Every finding on record at Advanced Health Care of Cincinnati

Based on medical record review, observation, staff interview, manufacturer directions and policy review, the facility failed to ensure medications were administered as ordered. There were four medication errors out of 26 opportunities for error which resulted in a 15.38 percent medication error rate. This affected four (#17, #18, #19, #20) of five residents reviewed for medication administration. The facility census was 34.Findings Include:1.Review of the medical record for Resident #19 revealed an admission date of 10/29/25. Diagnoses included metabolic encephalopathy and rhabdomyolysis.Review of the physician orders for Resident #19 revealed an order for a chewable 81milligram (mg) Aspirin tablet with a start date of 10/30/25.Observation on 11/05/25 at 7:39 A.M. Licensed Practical Nurse (LPN) #111 prepared and administered Resident #19 two Fluconazole (antifungal) 200 mg tablets, Gabapentin (nerve pain) 600 mg tablet and an 81 mg Enteric Coated (EC) Aspirin.Interview on 11/05/25 at 7:51 A.M. LPN #111 verified she had administered an EC aspirin and acknowledged the order was for a chewable tablet.2.Review of the medical record for Resident #20 revealed an admission date of 10/22/25. Diagnoses included intestinal obstruction, hypertension and peripheral vascular disease.Review of the physician orders for Resident #20 revealed an order for Folic Acid 1 mg tablet daily with a start date of 10/30/25.Observation and interview on 11/05/25 at 7:46 A.M. LPN #111 prepared and administered Resident #20 one Vitamin D (supplement) 5000 international unit (iu) capsule, one 30 mg coenzyme Q10 (supplement) capsule, Florenex (probiotic) capsule, Lidoderm (pain) five percent (%) patch, Vitamin B12 (supplement) 1000 microgram (mcg) tablet, Miralax (laxative) 17 gm. LPN #111 stated Resident #20 was scheduled to receive Folic Acid (supplement) 1mg tablet but it was not available for administration which resulted in an omission of the medication.3.Review of the medical record for Resident #18 revealed an admission date of 10/21/25. Diagnoses included hemiplegia following stroke affecting non dominant side, other sequalae of stroke, stroke and hypertension.Review of the physician orders for Resident #18 revealed an order for a chewable 81 mg Aspirin tablet with a start date of 10/21/25.Observation on 11/05/25 at 8:17 A.M. LPN #105 prepared and administered Resident #18 81 mg EC Aspirin, Amlodipine (blood pressure) 10 mg tablet, Preservision (supplement) tablet, Flomax (prostate) 0.4 mg tablet and a Multivitamin (supplement) tablet.4.Review of the medical record for Resident #17 revealed an admission date of 02/18/22. The resident was admitted with diagnoses including Parkinson's disease, rheumatoid arthritis, Cushing's syndrome and diabetes mellitus type two.Observation and interview on 11/05/25 at 8:36 A.M. LPN #105 prepared and administered Resident #17 allopurinol (Gout) 300 mg tablet, carbidopa levodopa (Parkinson's Disease) 25-100 mg tablet, Eliquis (blood thinner) 5 mg tablet, two Gabapentin (nerve pain) 100 mg tablets, Folic Acid (supplement) 1 gram, Torsemide (diuretic) 10 mg tablet. LPN #105 then removed a container of polyethylene glycol 3350 (laxative) from the medication cart. She poured the powder into a liquid medication cup to the five milliliter (ml) level. She then emptied the contents into approximately eight ounces of water, stirred it and then delivered it along with the tablets. Immediately following administration LPN #105 acknowledged she did not use the cap of the polyethylene glycol to measure the powder and chose to use the liquid medication cup to measure the powered medication.Review of the directions for the polyethylene glycol 3350 supplied by the facility revealed the bottle cap was a measuring cup designed to contain 17 grams of powder when filled to the brim.Review of the undated facility policy, Administration of Medication revealed to verify the correct medication and right dose prior to administration.This deficiency represents non-compliance investigated under Complaint Number 2651090.

Based on policy review, observation, and staff interview, the facility failed to store and prepare food in a manner that kept food safe. This had the potential to affect all 29 residents residing in the facility who received food from the kitchen. The facility census was 29. Findings include: Observation of dry storage area on 06/16/25 at 8:53 A.M. with Nutritional Services Director (NSD) #45 revealed nine bags of hamburger buns that were undated as well as three loaves of bread, all undated. During the tour, a box of cornstarch was discovered to be open and undated. NSD #45 confirmed the bags of buns, loaves of bread and cornstarch should all have been dated as it was received/opened. Observation of walk-in freezer on 06/16/25 at 9:14 A.M. with NSD #45 revealed bag of sweet potato fries were open and undated; a package of frozen saran wrapped homemade dough was undated; a bag of hash brown potatoes, open to air and undated; a bag of frozen pretzel dough open to air and undated; a bag of frozen garlic bread loaves open to air and undated; a box of frozen pre-baked French bread loaves open to air and undated; two boxes of tilapia, in open bags, open to air and undated. Upon further investigation, NSD #45 confirmed there were a bag of frozen hamburger patties open to air and undated, a bag of uncooked, frozen chicken breasts opened to air and undated and a box of frozen carrots in a bag unsecured, open to air and undated. NSD #45 confirmed all bags were open and undated and discarded all items. Review of the Food Storage Policy dated 11/27/24 revealed food should be dated as it is placed on the shelves as required by state regulation. All frozen foods should be covered, labeled and dated. All open foods should include a use by date. All foods will be checked to assure that foods will be consumed by their safe use-by dates or discarded. 2. Observation on 06/16/25 at 11:08 A.M. revealed [NAME] #43 preparing alternative food items for lunch and was using a kitchen knife with gloved hand to open a box of frozen hamburger patties. [NAME] #43 opened box with gloved hands, removed several hamburger patties never washing his hands or changing gloves after touching knife and box. [NAME] #43 confirmed he touched the box and knife with gloved hands and then reached in and removed hamburger patties with same gloved hands. [NAME] #43 confirmed he should have washed hands and donned new gloves before touching the frozen hamburger patties.

Based on record review, staff interview, and policy review, the facility failed to implement their water management plan to reduce the risk of Legionella (bacteria that causes a severe form of pneumonia with exposure generally from droplets of water). This had the potential to affect all 29 residents residing in the facility. Findings include: Review of the facility's undated Water Management Plan/Legionella Prevention revealed the monitors would be implemented and maintained in logs, which included monthly visual checks of temperatures and settings of hot water heaters, annual cleaning and disinfection of shower heads, weekly flushing of infrequently used outlets, and visual checks of identified high risk areas. Interview on 06/23/25 at 11:52 A.M. with the Administrator and Maintenance Director (MD) #23 verified the facility had no documentation for the visual checks of temperatures and settings of the hot water heaters, cleaning and disinfection of shower heads, flushing of infrequently used outlets, and visual checks of identified high risk areas. Review of the undated facility policy titled, Water Pathogen Risk Reduction, revealed logs and tracking/monitoring sheets would be utilized to document monitoring control strategies and control limits.

