold it any longer.
Interview on 09/22/22 at 7:33 A.M. with Resident #453 revealed her incontinence brief was wet now and had not been changed for three to four hours. Resident #453 stated she told an STNA at least two hours ago she needed changed, but the STNA did not change her. Resident #453 did not know the STNA's name.
Observation on 09/22/22 at 8:35 A.M. of STNA's #809 and #810 providing incontinence care for Resident #453 revealed her incontinence brief was soaked with urine, her draw sheet was soaked with urine, and her fitted sheet had a large wet area from urine with dried urine observed around the edges of the wet area. Resident #453's bilateral posterior thighs were reddened, and the resident stated the reddened areas were painful when touched. Resident #453's left buttock had an abrasion approximately the size of a quarter, and her right buttock had an approximately two-inch reddened area. STNA's #809 and #810 confirmed the presence of the abrasion on the left buttock and the two-inch reddened area on the right buttock.
Review of the facility policy titled Incontinence Care, reviewed 06/08/22, included the purpose was to keep skin clean, dry, free or irritation and odor; to identify skin problems as soon as possible so treatment can be started; to prevent skin breakdown; and to prevent infection.
9. Review of Resident #455's medical record revealed an admission date of 09/14/22 with diagnoses including Alzheimer's disease with late onset, dementia, and delusional disorders.
Review of Resident #455's admission assessment dated [DATE] included Resident #455 had cognitive impairment with poor decision-making skills. The resident displayed the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, and resistant to care. Resident #455 verbally expressed a desire to go home. Resident #455 ambulated without problem and with devices and was unsteady when standing without support. Resident #455 was dependent on staff assistance for completion of activities of daily living (ADL) and toilet use.
Review of Resident #455's admission Assessment Baseline Care Plan dated 09/14/22 included Resident #455 had non-slip socks, shoes. There was no care plan for potential for elopement or alteration in mood or behavior.
Interview on 09/20/22 at 8:35 A.M. with Resident #452 revealed she was positive for COVID-19 and had been placed in the COVID-19 unit. Resident #452 stated there was not enough staff, the staff was overworked, and their assignment included the COVID-19-unit residents as well as residents in the non-COVID-19 unit. Resident #452 stated Resident #455 would walk into their room, wander around, and walk over to her and get so close her face was inches away from her. Resident #452 stated Resident #455 could open the door to her room, and Resident #452 would place her rollator in the entrance to the room to keep Resident #455 from coming in. Resident #452 stated Resident #455 would become agitated and flip her gown at her. Resident #452 stated Resident #455's incontinence brief would fall around her ankles and feces would fall out on the floor while she was walking.
Observation on 09/20/22 at 10:30 A.M. of Resident #455 walking up and down the hall in the COVID-19 unit. Resident #455's gown was hanging lopsided from her shoulders and one end of her gown was dragging on the floor as she walked. Resident #455's incontinence brief could be seen as she walked up and down the hall. There was no staff present in the COVID-19 unit.
Observation on 09/21/22 at 11:14 A.M. revealed Resident #455 walking in the hall with her brief around ankles. Resident #455 was walking and reached down and pulled her incontinence brief up and held it up with her hands while she walked. There was no staff present in the COVID-19 unit.
Interview on 09/21/22 at 11:18 A.M. with STNA #809 confirmed Resident #455 pulled the tabs of her brief, the brief loosened, and the brief would fall around her ankles because was it not snug. STNA #809 stated she had to clean Resident #455 this morning and put a clean gown on her because she had a large amount of feces on her clothes and skin. STNA #809 stated Resident #455 walked all day.
Observation on 09/21/22 at 11:44 A.M. of Resident #455 walking into Resident #448's room; Resident #455 walked out of the room and down the hall into Resident #61's room. There was no staff present in the COVID-19 unit.
Interview on 09/21/22 at 11:44 A.M. with STNA #809 confirmed there was no staff in the COVID-19 unit, and Resident #455 walked into Resident #448's room, walked out, then walked into Resident #61's room. STNA #809 stated Resident #455 walked into other resident rooms all day every day. STNA #809 stated Resident #455 would be redirected out of the other resident rooms but then she would walk right back in. STNA #809 confirmed Resident #455 could open doors to resident rooms. STNA #809 stated the residents would activate their call light when Resident #455 walked into their rooms. STNA #809 stated what can we do, we cannot have a staff member in the COVID-19 unit all day watching Resident #455.
Interview on 09/21/22 at 11:47 A.M. with RN #696 revealed Resident #455 had dementia and wandered all day long in the COVID-19 unit.
Observation on 09/21/22 at 3:49 P.M. Resident #455 was walking around the COVID-19 unit dragging a blanket on floor between her legs. There was no staff present in the unit. Resident #455 was walking non-stop up and down hall.
Observation on 09/21/22 at 3:53 P.M. or Resident #455 walk into Resident #448's room. There was no staff present on the unit.
Interview on 09/21/22 at 4:30 P.M. with STNA #761 revealed Resident #455 opened the door to the COVID-19 unit and walked to the main entrance to the facility. STNA #761 stated she found her at the main entrance door and had to redirect Resident #455 back to the COVID-19 unit.
Interview on 09/22/22 at 7:16 A.M. with Resident's #452 and #453 revealed at 4:25 A.M. Resident #455 walked into their room and urinated on the floor by the bathroom. There was a large pool of urine on the floor and an unidentified STNA ran down the hall and redirected Resident #455 out of their room. The unidentified STNA returned about 15 minutes later with a sheet and cleaned up the urine by the bathroom. Resident #452 stated the STNA did not mop or disinfect the floor after Resident #455 urinated on it. Resident #453 stated there was still puddles of urine on the floor.
Observation on 09/22/22 at 7:16 A.M. revealed there was a puddle of urine in front of both Resident #452 and #453's beds. The floor was sticky when walked upo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility training the facility failed to ensure appropriate supervision for one resident with dementia. This affected one (Resident #455) of three residents reviewed for supervision. The facility census was 137.
Findings include:
Review of Resident #455's medical record revealed an admission date of 09/14/22 with diagnoses including Alzheimer's disease with late onset, dementia, and delusional disorders.
Review of Resident #455's admission assessment dated [DATE] included Resident #455 had cognitive impairment with poor decision-making skills. The resident displayed the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, and resistant to care. Resident #455 verbally expressed a desire to go home. Resident #455 ambulated without problem and with devices and was unsteady when standing without support. Resident #455 was dependent on staff assistance for completion of activities of daily living (ADL) and toilet use.
Review of Resident #455's admission Assessment Baseline Care Plan dated 09/14/22 included Resident #455 had non-slip socks, shoes. There was no care plan for potential for elopement or alteration in mood or behavior.
Interview on 09/20/22 at 8:35 A.M. with Resident #452 revealed she was positive for COVID-19 and had been placed in the COVID-19 unit. Resident #452 stated there was not enough staff, the staff was overworked, and their assignment included the COVID-19-unit residents as well as residents in the non-COVID-19 unit. Resident #452 stated Resident #455 would walk into their room, wander around, and walk over to her and get so close her face was inches away from her. Resident #452 stated Resident #455 could open the door to her room, and Resident #452 would place her rollator in the entrance to the room to keep Resident #455 from coming in. Resident #452 stated Resident #455 would become agitated and flip her gown at her. Resident #452 stated Resident #455's incontinence brief would fall around her ankles and feces would fall out on the floor while she was walking.
Observation on 09/20/22 at 10:30 A.M. of Resident #455 walking up and down the hall in the COVID-19 unit. Resident #455's gown was hanging lopsided from her shoulders and one end of her gown was dragging on the floor as she walked. Resident #455's incontinence brief could be seen as she walked up and down the hall. There was no staff present in the COVID-19 unit.