Based on record review, review of the self-reported incident (SRI), review of time punch card, staff interview, and policy review, the facility failed to follow their abuse policy following a staff-to-resident abuse allegation. This affected one (#87) of four residents reviewed for abuse. The facility census was 29. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/07/24 with a discharge date of 01/03/25. Diagnoses included congestive heart failure (CHF), and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had intact cognition. Review of the SRI dated 11/11/25 at 12:24 P.M. revealed Resident #87 reported Licensed Practical Nurse (LPN) #9 hit her while passing medications. When interviewed by the Administrator, Resident #87 wanted to retract her claim, but she was told it had to be reported. LPN #9 entered Resident #87's room to provide medications. Resident #87 was eating and asked LPN #9 to come back around 8:15 A.M. LPN #9 came back to the room around 8:20 A.M., and Resident #87 became verbally aggressive and combative towards LPN #9. LPN #9 attempted to redirect Resident #87 but was unsuccessful. LPN #9 left the room with medications. Soon after the encounter, another staff member was told by Resident #87 that LPN #9 hit her when she was in the room giving her the medication. LPN #9 was removed from caring for Resident #87 for the remainder of the shift. Review of the time punch card dated 11/11/24 for LPN #9 revealed she worked the remainder of her shift after abuse allegations were made. Interview on 06/23/25 with the Administrator verified LPN #9 was not suspended immediately and was able to work the rest of her shift after abuse allegations were made. The Administrator stated LPN #9 should have been suspended immediately pending investigation. Review of the facility policy titled, Abuse Policy and Procedure, dated 04/14/25 revealed any form of patient abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services would not be tolerated. If a staff member was accused of any of the above, that person must be interviewed regarding the allegations and that interview must be documented. In order to protect residents from further abuse, the accused staff person must be suspended until the investigation is completed. The accused staff person may not be reassigned to another department in the facility or to a sister facility.

Based on record review and staff and resident interviews, the facility failed to explain the arbitration agreement in a manner that residents could understand. This affected two (#9 and #14) of four residents reviewed for arbitration agreements. The facility identified there were four residents who recently signed arbitration agreements. The facility census was 29. Findings included: 1. Medical record review for Resident #9 revealed the resident was admitted to facility on 05/15/25. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #9 was cognitively intact. Review of the facility's arbitration agreement dated 05/15/25 revealed Resident #9 signed the arbitration agreement to have any dispute between the facility and herself decided by neutral arbitration and gave up the right to a jury or court trial. Interview with Resident #9 on 06/16/25 at 4:03 P.M., during resident council meeting, revealed Resident #9 did not understand what an arbitration agreement was. Resident #9 stated if someone had explained what an arbitration agreement was, she would not sign one. Once the facility arbitration was reviewed with group, Resident #9 stated she would never sign an agreement which gave up her rights to pursue legal action. 2. Medical record review for Resident #14 revealed the resident was admitted to facility on 05/19/25. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #14 had intact cognition. Review of the facility's arbitration agreement dated 05/21/25 revealed Resident #14 signed the arbitration agreement to have any dispute between the facility and herself decided by neutral arbitration and gave up the right to a jury or court trial. Interview with Resident #14 on 06/16/25 at 4:10 P.M., during resident council meeting, revealed the resident did not understand what an arbitration agreement was. Resident #14 stated if someone had it explained what an arbitration was, she would not sign it. Once the facility arbitration agreement reviewed, Resident #14 stated she would never sign an agreement which gave up her rights to pursue legal action. Interview with Patient Account Coordinator (PAC) #16 on 06/18/25 at 1:47 P.M. revealed the admission nurses explain to the admitting residents and families about the arbitration agreement. PAC #16 explained the only admission nurse present in the building on 06/16/25 was a new admission nurse who had not completed her training. PAC #16 explained that she also does admission paperwork with residents and families on occasion when the admission nurse was unavailable. PAC #16 revealed she explains the arbitration agreement to be something used when resident's insurances were not paying. PAC #16 revealed she believes the arbitration agreement can be revoked at any time. PAC #16 stated she did not know how choosing an arbitrator was done as that task was handled in their corporate offices. Interview with the Administrator and Corporate Nurse #81 on 06/18/25 at 2:24 P.M. revealed Corporate Nurse #81 trains all new admission nurses. Corporate Nurse #81 stated she explains the arbitration agreements are to be used for disputes especially around insurance payment issues. Corporate Nurse #81 revealed all incoming residents and families get copies of all signed documents. Neither the Administrator nor Corporate Nurse #81 were certain how an arbitrator was chosen and revealed they have never been involved in an arbitration dispute.

Based on record review, staff interview, and review of facility policy, the facility failed to provide timely and complete access to resident medical records. This affected one resident (#17) of three residents reviewed. The facility census was 13. Findings include: Review of the closed medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] and discharged to an unknown location on 02/09/23. His diagnoses included cerebral infarction, anxiety disorder, dysphagia, diabetes mellitus (DM), kidney failure, and essential primary hypertension. The limited medical record provided no additional information pertaining to nurse's progress notes, care plan and Minimum Data Set (MDS) information. Interview with the Director of Nursing (DON) and Rehabilitation (Rehab) Service Manager (#80) on 05/07/24 at 2:35 P.M. revealed the facility only utilized electronic medical records (EMR) for the resident's medical information. The DON stated the facility did not have access to Resident #17's medical record or any other resident's medical record prior to their acquisition date of 03/01/23. The DON verified Resident #17 was a resident at the facility; however, stated the previous owners took all of the resident's medical records with them. Rehab Service Manager #80 indicated the therapy notes were on a different platform and he was able to find a face sheet for Resident #17 that contained the admitted and some diagnosis but nothing else. Interview with the Administrator on 05/07/24 at 4:47 P.M. revealed the facility staff did not have access to any of the resident's medical records prior to the current owners acquiring the facility on 03/01/23. A subsequent interview with the Administrator on 05/08/24 at 9:10 A.M. confirmed the facility did not have access to the closed medical records for Resident #17 prior to the current ownership taking over in March 2023. The Administrator stated the Surveyor would have to reach out to the previous company in order to get access to Resident #17's medical records. The Administrator stated he updated the current policy on 05/07/24, to reflect the facility would start retaining medical records at their new acquisition date. Review of the facility policy titled, Medical Records, updated on 05/07/24, revealed the facility will maintain discharged records for approximately six-months, then the facility will transfer the medical record to a safe location and keep them for no less than seven years. Facilities that are purchased through acquisition shall preserve records beginning on the date of transfer of ownership (acquisition) and moving forward per the regulatory requirement of seven years. This was an incidental finding discovered during the course of the complaint investigation.