Observation on 09/21/22 at 11:14 A.M. revealed Resident #455 walking in the hall with her brief around ankles. Resident #455 was walking and reached down and pulled her incontinence brief up and held it up with her hands while she walked. There was no staff present in the COVID-19 unit.
Interview on 09/21/22 at 11:18 A.M. with State Tested Nursing Assistant (STNA) #809 confirmed Resident #455 pulled the tabs of her brief, the brief loosened, and the brief would fall around her ankles because was it not snug. STNA #809 stated she had to clean Resident #455 this morning and put a clean gown on her because she had a large amount of feces on her clothes and skin. STNA #809 stated Resident #455 walked all day.
Observation on 09/21/22 at 11:44 A.M. of Resident #455 walking into Resident #448's room; Resident #455 walked out of the room and down the hall into Resident #61's room. There was no staff present in the COVID-19 unit.
Interview on 09/21/22 at 11:44 A.M. with STNA #809 confirmed there was no staff in the COVID-19 unit, and Resident #455 walked into Resident #448's room, walked out, then walked into Resident #61's room. STNA #809 stated Resident #455 walked into other resident rooms all day every day. STNA #809 stated Resident #455 would be redirected out of the other resident rooms but then she would walk right back in. STNA #809 confirmed Resident #455 could open doors to resident rooms. STNA #809 stated the residents would activate their call light when Resident #455 walked into their rooms. STNA #809 stated what can we do, we cannot have a staff member in the COVID-19 unit all day watching Resident #455.
Interview on 09/21/22 at 11:47 A.M. with Registered Nurse (RN) #696 revealed Resident #455 had dementia and wandered all day long in the COVID-19 unit.
Observation on 09/21/22 at 3:49 P.M. Resident #455 was walking around the COVID-19 unit dragging a blanket on floor between her legs. There was no staff present in the unit. Resident #455 was walking non-stop up and down hall.
Observation on 09/21/22 at 3:53 P.M. or Resident #455 walk into Resident #448's room. There was no staff present on the unit.
Interview on 09/21/22 at 4:30 P.M. with STNA #761 revealed Resident #455 opened the door to the COVID-19 unit and walked to the main entrance to the facility. STNA #761 stated she found her at the main entrance door and had to redirect Resident #455 back to the COVID-19 unit.
Interview on 09/22/22 at 7:16 A.M. with Resident's #452 and #453 revealed at 4:25 A.M. Resident #455 walked into their room and urinated on the floor by the bathroom. There was a large pool of urine on the floor and an unidentified STNA ran down the hall and redirected Resident #455 out of their room. The unidentified STNA returned about 15 minutes later with a sheet and cleaned up the urine by the bathroom. Resident #452 stated the STNA did not mop or disinfect the floor after Resident #455 urinated on it. Resident #453 stated there was still puddles of urine on the floor.
Observation on 09/22/22 at 7:16 A.M. revealed there was a puddle of urine in front of both Resident #452 and #453's beds. The floor was sticky when walked upon. STNA #809 confirmed there were puddles of urine on the floor by Resident #452 and #453's bed.
Observation on 09/22/22 at 7:17 A.M. of Resident #455 walking barefoot up and down the hall of the COVID-19 unit. STNA #809 confirmed Resident #455 was barefoot and not wearing non-slip footwear.
Review of the facility training titled Dementia Cares, reviewed 03/23/21, included wandering may be a way of coping with boredom or stress, the resident may feel lost. The physical or emotional need needed to be addressed. The resident might want to go somewhere where the resident felt needed, loved, comfortable or in control. Play gentle familiar music or relaxing nature sounds. Increase structured activities in the late afternoon. Multiple interventions might be tried before one is found that works.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide an individualized activity plan and activities for Resident #149. This affected one of three residents (Resident #25, Resident #107 and Resident #149) reviewed for activities. The census was 150.
Findings include:
Review of the medical record revealed Resident #149 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, unspecified visual loss and end stage renal disease with dependence on dialysis. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive two-person assist for bed mobility, transfers, dressing, eating and personal hygiene. The resident was totally dependent on staff for locomotion and toilet use. The brief interview mental status (BIMS) score of 04 indicated severe cognitive impairment.
A care plan, dated 08/09/19 and revised 08/25/19, relative to activities revealed generic interventions including: the resident will express satisfaction with type of activities and level of activity involvement when asked, assist with arranging community activities, arrange transportation, assure the activities the resident attends are compatible with physical and mental capabilities, known interests and preferences. Adapted as needed (large print, holders), and with individual needs and abilities and are age appropriate. Encourage ongoing family involvement. Invite family to attend special events, activities, meals. Establish prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain the importance of social interaction, leisure activity time. Encourage participation. If resident chooses not to attend organized activities, turn on TV or music to provide sensory stimulation. Reassure resident that they may leave activities at any time for toileting and will be able to return to activity. Reassure resident that they may leave activities at any time, and that they are not required to stay for entire activity. The interventions also included Provide 1:1 bedside/in-room visits and activities if unable to attend out of room events.
Review of the Recreation admission Assessment completed on 08/08/19 revealed it was very important for Resident #149 to listen to choice of music and to participate in religious services or practices. The resident had an interest in music, television and movies. Resident #149 needed one-to-one visits and conversation.
Interview on 09/24/19 at 8:32 A.M. with Resident #149 revealed because she was blind there were no activities for her. She was not interested in group activities. Resident #149 did not know if there were any audio books available at the facility, but she might be interested in those. The resident could not think of any other activities she would enjoy.
Review of Resident #149's activity participation records for August and September 2019 revealed in August there was one notation indicating a one-on-one activity on 08/15/19. However, the resident had been in the hospital from [DATE] through 08/22/19 and from 08/28/19 through 09/03/19. In September the activity participation records log revealed the resident had three room visits, watched television (resident was blind) and was offered an independent activity four times (09/12/19, 09/21/19, 09/23/19 and 09/24/19) which the resident refused. There was no indication of what length of time the room visits had lasted or what independent activity had been offered.
Interview on 09/26/19 at 12:16 P. M. with Activities Assistant (AA) #801 revealed she had a short conversation a couple weeks ago with Resident #149. The resident had wanted to remain in her room and wanted the television on.
Interview on 09/26/19 at 12:46 P.M. with AA #801 revealed for residents who preferred to stay in their rooms they read them the news, had short conversations about news or what was on the television, they could do the resident ' s nails if the resident wanted them to. The facility had items that could be felt for different textures and shapes. Resident #149 didn't care for that much. To her knowledge they did not have audio books.
Interview on 09/26/19 at 12:53 P.M. with AA #802 and the administrator verified the activity log was accurate and that that the activities documented were what had been offered to Resident #149.
Interview on 09/26/19 at 3:23 P.M. with Activity Director #803 revealed she had started as activity director this week and had not worked with Resident #149. Activity Director #803 stated she went in to talk with Resident #149 today and asked Resident #149 about music therapy or audio books. The resident stated she did not like the person who came in for music therapy and she did not want him to visit again. The resident said she might be interested in audio books. Activities Director #803 stated she was trying to think of other things the resident might enjoy. She would be bringing new activities to the facility. The facility did not have audio books but Activity Director #803 indicated they should be able to get some on loan from the library.

Based on observation, interview, and record review the facility failed to ensure mechanical soft meat was prepared to the appropriate consistency. This had the potential to affect 36 of 36 residents who received mechanical soft diets (Residents #102, #40, #202, #21, #71, #76, #41, #89, #87, #68, #91, #75, #70, #109, #20, #11, #150, #143, #33, #83, #57, #47, #122, #14, #43, #154, #8, #53, #121, #51, #101, #131, #208, #4, #38, #206) and 36 of 148 residents who ate meals prepared in the kitchen. Residents #136 and #17 received nothing by mouth.