Based on record review and interview, the facility failed to ensure residents were visited by a physician every 60 days. This affected four (Residents #05, #06, #10, and #31) of four residents reviewed for physician visits. The facility census was 39. Findings include. 1. Record review revealed Resident #06 was admitted on [DATE]. Progress notes revealed the resident was seen by the Nurse Practitioner (NP) on 11/04/19. There was no further documentation in the medical record Resident #06 was seen by a physician every 60 days. 2. Record review revealed Resident #10 was admitted on [DATE]. Progress notes revealed Resident #10 was seen by the physician on 11/21/19 and 03/24/22. There was no documentation in the medical record Resident #10 had been seen by a physician every 60 days., 3. Record review revealed Resident #31 was admitted on [DATE]. Progress notes revealed Resident #31 was seen by the NP on 04/20/22. There was no further documentation in the medical record the resident had been seen by a physician since admission. 4. Record review revealed Resident #5 was admitted on [DATE]. Progress notes revealed Resident #5 was seen by the physician on 11/03/21 and 01/07/22. There was no documentation Resident #5 had been seen by the physician every 60 days. During interview on 05/11/22 at 5:10 P.M. the Clinical Director of Operations verified the facility does not have any records of the physician or nurse practitioner visits for the above residents. The physician progress are to be scanned and entered into the electronic health record on a regular basis. During interview on 05/12/22 at 8:08 A.M., Regional Nurse #110 stated the facility does not know when the residents had been seen by the physician. Review of the facility policy titled Monitoring Physician Visits, dated June 2016, documented to ensure that the physician, nurse practitioner and physician' s assistant visits to residents are timely and in compliance with facility policy and applicable regulatory requirements.

Based on record review, interview and policy review, the facility failed to hold Quality Assessment and Assurance meetings at least quarterly. This had the potential to affect all 39 residents in the facility. The facility census was 39. Findings include: Review of the Quality Assurance (QA) records revealed the last meeting was held on 12/27/21. There were no other QA meetings held in 2021 or 2022. During interview on 05/17/22 at 2:30 P.M. the Regional Administrator verified there was only one QA meeting held from January 2021 through May 2022. Review of the facility policy titled, QAPI Policy/Procedure, revealed the QA committee shall meet at least quarterly and as needed.

Based on record review and interview, the facility failed to ensure a resident's advanced directives were ordered and placed on the resident chart accurately. This affected one Resident (#45) out of three residents reviewed for advanced directives. The facility census was 39. Findings include: Resident #45 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes dated [DATE] at 6:49 A.M. documented Resident #45 was found unresponsive in his bed with no blood pressure and no pulse. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #45's code status was full code, give cardiopulmonary resuscitation (CPR). There was another order dated [DATE] that stated Resident #45's code status was do not resuscitate (DNR). During interview on [DATE] at 10:14 A.M. the Director of Nursing (DON) stated she admitted Resident #45 to the facility on [DATE]. The DON sated she read through the admission paperwork and placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to the end of her shift on [DATE], she located another form signed by the physician on [DATE] stating Resident #45 was a DNR comfort care (DNRCC). The DON stated she left the paperwork at the nursing station and gave report to the oncoming nurse regarding the incorrect code status entered as a full code. The DON stated she reviewed the chart the next day and found the oncoming nurse did not correct the code status in the computer. The DON stated the computer will not allow the corrected date to show on the day corrected and that is why the DNR code status appeared to be discharged on [DATE] and ordered on [DATE]. However, the DON did confirm Resident #45 had two orders for the same date, one listed as a full code and one listed as a DNRCC.

Based on record review, interview and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's current health care status. This affected one (Resident #5) of three residents reviewed for accurate MDS assessments. The facility census was 39. Findings include: Record review revealed Resident #5 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessments,dated 11/04/22 and 02/09/22, did not have [CONDITION(S)] coded on the assessment. Review of the plan of care for Resident #5, dated 10/27/21 revealed the resident was at risk for complications related to [CONDITION(S)] due to end stage renal disease. Interventions include administer medication as ordered, [CONDITION(S)] Monday, Wednesday and Friday, diet as ordered, and [CONDITION(S)] will communicate results and complications to facility as needed. During interview on 05/10/22 at 11:10 A.M., Resident #5 stated he goes to [CONDITION(S)] on Mondays, Wednesdays, and Fridays. Resident #5 does not remember when [CONDITION(S)] started but stated he has gone to [CONDITION(S)] since arriving to the facility. During interview on 05/12/22 at 2:25 P.M., the MDS nurse, Registered Nurse (RN) #40, verified the assessments dated 11/04/22 02/09/22 for Resident #5 did not have [CONDITION(S)] coded. Review of the facility policy titled Resident Assessment Accuracy of assessment dated [DATE], stated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS.

Based on record review, interview and policy review, the facility failed to notify the resident, representative or Ombudsman in writing of a transfer from the facility. This affected five (Residents #5, #8, #26, #7 and #44) of five residents reviewed for transfer notices. The facility census was 39. Findings include: 1. Review of progress notes revealed Resident #5 was transferred to the hospital on 10/21/21 and 05/01/22. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. During interview on 05/10/22 at 11:10 A.M., Resident #5 stated he did not receive any information related the transfers. 2. Review of progress notes revealed Resident #8 was transferred from the facility with the anticipation to return on 02/26/22. The resident returned on 03/04/22. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 3. Review of the progress notes for Resident #26 revealed she was discharged to the hospital on 03/21/22 and returned to the facility on [DATE]. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 4. Review of the nursing progress notes for Resident #27 revealed he was discharged to the hospital on 03/10/22 and returned to the facility on [DATE]. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 5. Review of the nursing notes for Resident #44 he discharged to the hospital on 04/20/22. The medical record . During interview on 05/10/22 at 3:35 P.M., Business office Manager (BOM) #112 stated she does not notify the family or resident in writing of discharge notification.

Based on medical record review, staff interview, observations and facility policy review, the facility failed to ensure a written bed hold policy was given to the resident prior to transfer from the facility. This affected five residents (#8, #5, #26, #27, #44) of five residents reviewed for bed hold policy. The facility census was 39. Finding include: Medical record review for Resident #5 revealed an admission on 10/20/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed an intact cognition. Resident #5 requires total assist for bed mobility and transfers. Resident #5 required extensive assist for eating and toileting. Review of the plan of care for Resident #5 dated 12/09/21 revealed resident has behaviors related to placing calls to 911 multiple episodes without reason and after medical assessment. Interventions include engage resident in self-care and physical activities to channel energy, encourage ventilation of feelings, fears and anxiety, reinforce and focus on reality, and do not confront resident's belief system. Review of the Progress note for Resident #5 dated 10/28/21 at 11:36 A.M. as a late entry for 10/21/21 at 11:19 A.M revealed resident called 911 for transfer to the hospital. Review of the Progress notes for Resident #5 dated 10/21/21 through 10/26/21 when resident was readmitted to the facility was silent for transfer notice to resident or resident representative. Review of the Progress note for Resident #5 dated 05/01/22 at 10:52 A.M. revealed resident complained of pain in his toe. Acetaminophen 500 mg given however resident called 911 and went to the hospital. The medical record was silent for transfer notice to resident or resident representative. Observation on 05/10/22 at 11:09 A.M. of Resident #5 revealed resident resting in bed with eyes closed. Awakened easily with knock on door. Interview on 05/10/22 at 11:10 A.M. with Resident #5 stated he did not receive any information related the transfers. Further stated the facility staff give all the papers to the squad when they come and get me. Interview on 05/10/22 at 3:30 P.M. with the Admissions and Marketing Representative #111 stated she does not notify the family/residents in writing of bed hold policy. Interview on 05/10/22 at 3:35 P.M. with the Business office Manager (BOM) #112 confirmed she does not notify the family or resident in writing of bed hold policy. Interview on 05/10/22 at 3:36 P.M with the Clinical Director of Operations #110 confirmed the facility has not notified resident or resident families of bed hold policy on or before transfer. Interview on 05/11/22 at 12:59 P.M. with Registered Nurse (RN) #54, via phone interview, verified she transferred resident to the hospital on 05/01/22 stated she sent face sheet and medication list with emergency personnel. Interview on 5/12/22 at 11:30 A.M. with Unit Manager Licensed Practical Nurse (LPN) #31 stated the nurses send a medication list and a face sheet with all transfers and appointments. Unaware of any additional documents that is provided to the resident regarding the bed hold policy. Review of the facility policy titled Bed Hold dated 04/2018 and reviewed 01/2022 revealed the facility failed to implement the policy as written. Number three states in the event of an emergency transfer to the hospital, the facility social worker or designee will attempt to contact the resident or resident representative within twenty-four hours of the transfer and determine whether to [NAME] the resident's bed. The facility will document multiple attempts if necessary to reach the resident and or the resident representative in case when the facility was unable to notify. 2. Record review for Resident #08 revealed she was admitted to the facility on [DATE] and discharged to a facility out of state on 05/09/22. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) 02/20/22 revealed Resident #08 had impaired cognition as evidenced by a brief interview for mental status (BIMS) score of 12. Resident #08 required extensive assistance with bed mobility, walking on the unit, dressing, toilet use, personal hygiene, and supervision from staff with eating. Review of Resident #08's nursing progress notes revealed Resident #08 discharged from the facility with the anticipation to return on 02/26/22. Further review of the nurse's charting for Resident #08 revealed she returned to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 3. Record review for Resident #26 revealed an admitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 04/04/22, revealed Resident #26 had severely impaired cognition as evidenced by her BIMS score of 04. Further review of the MDS assessment revealed Resident #26 required limited assistance from staff with transfers, walking, toilet use, personal hygiene, dressing, bed mobility. She required supervision from staff with eating. Review of the progress notes for Resident #26 revealed she was discharged to the hospital on 03/21/22 and returned to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 4. Record review for Resident # 27 revealed an admitted [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 04/05/22, revealed Resident #27 had moderately impaired cognition as evidenced by a BIMS score of 09. Resident #27 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. Further review of the MDS assessment revealed Resident #27 was totally dependent on staff with transfers, walking, and bathing. However, he only required supervision from staff with eating. Review of the nursing progress notes for Resident #27 revealed he was discharged to the hospital on 03/10/22 and return to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 5. Review of the nursing notes for Resident #44 revealed an admitted [DATE] and he discharged to the hospital on 04/20/22. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day MDS assessment, dated 04/18/22 revealed Resident #44 was moderately cognitively impaired as evidenced by his BIMS score of 10. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility and was totally dependent on staff with assistance with transfers. Resident #44 required supervision assistance from staff with eating, toilet use, personal hygiene, and bathing. Review of the nurse charting for Resident #44 revealed he was discharged to the hospital on 04/20/22. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. Interview on 05/10/22 at 3:30 P.M. with the Admissions and Marketing Representative #111 stated she does not notify the family/residents in writing of bed hold policy. Interview on 05/10/22 at 3:35 P.M. with the Business office Manager (BOM) #112 confirmed she does not notify the family or resident in writing of bed hold policy. Interview on 05/10/22 at 3:36 P.M with the Clinical Director of Operations #110 confirmed the facility has not notified resident or resident families of bed hold policy on or before transfer. Interview on 05/11/22 at 12:59 P.M. with Registered Nurse (RN) #54, via phone interview, verified she transferred resident to the hospital on 05/01/22 stated she sent face sheet and medication list with emergency personnel. Interview on 5/12/22 at 11:30 A.M. with Unit Manager Licensed Practical Nurse (LPN) #31 stated the nurses send a medication list and a face sheet with all transfers and appointments. Unaware of any additional documents that is provided to the resident regarding the bed hold policy. Review of the facility policy titled Bed Hold dated 04/2018 and reviewed 01/2022 revealed the facility failed to implement the policy as written. Number three states in the event of an emergency transfer to the hospital, the facility social worker or designee will attempt to contact the resident or resident representative within twenty-four hours of the transfer and determine whether to [NAME] the resident's bed. The facility will document multiple attempts if necessary to reach the resident and or the resident representative in case when the facility was unable to notify.

Based on a closed medical record review, staff interviews, interview with home care staff, and review of the facility policy titled Standard of Nursing Practices, the facility failed to apply a Bilevel Positive Airway Pressure ([CONDITION(S)]) device (a non-invasive ventilation therapy used to facilitate breathing) for sleep apnea as ordered for one resident (#53) upon discharge from the hospital. This resulted in Immediate Jeopardy when the [CONDITION(S)] device was not applied, and Resident #53 was found unresponsive and ultimately expired at the facility. This affected one (Resident #53) of three residents reviewed for death in the last three months. The census was 50. On [DATE] at 9:34 A.M., the Director of Nursing (DON) and Regional Director of Operations (RDO) #350 were notified the Immediate Jeopardy began on [DATE] at 8:45 P.M. when Resident #53 was admitted to the facility with physician orders for the use of a [CONDITION(S)] machine/device. The orders were received by the facility on [DATE] at 12:51 P.M. and the orders were never transcribed to the facility's Electronic Medical Record (EMR). The [CONDITION(S)] was never applied to Resident #53, and she was found unresponsive on [DATE] at 2:40 A.M. Cardiopulmonary Resuscitation (CPR) was initiated by the facility staff until Emergency Medical Services (EMS) personnel arrived and took over CPR. The EMS personnel stopped CPR on [DATE] at 3:05 P.M. and Resident #53 was pronounced dead. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], the facility reviewed all in-house residents and none of them required the use of a [CONDITION(S)] machine/device. · On [DATE], the DON provided education to all licensed nursing staff to ensure hospital discharge orders are properly transcribed to maintain continuity of care in accordance with physician orders. · On [DATE], education was provided to all licensed nursing staff to ensure policies and procedures were being followed when residents are admitted and physician orders are clarified to prevent same or similar actions, and/or practices form occurring in the future. · On [DATE], the DON reviewed residents in the facility to ensure hospital discharge orders were properly transcribed to maintain continuity of care per physician orders. · On [DATE], the DON reviewed physician orders to ensure policy and procedures are being followed for residents currently residing in the facility. · On [DATE], the DON completed competencies on the [CONDITION(S)] machine/device to all the licensed nursing staff. · Audits will be conducted by the DON or designee daily of residents who may require the use of a [CONDITION(S)] machine to facilitate breathing, to ensure orders state when the [CONDITION(S)] device will be applied daily for one week, weekly for four weeks, then monthly for two months. · Audits will be conducted by the DON or designee to ensure orders are transcribed from the discharge instructions to the nursing home and the orders clarified as to when the [CONDITION(S)] device was to be applied daily for one week, weekly for four weeks, then monthly for two months. · Audits will be conducted in the morning clinical meeting by the DON or designee to ensure hospital discharge orders are properly transcribed to maintain continuity of care in accordance with physician orders. · Facility will review findings in the Quality Assurance and Performance Improvement (QAPI) committee weekly for four weeks then monthly for two months to ensure on-going compliance. Any negative findings will be corrected immediately and referred to the QAPI committee for follow-up. The Administrator will monitor to ensure on-going compliance. · On [DATE] at 11:24 A.M., telephone interviews with Licensed Practical Nurse (LPN) #01 and LPN #75 verified they were educated on policies and procedures when residents are admitted and to make sure physician orders are clarified.? LPN #01 and LPN #75 verified competency training on the use of the [CONDITION(S)] machine/device. · On [DATE] at 11:32 A.M., telephone interview with LPN #186 verified they were educated on policies and procedures when residents are admitted and to make sure physician orders are clarified.? LPN #186 verified competency training of the use of the [CONDITION(S)] machine/device. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record of Resident #53 revealed he was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital discharge orders, received by the facility via facsimile on [DATE] at 12:51 P.M. documented [CONDITION(S)] at a total inspiratory pressure of 10, expiratory pressure of 5, fractured of inspired oxygen (FiO2) at 50 percent and titrate to keep oxygen saturation above 92 percent. Review of the progress notes revealed Resident #53 was admitted to the facility on [DATE] at 8:45 P.M. from a local hospital. Resident #53 was alert and oriented times two. Vital signs recorded were blood pressure ,d+[DATE] millimeters of mercury, heart rate 74 beats per minute, respirations 18 breaths per minute, temperature 97.9 degrees Fahrenheit (F), and oxygen saturation of 96 percent on four liters of oxygen per nasal cannula. Review of the physician orders for Resident #53 in the facility's EMR revealed no order for a [CONDITION(S)] machine/device. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #53 on [DATE] or [DATE]. Review of the progress notes for Resident #53 revealed no documentation of the [CONDITION(S)] being administered on [DATE] or [DATE]. Review of the progress notes dated [DATE] at 1:35 A.M. documented an oxygen tank was changed. On [DATE] at 3:13 A.M., progress notes documented Resident #53 was found non-responsive. Resident #53's blood pressure, pulse, respirations and temperature could not be obtained. Resident #53 was warm to touch with flaccid limbs. CPR was initiated, and EMS was called via 911. At 3:33 A.M., EMS stopped CPR and Resident #53 was pronounced dead. During a telephone interview on [DATE] at 10:49 A.M., the DON stated she received Resident #53's [CONDITION(S)] machine from her group home on [DATE]. Resident #53's [CONDITION(S)] machine was delivered before she was admitted to the facility. The DON confirmed there was no documentation of the [CONDITION(S)] machine being administered to Resident #53. During a telephone interview on [DATE] at 8:56 A.M., Registered Nurse (RN) #250 stated she cared for Resident #53 on [DATE] and [DATE]. RN #250 stated Resident #53 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53 was last seen resting on [DATE] at approximately 1:30 A.M. Resident #53's portable oxygen tank was changed at that time. Resident #53 was found unresponsive on [DATE] at 2:40 A.M. CPR was initiated with the help of another nurse, 911 was called, and EMS personnel arrived and took over care of the resident. Resident #53 was pronounced dead by the EMS personnel. During a telephone interview on [DATE] at 11:25 A.M., Home Care Registered Nurse (HCRN) #300 stated Resident #53 was supposed to wear the [CONDITION(S)] every night. The home care house manager delivered Resident #53's [CONDITION(S)] machine to the facility on [DATE] at approximately 5:00 P.M. During a telephone interview on [DATE] at 4:50 P.M., Battalion Chief #100 stated EMS received the 911 call at 2:53 A.M. They arrived on scene at 2:56 A.M. EMS took over CPR from the facility staff at 2:58 A.M. Resident #53 was pronounced dead at 3:30 A.M. Review of the facility policy titled Standard of Nursing Practices, dated [DATE], documented the admission nurse will review transfer orders on new admissions and immediately verify orders with the physician. This deficiency substantiates Complaint Number OH 143.

Based on observation, record review and interview, the facility failed to have pain medication available for administration. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 50: Findings include: Review of the medical record for the Resident #7 revealed an admitted [DATE]. Diagnoses included infection to internal right knee prosthesis, [CONDITION(S)], hypertension, and hepatic failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/08/21, revealed the resident was cognitively intact. Review of the care plan dated 12/06/2021 revealed Resident #7 was at risk for pain which affected the resident's sleep and limited his activities of daily living function. Interventions included medications as ordered and rest periods. Review of the medical record revealed Resident #7 had physician orders for [MEDICATION(S)] five milligrams (mg) tablets, two tablets every four hours as needed. Review of the narcotic count sheet for Resident #7's [MEDICATION(S)] revealed Resident #7 received three to four administrations daily of the [MEDICATION(S)] for pain. Resident #7 received his last dose of [MEDICATION(S)] on 01/11/22 at 7:00 P.M. Review of the Medication Administration Record dated January 2022 revealed Resident #7 received the last dose of [MEDICATION(S)] on 01/11/22 at 11:37 A.M. During observation on 01/12/22 at 10:07 A.M., Licensed Practical Nurse (LPN) #77 answered Resident #7's call light and informed the resident that she could not administer his [MEDICATION(S)] requested because the medication was unavailable. The pharmacy would not deliver the medication without a new prescription from the physician. LPN #77 offered Resident #7 a routine dose of [MEDICATION(S)], a muscle relaxer, instead. During interview on 01/12/22 at 10:39 A.M., Resident #7 stated he had been without his as needed [MEDICATION(S)] medication since yesterday (01/11/12) and the pain was continuous. The resident stated agency nurses at night, unidentified, were unable to access his pain medication and stated they said they did not have the key to unlock the box to get it. During interview on 01/12/22 at 4:14 P.M., LPN #77 stated she it had never occurred to her to request an authorization from pharmacy to dispense the medication from the Pyxis machine, which held emergency medications, because she usually worked Assisted Living and they did not have emergency medications. LPN #77 stated she had not reassessed the resident for pain since she had administered the [MEDICATION(S)] and to her knowledge, the resident had not requested any more pain medication. During interview on 01/13/22 at 11:43 A.M., the Director of Nursing (DON) stated Resident #7's [MEDICATION(S)] was not received from pharmacy until 01/13/2021 at 5:18 A.M. The DON verified [MEDICATION(S)] was available in the Pyxis machine and there had been no [MEDICATION(S)] dispensed from the emergency drug kit in the Pyxis. Resident #7 had not had any [MEDICATION(S)] administered between 01/11/2021 at 7:00 PM and, 01/13/2022 at 6:00 A.M. Review of policy titled Medication Administration Procedures, dated May 2019, revealed narcotic medications were signed out when taken form the narcotic box and after administered. This deficiency substantiates Complaint Numbers OH 874 and OH 685.

Based on staff interview, resident interview, and record review, the facility failed to provide sufficient staff during care to prevent residents from rolling out of bed during care. This affected one resident (#50) out of three residents sampled for falls. The facility census was 48. Findings include: Review of the medical record for the Resident #50, revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to Spondylolisthesis, unspecified protein-calorie malnutrition, and hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had verbal behaviors, frequently rejected care, and did not wander. Resident #50 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, and toileting, limited assistance with personal hygiene, setup assistance with eating, and locomotion did not occur. Review of the care plan dated 10/13/21 revealed Resident #50 was at risk for falling related to medications, and impaired balance and mobility. Interventions included floor mats to side of bed, environment free from clutter, proper footwear, bed in lowest position, frequently used items within reach, call light within reach at all times, change positions slowly, educate resident not to transfer without assistance, and assistive devices (walker/wheelchair). Resident #50 was at risk for deterioration in activities of daily living (ADL) related to impaired mobility and recent back surgery. Interventions included report deterioration, consistent approach, adequate rest periods, allow time to complete ADL's, provide as much assistance as needed to meet ADL's, and encourage as much independence as possible. Review of progress notes dated 10/13/21 revealed at 1:30 A.M. Certified Nursing Assistant (CNA, unidentified) reported to Licensed Practical Nurse (LPN) #70 that Resident #50 turned to assist with repositioning and rolled off the bed. Interview on 12/10/21 at 2:12 P.M. the DON verified Resident #50 required two-person extensive assistance with toileting and bed mobility. Interview on 12/10/21 at 3:44 P.M. Resident #50's spouse stated there was only one attendant in the room assisting his wife when she rolled out of bed. He further stated the CNA came in to change his wife, told her to roll over, and the resident rolled out of bed. He stated if there had been two staff like there were supposed to be, the fall would likely not have happened. This deficiency substantiates Complaint #OH 815.

Based on medical record review, review of the resident council minutes and facility's policy, and resident and staff interview, the facility failed to promptly address the resident's concerns. This had the potential to affect all 44 residents residing in the facility. Findings include: Medical record review for Resident #5 revealed an admitted d of 11/18/19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/21, revealed Resident #5 was cognitively intact. Medical record review for Resident #24 revealed an admitted d of 10/02/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 04/23/21, revealed Resident #24 was cognitively intact. Interview on 05/20/21 at 11:32 A.M. with Resident #24 reported she does not receive her medications in a timely manner and that she reported it in last month's resident council meeting. The Activity Director (AD) #141 keeps the minutes and writes down members' concerns. The Administrator attended council meeting held on 04/27/21. Resident #24 denied being informed (orally or written) by staff regarding her concerns. Resident #24 denied receiving any feedback because of complaint she made during resident council minutes. Review of the resident council minutes revealed the minutes, dated 04/27/21, revealed the Administrator and AD #141 were in attendance. There was no signature from the Resident Council president indicating the minutes were not approved. There was no mention that medications were not being administered in a timely manner. The minutes mentioned communication to residents with medication changes. Interview on 05/20/21 at 1:24 P.M. with Social Services Designee (SSD) #122 reported she handles general complaints by residents. SSD #122 reported she receives the information and sends it to the department heads. A response was expected within 24 hours. The facility addresses it immediately. Interview on 05/20/21 at 1:30 P.M. with the Administrator reported she started at the facility on 04/07/21, and was the interim Administrator. The Administrator denied hearing of any concerns related to medications not being administered in a timely manner. Interview on 05/20/21 at 2:00 P.M. with Resident #5, the resident council president, reported all attendee members including herself spoke about medications not being administered according to state guidelines. Resident #5 reported she was scheduled to get medications in the morning but did not receive it until 1:30 P.M. and she did not like it. After the resident council meeting, AD #141 transfers the notes onto a resident council form and the resident council president reviews it and sign off. Resident #5 reviewed the notes and refused to sign them since medications being passed out late was not strongly mentioned. Resident #5 reported AD #141 reported the Administrator told her to take some things out because it made the facility look bad. AD #141 reported the Administrator made her tear up the paper and rewrite another one. Resident #5 denied being informed (orally or written) by staff regarding her concerns. Resident #5 denied receiving any feedback because of the complaint she made during resident council minutes. Telephone interview on 05/20/21 at 2:15 P.M. with AD #141 confirmed the residents in the council meeting discussed medications not being given in a timely manner but was told to scratch it out by the Administrator. AD #141 reported the Administrator corrected her minutes and told her what to write in the resident council minutes held on 04/27/21. Review of the facility's undated policy titled Grievances/Concerns Chapter 6.6, revealed the residents have the right to voice grievances without discrimination or fear of reprisal. Social Services will oversee the implementation of the facility grievance procedure. Social Services will instruct facility staff to submit to the Social Services Director that all grievances received will be investigated within 72 hours following receipt of the complaint. Within seven days following the receipt of the complaint, the facility will inform the complainant with the results of the investigation. This deficiency substantiates Complaint Number OH 440.

Based on record review, observation, staff and local health department (LHD) interview, review of facility policy, and review of online resources per the Center for Medicare and Medicaid Services (CMS), the facility failed to test staff at the appropriate frequency and/or failed to test/verify testing for transport staff providing services to residents. This had the potential to affect all residents residing in the facility. The census was 46. Findings include: 1. Review of the facility's Coronavirus Disease 2019 (COVID-19) staff testing log for November and December 2020 revealed the facility tested staff once per week for COVID-19. Interview on 12/17/20 at 10:05 A.M. with the Administrator on 12/17/20 at 10:05 A.M. confirmed the facility tested staff for COVID-19 once per week and the frequency of staff testing was based upon direction from the LHD. Interview on 12/18/20 at 9:35 A.M. with LHD Representative #190 confirmed the LHD had provided the facility no direction regarding the frequency of COVID-19 testing for staff and further confirmed nursing homes should follow state and federal testing guidelines for long term care facilities. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a high spread of COVID 19 with a positivity rate of 16.8 percent (%) and the county was red for the week ending in 12/16/20. For the week ending 12/09/20 the county positivity rate was 17.3% and the county was red. Review of CMS memo QSO-20-38-NH dated 08/26/20 titled Long-Term Care (LTC) Facility Testing Requirements revealed routine testing of staff should be based on the extent of [MEDICAL CONDITION] in the community and facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Review of the memo revealed reports of COVID-19 county-level positivity rates would be available on the following website: https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg. Further review of the memo revealed facilities situation in counties with a positivity rate of greater than 10% or identified as red should test all staff twice weekly. 2. Review of the medical record for Resident #26 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #26 dated 12/05/20 revealed the resident was cognitively intact and required supervision of one staff with dressing, toilet use, and personal hygiene. Observation on 12/17/20 revealed Transporters #120 and #130 entered the facility at 10:45 A.M. and entered Resident #26's room, assisted with dressing (putting on shoes, hat, and coat), assisted with transferring resident from bed to transport stretcher, and wheeled resident out of the facility to her [MEDICAL TREATMENT] appointment at 11:00 A.M. Observation on 12/17/20 at 11:00 A.M. revealed Transporters #120 and #130 wheeled Resident #26 on a transport stretcher from her room, through the hallways and to front door without offering resident a mask. The Administrator provided Resident #26 with a mask just before she exited the facility with transport personnel to go on an appointment. Resident #26 donned the mask when it was offered to her and wore it as she left the building. Interview with the Administrator on 12/28/20 at 1:52 P.M. confirmed the facility had no record regarding COVID-19 testing for Transporters #120 and #130. Review of CMS Memo QSO-20-38-NH dated 08/26/20 revealed nursing facilities are required to test individuals for COVID-19 who provide resident services under arrangement. Review of CMS document Nursing Home COVID-19 Frequently Asked Questions revealed personnel who are providing non-urgent transportation (e.g., for scheduled medical appointments) are considered to be providing services under arrangement and should be tested at a frequency consistent with the facility's routine testing frequency. This deficiency substantiates Complaint Number OH 446.

Based on record review, observation, staff interview, review of facility policy, review of facility documents and review of online resources per the Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS), the facility failed to wear appropriate personal protective equipment (PPE), failed to wear PPE in an appropriate manner, and/or failed to provide masks to residents during transport out of the facility in order to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all residents residing in the facility, except for five (#13, #14, #15, #16, #17) residents who were COVID-19 positive. The census was 46. Findings include: 1. Observations on 12/17/20 at 8:39 A.M. of Dietary Aide (DA) #70, at 8:40 A.M. of Cook #80, and at 8:41 A.M. of DA #90 revealed the staff were on the resident care units delivering meals and were not wearing eye protection. Observation of Licensed Practical Nurse (LPN) #100 was administering medications and was not wearing eye protection. Interviews on 12/17/20 at 8:39 A.M. with DA #70 confirmed she had forgotten to don her eye protection when she entered the resident care area and she wasn't sure if she had it with her at work. Interview on 12/17/20 at 8:41 A.M. with Cook #80 confirmed he had eye protection provided to him by the facility for use in the resident care area, but he had left it downstairs and he thought his prescription eyeglasses were sufficient to provide eye protection. Interview on 12/17/20 at 8:41 A.M. with DA #90 confirmed she had eye protection provided to her by the facility for use in the resident care area, but she had left it downstairs and had not donned it before entering the resident care area. Interview on 12/17/20 at 8:42 A.M. with LPN #100 confirmed she had left her eye protection in her car and had not donned eye protection prior to passing medications. Interview on 12/17/20 at 8:20 A.M. with the Administrator confirmed facility staff were required to wear eye protection at all times in resident areas. Observations on 01/03/21 at 6:35 P.M. of LPN #200, at 6:48 P.M. of LPN #160, at 6:50 P.M. of LPN #210, at 6:55 P.M. of STNA #220, at 6:59 P.M. of Registered Nurse (RN) #230, and at 7:00 P.M. of LPN #240 revealed the staff were not wearing eye protection in resident areas. Interviews on 01/03/21 at 6:35 P.M. with LPN #200, at 6:48 P.M. with LPN #160, at 6:50 P.M. with LPN #210, at 6:55 P.M. with STNA #220, at 6:59 P.M. with Registered Nurse (RN) #230, and at 7:00 P.M. with LPN #240 confirmed staff were not wearing eye protection in resident areas. Interview with the Administrator on 01/04/21 at 12:00 P.M. confirmed staff were expected to wear eye protection at all times in resident areas. The facility confirmed there are five (#13, #14, #15, #16, #17) residents who are COVID-19 positive residing in the facilities COVID-19 unit. Review of the facility policy titled Public Health Emergency undated revealed in the event of a public health emergency such as an infectious disease outbreak the facility would follow the guidance of the CDC. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a high spread of COVID 19 with a positivity rate of 16.8 percent (%) for the week ending in 12/16/20. Further review revealed the county in which the facility was situated was experiencing a high spread of COVID 19 with a positivity rate of 16.0 ercent (%) for the week ending in 12/23/20. 2. Observations on 12/17/20 at 8:42 A.M. of LPN #100 revealed she was wearing an N-95 mask with the bottom strap hanging down and not secured behind her head as she was administering medications. Interview on 12/17/20 at 8:42 A.M. with LPN #100 confirmed both straps of the N-95 should be secured behind her head to ensure the mask fit properly. Observation on 12/17/20 at 8:47 A.M. of State tested Nursing Assistant (STNA) #110 revealed she was wearing an N-95 mask with both straps behind her neck and below her ears and she had long hair covering the straps while she was in the resident care area. Interview on 12/17/20 at 8:47 A.M. with STNA #110 confirmed she was wearing an N-95 mask with both straps behind her neck and below her hairs. STNA #110 further confirmed she wore the N-95 so as not to mess up her hair. Observation on 12/17/20 at 10:20 A.M. of Housekeeper #180 revealed she was wearing an N-95 mask with both straps crisscrossed on the back of her head and both straps were positioned above her ears while she was in the resident care area. Interview on 12/17/20 at 10:20 A.M. with Housekeeper #180 confirmed she was unsure of the proper way to don an N-95 mask. Observation on 12/17/20 at 11:20 A.M. of STNA #170 revealed she was wearing an N-95 mask with the bottom strap hanging down and not secured behind her head while she was in the resident care area. Interview on 12/17/20 at 11:20 A.M. with STNA #170 confirmed both straps of the N-95 should be secured behind her head to ensure the mask fit properly. Review of the facility policy titled Public Health Emergency undated revealed in the event of a public health emergency such as an infectious disease outbreak the facility would follow the guidance of the CDC. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html revealed masks should be properly secured with ties and should completely cover the nose and mouth and fit snugly against the face. Review of an online resource per the CDC at https://www.cdc.gov/vhf/ebola/hcp/ppe-training/n95respirator_gown/donning_09.html revealed the following steps were included when donning an N-95 mask: hold the respirator in the palm of your hand with the straps facing the floor, place the N95 on your face covering your nose and mouth, pull the bottom strap up and over top of your head, and put it behind your head below your ears, take the upper strap and put it behind your head towards the crown of your head, mold the nose piece of the respirator over the bridge of your nose to obtain a tight seal, perform a fit check to ensure there is a good seal against the skin. 3. Review of the medical record for Resident #26 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #26 dated 12/05/20 revealed the resident was cognitively intact and required supervision of one staff with dressing, toilet use, and personal hygiene. Observation on 12/17/20 at 11:00 A.M. revealed Transporters #120 and #130 wheeled Resident #26 on a transport stretcher from her room, through the hallways and to front door without offering resident a mask. Interview on 12/17/20 at 11:01 A.M. with Transporters #120 and #130 confirmed they did not provide residents with masks and further confirmed Resident #26 would get a mask once she arrived at the [MEDICAL TREATMENT] clinic. Observation on 12/17/20 at 11:02 A.M. revealed the Administrator provided Resident #26 with a surgical mask at the request of the surveyor. Further observation revealed Resident #26 was able to place the mask on herself and position it properly. Interview on 12/17/20 at 11:15 A.M. with Licensed Practical Nurse (LPN) #160 confirmed the facility should provide facemasks to residents when they must leave their rooms for medically necessary appointments. Review of the facility policy titled Isolation Categories dated March 2018 revealed the facility is responsible for notifying transport staff of recommended infection control precautions. Review of CMS Memo QSO-20-28-NH Frequently Asked Questions updated 09/28/20 revealed if a resident's attending an outside appointment is necessary, the facility should help arrange for the resident to attend the appointment by taking precautions to minimize the risk of transmission of COVID-19 including giving the resident a surgical mask to wear to their appointment. This deficiency substantiates Complaint Number OH 446.

Based on review of Resident Council Meeting Minutes , staff interview, review of facility documents and review of facility policy, the facility failed resolve resident concerns regarding provision of food for residents who leave the facility for [MEDICAL TREATMENT] treatments. This had the potential to affect the following facility identified residents who receive [MEDICAL TREATMENT] outside the facility (#12, #13, #19, #26 and #50). The census was 46. Findings include: Review of the facility Resident Council Meeting Minutes dated 10/28/20 under new business revealed residents express concern regarding no bagged lunches or meals waiting for [MEDICAL TREATMENT] resident. Review of Resident Council concern form initiated 11/03/20 revealed the concern regarding the facility's failure to have bagged lunches or lunch for residents upon return from [MEDICAL TREATMENT] was referred to the dietary manager. Typed verbiage at the top part of the form read Please respond in writing with your plan of action to address the concern listed from our Resident Council meeting dated 10/28/20. You have seven days to respond to the concern. A copy of the concern listed, and your plan of action will go to the Administrator for follow-up. The form included a space for the department head's plan of action and was signed by the dietary manager on 11/10/20 and by the Administrator on 11/29/20. Further review of the concern form revealed other concerns listed at top of the form were addressed but there was no plan of action listed regarding the concern of lunches for residents upon return from [MEDICAL TREATMENT]. Review of the facility Resident Council Meeting Minutes dated 12/07/20 under old business revealed the residents concern expressed regarding lunches or meals for [MEDICAL TREATMENT] residents was not noted to be resolved. Review of Resident Council concern form initiated 12/08/20 revealed the following concern was noted, Has food (to go) for [MEDICAL TREATMENT] patients taken place this month? Is the kitchen staying open longer? Please respond in writing with your plan of action to address the concern listed from our Resident Council meeting dated 12/07/20. You have seven days to respond to the concern. A copy of the concern listed, and your plan of action will go to the Administrator for follow-up. The bottom of the top form included a space for the department head's plan of action and was blank. Interview on 12/17/20 at 9:13 A.M. with Resident #50 confirmed the facility did not consistently provide meals upon her return from [MEDICAL TREATMENT] appointments. Interview on 12/23/20 at 10:01 A.M. with the Administrator confirmed he believed the concern brought up in the Resident Council on 10/28/20 and again on 12/07/20 regarding provision of meals for residents upon their return from [MEDICAL TREATMENT] had been resolved following the meeting on 10/28/20. The Administrator confirmed the facility had no written documentation of the facility's response or resolution of the concern. The facility confirmed there are five (#12, #13, #19, #26 and #50) residents who go out of the facility for [MEDICAL TREATMENT] appointments. Review of the facility policy titled Grievances and Concerns undated revealed residents had a right to express concerns/grievances either orally or in writing, all concerns would be tracked for timely and appropriate response with seven days being the time frame for resolution of the grievance/concern. This deficiency substantiates Complaint Number OH 459 and Complaint Number OH 446.

Based on record review, observation, resident, vendor and staff interview, and review of facility policy, the facility failed to promote resident dignity by ensuring residents were appropriately dressed and groomed prior to going to outside appointments. This affected one (#26) of three residents reviewed for dignity and respect. The census was 46. Findings include: Review of the medical record for Resident #26 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #26 dated 12/05/20 revealed the resident was cognitively intact and required supervision of one staff with dressing, toilet use, and personal hygiene. Review of the care plan for Resident #26 dated 08/31/2019 revealed resident was at risk for deterioration in activities of daily living (ADL's) related to medications and potential side effects of medications. Goal of the plan was for Resident #26 to be clean, dry, appropriately attired, and odor free throughout the review period. Interventions included: do not rush the resident, allow extra time to complete ADL's, provide assistance with ADL's. Observation on 12/17/20 at 10:45 A.M. revealed Transporter #120 and #130 came to Resident #26's room with a stretcher to transport resident to [MEDICAL TREATMENT] and asked resident if she was ready. Resident #26 responded she was not ready. Resident was observed to be wearing pajamas and had no shoes on. Resident had no hair and surveyor observed a wig resting on a wig stand in her room. Transporter #120 asked the Administrator to get a staff person to assist with getting the resident ready to go to [MEDICAL TREATMENT] and Administrator said he would send an aide to the room. Transporters #120 and #130 placed shoes, a hat, and a coat on resident. Observation on 12/17/20 at 10:50 A.M. revealed State tested Nursing Assistant (STNA) #140 arrived at Resident #26's room to offer assistance. STNA #140 assisted in transferring Resident #26 from her bed to the transport stretcher using a draw sheet. Further observation revealed Transporters #120 and #130 took Resident #26 out of the facility on a stretcher for her [MEDICAL TREATMENT] appointment at approximately 11:00 A.M. and resident was wearing her pajamas, shoes, a hat, and a coat. Interview on 12/17/20 at 10:46 A.M. with Resident #26 confirmed she did not feel ready to go to [MEDICAL TREATMENT] because she was not dressed appropriately, but she did not want to miss her appointment so she would go anyway. Interview on 12/17/20 at 10:47 A.M. with Transporter #120 confirmed Resident #26 needed to be at [MEDICAL TREATMENT] by 11:45 A.M. on 12/17/20 and the facility was supposed to have her ready to go (dressed for the weather and appropriately groomed) when they arrived to pick her up for her appointments. Interview on 12/17/20 at 11:05 A.M. with STNA #140 confirmed she was not Resident #26's usual aide and she assisted Transporters #120 and #130 with transferring resident from bed to transport stretcher but confirmed she had not provided any ADL assistance or grooming as she was not familiar with resident's care needs. STNA #140 confirmed STNA #150 was resident's aide and she would be able to provide more information about resident. Interview on 12/17/20 at 11:10 A.M. with STNA #150 confirmed she was Resident #26's aide for the 12/17/20 and she had been working since 7:00 A.M. in the morning. STNA #150 confirmed she had not been in Resident #26's room that morning, had not provided grooming or dressing assistance and was not aware she had a [MEDICAL TREATMENT] appointment. Interview on 12/17/20 at 11:15 A.M. with Licensed Practical Nurse (LPN) #160 confirmed STNA's should assist residents with dressing and grooming prior to resident going out to an appointment and the licensed nurse should provide a report to the assigned STNA of any appointments so they could ensure residents were appropriately dressed and groomed before they left the facility. LPN #160 confirmed she was not Resident #26's nurse for 12/17/20 and resident's assigned nurse was not available for interview. Interview on 12/2/20 at 9:15 A.M. with STNA #170 confirmed she regularly cared for Resident #26 and resident required hands-on assistance with grooming and dressing prior to going out for appointments. STNA #170 further confirmed Resident #26 wore a wig when she went out for appointments and she required assistance with adjusting the wig. STNA #170 confirmed Resident #26 was able to express her needs and she didn't think resident would go out to an appointment without her wig and without being properly dressed unless she was in a hurry to get somewhere. Review of facility policy titled Standards of Nursing Practice dated May 2018 revealed the licensed nurse would communicate needed care to the direct staff responsible and all direct care staff will be provided with training and demonstrate competency of skills necessary in resident care duties prior to acceptance of a resident care assignment. This deficiency substantiates Complaint Number OH 446 and Complaint Number OH 368.