Findings include:
Observation on 09/24/19 from 4:30 P.M. to 4:35 P.M. of tray line with Dietary [NAME] (DC) #806 revealed the mechanical soft meat appeared to be chopped chicken roast. Review of the menu extension sheet revealed the chicken roast should have been ground. DC #806 stated the chicken came chopped up and he just chopped it up more with a spoon. At this time Dietary Manager (DM) #804 verified on the menu extension the chicken roast should be ground.
Interview on 09/24/19 at 4:45 P.M. with Registered Dietitian (RD) #805 confirmed the menu extension sheets indicated the chicken roast should be ground for the mechanical soft diets. During observation and interview at this time RD #805 stated the chopped chicken was a little chunky and asked DC #806 if he ran it through the Robocoup (food processor). DC #806 replied, no. RD #805 then asked DC #806 to run the chopped chicken through Robocoup.
Review of a list provided by the facility revealed Residents #102, #40, #202, #21, #71, #76, #41, #89, #87, #68, #91, #75, #70, #109, #20, #11, #150, #143, #33, #83, #57, #47, #122, #14, #43, #154, #8, #53, #121, #51, #101, #131, #208, #4, #38, #206 were ordered mechanical soft diets.

Based on observation, record review, and interview the facility failed to maintain the nursing unit refrigerators and microwaves in a clean and sanitary condition. This had the potential to affect all residents except Residents #136 and #17, who received nothing by mouth.
Findings include:
Observations of the nursing unit refrigerators on 09/23/19 from 9:40 A.M. to 10:00 A.M. with Food Service Director (FSD) #500 revealed the A wing nursing unit freezer had various spills. The B wing nursing unit refrigerator contained a small green bowl with a white plastic lid with no label or date, a carton of nectar thickened cranberry juice without a top and handwritten date of 9/15 on the side of the container. Both the freezer and refrigerator had various food spills. The C wing nursing unit refrigerator had a clear plastic container of what appeared to be apple juice without a lid, label, or date. The D wing nursing unit freezer had a brown colored splatter on the back wall of freezer and on the bottom shelf. The refrigerator also had other various food splatters. The E wing nursing unit microwave had a large dried brownish-tannish spill that covered the microwave plate. The refrigerator had a moderate amount of a whitish food splatter on the inside wall and various food splatters and debris where the shelves lay in place in the refrigerator.
Interview on 09/23/19 from 9:40 A.M. to 10:00 A.M. with FSD #500 confirmed the above findings.
Review of the facility policy titled Food in Nutrition Pantry Cooler revised 09/18/18 revealed nutrition coolers were used to hold always available items, food brought in from outside of the community, thickened liquids and supplements. All items were to be properly dated, labeled, and discarded. Thickened liquids would be dated when opened and discarded per manufacturer's recommendation within seven days of opening. Housekeeping was to clean the nutrition pantry coolers weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to use alcohol-based hand sanitizer within dispensers mounted in resident rooms and resident care areas throughout the facility, ensure contact precautions were maintained, and ensure contaminated dressings were handled in a manner to prevent the spread of infection. This had the potential to affect all 150 residents residing within the facility.
Findings include:
1. During tour of medication storage rooms on 09/24/19 between 2:29 P.M. and 2:57 P.M., five hand sanitizer dispensers were observed mounted within resident care areas outside the medication storage rooms, and were observed to contain hand sanitizer gel labeled no alcohol.
Review of Centers for Disease Control Guidelines for Healthcare Providers for Hand Hygiene, located at https://www.cdc.gov/handhygiene/providers/index.html, last reviewed 04/29/19, revealed alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers, and alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations.
Review of facility policy entitled Engineering and Work Practice Controls, undated, revealed at this facility, handwashing facilities are located in resident rooms, medication rooms, utility rooms, shower rooms and other areas where exposure to blood or other potentially infectious materials may occur, and alcohol hand sanitizer is available for employee use in areas where immediate access to handwashing facilities is not feasible.
Interview on 09/25/19 at 10:50 A.M. with Housekeeping Supervisor (HS) #800 revealed 109 hand sanitizer dispensers were located throughout the facility, one in each resident room and additionally in other resident care areas. HS #800 further verified each dispenser contained non-alcohol based hand sanitizer, and the facility orders non-alcohol based hand sanitizer gel for each dispenser.
2. Record review of Resident #96 revealed an admission date of 06/25/19. Diagnoses included retention of urine unspecified, hypertension, and gout. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 was cognitively intact, required extensive assistance of two staff for bed mobility, transfers, and toilet use, and was frequently incontinent of bowel.
Review of the care plan revised on 09/10/19 for Clostridium difficile (C. diff) revealed interventions included contact precautions related to C. diff to post See Nurse Before Entering sign on door, provide personal blood pressure cuff, stethoscope, and thermometer, wear gloves, mask, and gown as needed, and wash hands when touching environment and with direct patient care.
Observation on 09/23/19 3:05 P.M. of Resident #96's room door revealed a yellow, plastic bag with slots that contained yellow gowns, mask, other miscellaneous disposable items. To the left on the door frame was a small sign that read contact precautions. At this time knocked and was allowed to enter room by Resident #96. Interview at this time with Resident #96 revealed he was on contact precautions for C. diff.
Observation on 09/25/19 at 10:53 A.M. revealed the call light outside of Resident #96's room was on. At this time State Tested Nurse Aide (STNA) #809 knocked on door and entered, leaving the door open, without wearing a gown or gloves. Continued observations revealed while in the room STNA #809 took a gray container from Resident #96's tray table, went into the resident's bathroom, and water was heard running. STNA #809 then left Resident #96's room. At this time observation revealed staff wearing gray scrubs enter Resident #96's room without putting on a gown or gloves. STNA #808 grabbed a gown from the yellow plastic slotted bag hanging on door, knocked and told the staff in gray scrubs he needed to put on a gown. STNA #808 then handed the staff in the gray scrubs the yellow gown.
Interview on 09/25/19 at 10:56 A.M. with STNA #808 revealed the staff in gray scrubs was the podiatrist, an outside contracted staff. STNA #808 stated that the podiatrist was wearing a gown now.
Interview on 09/25/19 at 10:57 A.M. with STNA #809 confirmed she did not have on a gown or gloves when she entered Resident #96's room. STNA #809 stated she went in to answer the call light and threw away a cup for the resident. STNA #809 stated she washed her hands after. STNA #809 stated for residents in contact precautions she was to wear a gown and glove if doing patient care.
Interview on 09/26/19 at 12:50 P.M. with Licensed Practical Nurse (LPN) #807 revealed as part of the infection control practice staff should be putting on a gown and gloves prior to entering an isolation room, which included outside contractors such as the podiatrist.
Review of facility's undated policy titled Contact Precautions, revealed wear clean gloves when entering the resident's room or unit if a multi-bed room. Wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent.
3. Record review for Resident #20 revealed he had a right foot wound that required daily padding, wrapping with Kerlix and an ACE wrap. During an observation on 09/23/18 at 2:44 P.M., Licensed Practical Nurse(LPN) #811 removed the contaminated dressing materials from Resident #20's legs and placed them on the bed and personal blanket of Resident #4, Resident #20's roommate. During an interview with LPN #811 she verified that she had placed soiled dressing materials from Resident #20 onto the blanket on Resident #4's bed without any type of barrier.
During an interview with the Administrator on 09/26/19 at 10:16 A.M., she was informed that LPN #811 had placed contaminated dressing materials from Resident #20 onto the bed of Resident #4. During a follow up interview with the Administrator, she indicated that Resident #4's showers days were Monday and Thursday and that his bed had been stripped and linens replaced on Monday, 09/23/19.
Review of the facility's undated infection control policy indicated the facility has developed and maintains an infection control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection.