Every finding on record at Arbors at Sylvania

Based on observation, resident and staff interview, and policy review, the facility failed to ensure resident bathrooms and shower rooms were kept in a clean and sanitary manner, and in good repair. This affected 11 residents (#20, #23, #24, #29, #35, #40, #54, #59, #60, #70, and #73) residing on the 400 hall and 39 residents (#1, #2, #3, #6, #7, #13, #14, #17, #18, #21, #25, #26, #27, #31, #32, #33, #34, #36, #37, #38, #39, #42, #43, #44, #47, #48, #49, #50, #52, #53, #55, #56, #58, #62, #63, #64, #66, #69, and #72) on the 100/200 hall. The facility census was 72.Findings include:Observation on 06/29/26 at 9:46 A.M. with Housekeeping Group Manager (HGM) #300 of the shared bathroom for Resident #20 and Resident #73 revealed there was a buildup of debris and grime in the bathroom corners, dust on the air vent above the toilet, stained flooring, and the shower tiles had a buildup of a black/brown substance in the grout lines.Interview on 06/29/26 at 9:46 A.M., with HGM #300 verified the condition of the bathroom. HGM #300 revealed it was on the list to clean the grout in the showers. Observation on 06/29/26 at 9:51 A.M. of Resident #29 and Resident #35's shared bathroom revealed there was a rusted and exposed drywall seam with missing drywall at the entrance to the shower.Interview on 06/29/26 at 9:51 A.M., with HGM #300 verified the exposed drywall seam with missing drywall. HGM #300 revealed staff should have reported about the area. Observation on 06/29/26 at 9:53 A.M. in Resident #54 and Resident #59's shared bathroom revealed there was a buildup of a black-brown substance on the tile grout lines in the shower.Interview on 06/29/26 at 9:53 A.M., with HGM #300 verified the presence of the black/brown substance on the shower tiles. Observation on 06/29/26 at 9:56 A.M. in Resident #70 and Resident #23's shared bathroom revealed a buildup of black-brown discoloration on the edges of the shower floor, a buildup of debris/grime on the floor behind the toilet, and rust discoloration on the bathroom air vent. Interview on 06/29/26 at 9:56 A.M., with HGM #300 verified the findings in Resident #70 and Resident #23's bathroom.Observation on 06/29/26 at 10:00 A.M., of Resident #40 and Resident #24's shared bathroom revealed the shower light was not working, there were stained floors behind the toilet, and a patched area of drywall on the wall with broken pieces and no paint.Interview on 06/29/26 at 10:00 A.M., with HGM #300 verified the shower light was not working, the stained floors and the area of drywall in disrepair. Observation on 06/29/26 at 10:03 A.M. in Resident #60's bathroom revealed a buildup of a black-brown substance on the tile grout lines in the shower and a buildup of debris/grime on the floor behind the toilet.Interview on 06/29/26 at 10:03 A.M., with HGM #300 verified the buildup of the black-brown substance on the tile and grime behind the toilet. Observation on 06/29/26 at 11:34 A.M. with Director of Maintenance (DOM) #226 in the shower room on the 100/200 hall revealed two of the shower stalls had a heavy buildup of a black-brown substance on the tile grout lines and in the corners of the shower walls near the floor. Additionally, there were greater than 90 black circular spots surrounding the ceiling air vent in the shower room/bathroom. Interview on 06/29/26 at 11:34 A.M., with DOM #226 verified the shower room needed cleaned and stated he would report the condition of the shower room to HGM #300. Interview on 06/30/26 at 9:22 A.M., with Resident #73 revealed her family member had assisted her with a shower and the family member lifted her legs so they would not touch the shower floor because she was scared of what looked like black mold on the shower floor. Resident #73 revealed she had not reported the condition of the shower to staff. Observation on 06/30/26 at 10:25 A.M. in the shower room on the 100/200 hall revealed there were still greater than 90 black circular spots surrounding the ceiling air vent in the bathroom. Also, there was still a buildup brown-black debris in the corners of the two shower stalls. Interview on 06/30/26 at 10:25 A.M., with Certified Nurse Aide (CNA) #228 verified the black circular spots on the ceiling in the shower room. CNA #228 revealed the condition of the shower room and resident bathrooms had been reported numerous times to housekeeping. Interview on 06/30/26 at 10:44 A.M., with the Administrator verified all residents residing on the 100/200 hall were using the shower room. Further interview on 06/30/26 at 10:58 A.M., the Administrator verified the presence of the black circular spots on the ceiling in the shower room. Review of the facility policy titled, 7-Step Daily Washroom Cleaning, dated 10/25/16, revealed staff would mop the floor with disinfectant daily. Also, staff were to run the mop along the edges and never push dirt into the corners. Further review of the policy revealed no guidelines for cleaning ceilings. Review of the facility policy titled, Routine Bathroom Cleaning, revised 02/01/22, revealed the facility would establish policies, procedures, and guidelines to provide a clean and sanitary environment for residents, staff, and visitors in order to prevent cross contamination and transmission of healthcare-associated infection. Further review of the policy revealed staff would report areas of mold, cracked, leaking, or damaged items in need of repair. This deficiency represents non-compliance investigated under Master Complaint Number 3047691.

Based on review of the medical record, review of the facility's resident appointment calendar, resident interview, and staff interview, the facility failed to ensure transportation was timely scheduled for an echocardiogram. This affected one (#7) of three residents reviewed for medical appointments and transportation. The facility census was 72. Findings include:Review of the medical record for Resident #7 revealed an admission date of 12/08/23. Diagnoses included type two diabetes mellitus, congestive heart failure, atrial fibrillation, hypertension, chronic kidney disease stage three, and the presence of a cardiac pacemaker. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had mild cognitive impairment. Review of the care plan last revised 12/15/25 revealed Resident #7 had impaired cardiovascular status related to atrial fibrillation, coronary artery disease, heart failure, hypertension, pacemaker placement, obesity, chest pain, and hyperlipidemia. One of the interventions included for staff to ensure the completion of laboratory tests and diagnostic testing as ordered. Review of Resident #7's physician after visit summary dated 03/17/26 revealed physician orders for an echocardiogram without contrast. Review of a physician after visit summary dated 04/29/26 revealed Resident #7 had an appointment for an echocardiogram to be completed on 05/28/26 at 10:45 A.M. Review of a handwritten facility calendar dated 05/28/26 revealed Resident #7 had an appointment scheduled for an echocardiogram at 10:45 A.M. Above the appointment was the handwritten word, Transport, followed by a question mark.Review of Resident #7's medical record revealed no documentation the echocardiogram was completed on 05/28/26.Review of Resident #7's laboratory results progress note dated 06/25/26 revealed the echocardiogram was not completed until 06/25/26. Review of the nursing progress notes dated 03/17/26 through 06/28/26 revealed no documentation regarding Resident #7's appointment and transportation for the echocardiogram. There was no documentation the procedure was not completed on 05/28/26 and there was no documentation about why or when the procedure was rescheduled. Interview on 06/29/26 at 10:05 A.M., with Registered Nurse (RN) #202 revealed Resident #7 had an appointment for a cardiology procedure about a month ago and no transportation had been set up for the appointment. RN #202 revealed the resident's family member was very upset. Interview on 06/29/26 at 2:22 P.M., with Resident #7 stated she missed a cardiology appointment because the facility forgot to get her transportation. Resident #7 was unsure of the date of the appointment. Interview on 06/29/26 at 4:11 P.M., with the Director of Nursing (DON) revealed the floor nurse was responsible to enter an order for a scheduled appointment and also to arrange transportation for the appointment. Interview on 06/30/26 at 8:34 A.M., with Unit Manager Licensed Practical Nurse (UM LPN) #212 revealed she was off work on leave until 06/01/26. UM LPN #212 verified Resident #7 did not go to the appointment for the echocardiogram on 05/28/26. UM LPN #212 verified there was no documentation in the medical record the appointment had been missed or rescheduled. UM LPN #212 verified the nurses should have documented the missed appointment and the rescheduled appointment in the medical record. Interview on 06/30/26 at 8:42 A.M., with RN #214 revealed she scheduled the resident's echocardiogram on 05/28/26 and wrote the appointment down on the calendar. RN #214 revealed the insurance company usually would not allow transportation to be set up too far in advance for an appointment and she had not set up transportation for the appointment. RN #214 confirmed she was the staff member who wrote transportation with a question mark next to the resident's appointment. RN #214 revealed she was, not taking responsibility for not setting up the transport for Resident #7's appointment. RN #214 revealed she was not sure who should have set up the transportation. RN #214 revealed the night shift nurses used to ensure transportation for appointments, but their responsibilities had been whittled down.Interview on 06/30/26 at 9:40 A.M., the Administrator revealed she could not find a policy/procedure for arranging resident appointments and transportation. This deficiency represents non-compliance investigated under Complaint Number 2968736.

Based on medical record review, facility investigation documents, review of an incident and accident log, review of a performance improvement document, staff interview, and review of a facility policy, the facility failed to ensure appropriate medications were ordered upon admission to prevent significant medication errors. This affected one (#100) of three residents reviewed for medications. The facility census was 70.Findings include:Review of the medical record for Resident #100 revealed an admission date of 08/18/25 and a discharge date of 09/03/25. Diagnoses included depression and displace Maisonneuves fracture of the left leg (severe ankle injury that caused a spiral fracture in the tibia bone of the leg).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #100 revealed the resident was cognitively intact.Review of the community referral form (CRF; a document on which admitting physician orders are obtained from for continued medication compliance) dated 08/18/25 for Resident #100 revealed no physician order for the antipsychotic medication, Seroquel 100 milligrams (mg). Further review of the CRF for Resident #100 revealed an order for the antidepressant medication sertraline 100 mg daily.Review of a physician order dated 08/18/25 for Resident #100 revealed Seroquel 100mg was ordered upon admission to the facility. Review of Resident #100's August 2025 medication administration record (MAR) revealed Seroquel 100 mg was administered on 08/19/25 for the morning dose.Review of the incident and accident log for August 2025 revealed a medication error for Resident #100 where a transcription error occurred, and Resident #100 received one dose of Seroquel 100 mg instead of the correct order for sertraline 100 mg.Review of the facility's investigation for a medication error dated 08/19/25 revealed Resident #100 was involved in a medication error where a medication was transcribed incorrectly on admission. Resident #100 was ordered sertraline 100 mg and Seroquel 100mg was ordered in error. Resident #100 was administered Seroquel 100mg in error on 08/19/25.Review of the performance improvement form for Licensed Practical Nurse (LPN) #300 revealed LPN #300 was provided education on transcription of medications and verification with a second nurse.Interview on 12/17/25 at 10:44 A.M. with Registered Nurse (RN) #350 verified the medication error that involved Resident #100 for the administration of Seroquel 100 mg on 08/19/25. RN #350 verified the medication to be administered should have been sertraline 100 mg. RN #350 stated she identified the medication error the day after Resident #100's admission on [DATE] when she reviewed the medications for admission. RN #350 stated by the time she identified the medication error the morning dose of Seroquel 100 mg had already been administered. RN #350 stated the physician was notified and the provider ordered the facility to monitor Resident #100. RN #350 stated ideally the nurses should have a second verification upon admission and that did not happen.Review of the facility policy titled, Medication Administration, revised 01/17/23, revealed medications are administered by licensed nurses or other staff who are legally authorize to do so in the state, as ordered by the physician.This deficiency represents non-compliance investigated under Complaint Number 2612349.

Based on record review, interview, and policy review, the facility failed to ensure interventions were in place for significant weight loss. This affected one (Resident #274) of four reviewed for significant weight loss. The facility census was 77. Findings include: Review of the medical record revealed Resident #274 was admitted on [DATE]. Diagnoses include myasthenia gravis, benign prostatic hyperplasia, dementia, gastroparesis, anxiety disorder, depression, paraplegia (paraparesis), and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had mild cognitive impairment and required partial to moderate assistance for toileting and showering. Further, the resident required setup assistance for eating and personal hygiene. Review of Resident #274's weight record revealed a significant weight loss noted between the dates of 01/30/25 (admission) and 06/10/25. On 01/30/25 Resident #274 weighed 165 lbs. On 05/03/25 (prior to hospitalizations) Resident #274 weighed 147.3 lbs (-10.91% since admission) and on 06/10/25 the resident weighed 133 lbs (-19.39% since admission). Review of Resident #274's medical record revealed no interventions were in place to address the resident's weight loss. Additionally, no progress notes or assessments by the dietician or nursing staff were noted in the medical records. Interview with Unit Manager (UM) #368 on 06/10/25 at 10:57 A.M. revealed Certified Nursing Aides (CNAs) are responsible for obtaining residents weights and if any changes were noted, then the resident would be weighed more often. If there are any significant weight loss noted the dietician would be contacted for interventions. Interview with the Director of Nursing (DON) on 06/10/25 at 11:05 A.M. revealed the dietician is responsible for monitoring residents weight. The DON was not aware of Resident #274's significant weight loss. Interview with Dietician #410 on 06/10/25 at 11:31 A.M. revealed that she is in facility every Wednesday and reviews all residents weights and they are also reviewed in meetings. If weight loss is noted, then a supplemental nutrition drink is offered and medications that may cause weight loss are reviewed. Additionally, if any significant weight loss is noted, the DON is notified. Dietician #410 also stated that she didn't know why interventions were not put in place for Resident #274. Interview with Resident #274 on 06/10/25 at 11:54 A.M. revealed he doesn't get enough food to eat and he doesn't like the food the facility serves. Resident #274 also indicated that he was concerned with his weight loss but doesn't know if he expressed that to the facility. Interview with Physician #400 on 06/10/25 at 2:15 A.M. revealed he was aware of the weight loss and the dietician should have been aware. Furthermore, Physician #400 revealed the dietician will give nutrition recommendations and the physician will sign off on them. Interview with Licensed Practical Nurse (LPN) #350 on 06/10/25 at 4:22 A.M. revealed that on 05/16/25 LPN #350 had filled out a therapy referral slip indicating weight loss for Resident #274. LPN #350 indicated that she noticed Resident #274's weight loss and that he hadn't been eating much. The therapy referral slip was given to the therapy department but LPN #350 doesn't know if the dietician ever got the referral slip. Interview with Lead Dietician #418 on 06/11/25 at 1:16 P.M. verified significant weight loss for Resident #274 and from what she knows, the facility was encouraging food intake and the resident would order from Uber Eats. Additionally, Lead Dietician #418 did not know why interventions for Resident #274 were not in place. Review of a policy titled, Weight Monitoring Policy, dated 10/30/20 revealed that based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident's preference indicate otherwise. This deficiency represents non-compliance under Complaint Number OH00165990.

Based on interview, medical record review, and policy review, the facility failed to obtain and administer ordered medication for Resident #274 in a timely manner. This affected one (#274) of four residents reviewed for medication administration. The facility census was 77. Findings include: Review of the medical record revealed Resident #274 was admitted on [DATE]. Diagnoses include myasthenia gravis, benign prostatic hyperplasia, Dementia, gastroparesis, anxiety disorder, depression, paraplegia (paraparesis), and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had mild cognitive impairment and required partial to moderate assistance for toileting and showering. Further, the Resident required setup assistance for eating and personal hygiene. Further review of the medical record for Resident #274 revealed upon admission, the resident had a medication order for Pyridostigmine Bromide 30 milligrams (mg) three times a day. Pyridostigmine is a medication ordered to treat a condition called mysthenia gravis which affects muscle control. The medication omission was not discovered until a hospital admission on [DATE]. Upon Resident #274's discharge on [DATE] the medication was ordered again to be dispensed to resident at the facility. Review of the Medication Administration Record (MAR) dated May 2025 and June 2025 revealed the medication Pyridostigmine Bromide was not given due to unavailability between 05/30/25 and 06/02/25 for a total of nine missed doses. Review of document titled Pharmacy Packing Slip dated 06/02/25 revealed the medication was delivered, but next to the medication on the packing slip, a hand written note indicated the medication was returned due to the resident being admitted to the hospital. Additionally, a pharmacy packaging slip dated 06/06/25 indicated the medication was delivered. Interview with Physician #400 on 06/10/25 at 2:15 P.M. revealed the physician was not aware of the of the order for the medication until Resident #274 came back from the hospital on [DATE]. Physician #400 further stated that without the medication Resident #274 could have muscle decline and fatigue and it is possible that could be part of the reason for the resident's decline. Interview with the Director of Nursing (DON) on 06/10/25 at 2:43 P.M. revealed when a hospital discharges a resident back to the facility, any medications orders would be put in by the nurses. Unit managers are responsible for doing the chart audits on all residents and part of the audit is medication orders. Further, the DON was not aware of the medication error and believes the order was just missed. The DON also indicated that the facility gets two shipments a day from pharmacy so no drop shipment for this medication would have been necessary. Review of policy titled, Medication Administration, dated 10/30/20 revealed that medications are to be administered as ordered by the physician. Additionally, any discrepancies should be corrected and reported to the nurse manager. This deficiency represents non-compliance investigated under Complaint Number OH00165123.

Based observation, staff interview and review of facility policy, the facility failed to ensure adequate infections control practices were carried out. This had the potential to affect the 38 residents (#55, #37, #4, #33, #50, #5, #29, #47, #17, #11, #35, #28, #26, #9, #44, #42, #41, #18, #51, #43, #67, #7, #15, #25, #30, #6, #277, #52, #24, #12, #22, #8, #36, #54, #13, #27, #1, and #49) who resided on the 100 and 200 hallways. The facility census was 73. Findings include: 1. Observation on 04/14/25 at 9:18 A.M. of the 200 hallway found four rooms identified as being on droplet isolation. Personal Protective Equipment (PPE) including gowns, gloves, respirators (N-95s), and a face shields were available for each room on the over the door organizer. Signs with directions for donning personal protective equipment (PPE) were posted on the doors. Observation on 04/14/25 at 9:21 A.M. found Certified Nursing Assistant (CNA) #562 donned a gown, N-95, gloves and face shield and entered room [ROOM NUMBER]. Observation on 04/14/25 at 9:24 A.M. found CNA #562 had removed gown, gloves inside the room and placed the face shield back in the over the door organizer. CNA #562 did not disinfect the face shield after use. Interview on 04/14/25 at 9:25 A.M. with CNA #562 verified the face shields were reused and he had placed the used face shield back in the over door organizer after exiting the room. Observation on 04/14/25 at 9:26 A.M. of CNA #562 found CNA #562 donned a gown, gloves, a N-95, and the face shield from the over the door organizer from room [ROOM NUMBER]. CNA #562 did not disinfect the face shield prior to applying the face shield and entering room [ROOM NUMBER]. Observation on 04/14/25 at 9:29 A.M. of CNA #562 found CNA #562 exited room [ROOM NUMBER] having doffed gown and gloves. CNA #562 removed his face shield and placed it back into the over the door organizer without disinfecting the face shield. Coinciding interview with CNA #562 verified there were bleach wipes available at the nurses station for disinfecting surfaces and had not been used on the face shields. Review of the undated posted signage with the steps for removing personal protective equipment (PPE) revealed in step two of the process it stated the outside of the goggles or face shield were contaminated. If the item was reusable, it was to be placed in designated receptacle for reprocessing, or otherwise discard in the waste container. Review of the facility policy titled, Infection Prevention and Control Program, revised 10/24/22 revealed all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with out current procedure governing the cleaning and sterilization of soiled or contaminated equipment. Single use devices must be discarded after use and are never used for more than one resident. 51513 2. Observation on 04/15/25 at 7:48 A.M. revealed Certified Nurse Assistant (CNA) #562 delivered a breakfast tray into room [ROOM NUMBER] without performing hand hygiene. CNA #562 then exited room without performing hand hygiene and proceeded to room [ROOM NUMBER] which was a Covid isolation room. CNA #562 then proceeded to don all required PPE including gown, N-95, face shield, and gloves and entered the Covid isolation room without performing hand hygiene. CNA #562 then delivered a morning breakfast tray into room. Upon exiting the room and removing PPE CNA #562 did not perform hand hygiene and walked down the hall towards nursing station. Interview on 04/15/25 at 7:55 A.M. with CNA #562 confirmed no hand hygiene was performed before or after entering neither room [ROOM NUMBER] or 207. Review of the undated posted signage with the steps for removing PPE revealed that step four is to wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. Review of policy titled, Hand Hygiene with a revised date of 12/13/2023 revealed that all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.

Based on observation, medical record review, resident interview and staff interview the facility failed to ensure a comfortable mattress was provided following a request. This affected one (#53) of 24 residents reviewed for reasonable accommodation of needs and requests. The facility census was 73. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including cervical disc disorder with myelopathy, chronic venous hypertension with ulcer of bilateral lower extremity, chronic obstructive pulmonary disorder, type 2 diabetes mellitus, spinal stenosis, benign prostatic hyperplasia, neuromuscular dysfunction of bladder, mood disorder, chronic kidney disease stage 4, hypertension, coronary artery disease, congestive heart failure, and muscle weakness. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #53 had intact cognition, had range of motion impairment to upper and lower bilateral extremities, was dependent on staff for the completion of activities of daily living including bed mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. On 02/14/25 a skin risk assessment completed for Resident #53 revealed score of 14, indicating moderate risk for developing skin breakdown. According to a physician order dated 12/27/24 a low air loss mattress was to be placed in use, instructions included to monitor function and settings every shift. Observation on 04/14/25 at 9:09 A.M. noted Resident #53 in bed with the air mattress in place. Resident #53 stated the air mattress was partially inflated and his buttock was resting against the bed frame. The resident stated he requested a new mattress in December and one had not been provided. On 04/15/25 at 9:18 A.M. observation with Licensed Practical Nurse (LPN) #527 assessed Resident #53 while in the bed with the air mattress in place. LPN #527 verified Resident #53 buttock in contact with the bed frame. Additional observation noted Resident #53 had no current skin breakdown, however, scaring was identified from previously healed skin breakdown. On 04/16/25 at 7:40 A.M. interview with LPN #532 revealed nursing staff are to check Resident #53's air mattress setting each shift. LPN #532 was aware Resident #53 had reported concerns with the comfort of the mattress. LPN #532 stated the air mattress settings were determined appropriate and no attempts to obtained a replacement air mattress had occurred. This deficiency represents non-compliance investigated under Complaint Number OH00163310.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions to address edema were initiated. This affected one (#01) of two residents reviewed for edema prevention and monitoring. The facility census was 73. Findings include: Review of the medical record revealed Resident #01 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, anxiety disorder, contracture to bilateral hands, elbows and shoulders, localized edema, and chronic pain. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #01 had severely impaired cognition, no refusals of care, bilateral upper and lower extremity range of motion impairment, was dependent on staff for all activities of daily living, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. Observation on 04/14/25 at 8:55 A.M. noted Resident #01 seated in a specialized wheelchair with bilateral arms resting dependent at her sides. Resident #01's left hand was observed with edema and a closed fist. Observations on 04/15/25 at 5:46 A.M., 11:43 A.M., 12:42 P.M., 04/16/25 at 5:37 A.M., 11:43 A.M., and 12:42 P.M. noted Resident #01 in bed with bilateral arms resting dependently at each side and hands with closed fists. On 04/17/25 at 8:35 A.M. observation with Licensed Practical Nurse (LPN) #523 assessed Resident #01 with one plus pitting edema to the left hand and middle forearm. LPN #523 verified no interventions were contained in the medical record to address Resident #01 history of edema. On 04/17/25 at 8:40 A.M. interview with LPN #529 during review of Resident #01's medical record verified Resident #01 with dependent edema to left hand and forearm. LPN #529 verified Resident #01 did not have interventions in place to address the edema.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to prevent deterioration of contractures. This affected one (#01) of two residents reviewed for range of motion and positioning. The facility census was 73. Findings include: Review of the medical record revealed Resident #01 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, anxiety disorder, contracture to bilateral hands, elbows and shoulders, localized edema, and chronic pain. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #01 had severely impaired cognition, no refusals of care, bilateral upper and lower extremity range of motion impairment, was dependent on staff for all activities of daily living, was incontinent of bowel and bladder, and at risk for pressure ulcer development with no skin breakdown. On 08/27/21 a physician order was written to place a washcloth in each of Resident #01's hands to keep fingers from clenching into palms of hands every shift due to bilateral hand contractors. On 08/09/23 a nursing plan of care was implemented to address Resident #01's impaired musculoskeletal status related to contractures with interventions to include for Resident #01 to be free of complications related to altered musculoskeletal status through the next review, administer treatments as ordered, observe for and report to nurse any pain or skin integrity issues related to use of the washcloth in hands, cleanse hands and dry completely prior to application of washcloths in hands, and to provide range of motion (ROM) as indicated prior to use of washcloth in hands to keep fingers from clenching into palms of hands. In addition, on 02/25/24 a nursing plan of care was implemented to address Resident #01's inability to participate in a restorative programs related to the distress it caused her. Resident #01 does not tolerate passive range of motion (PROM) to her bilateral hands as they are severely contracted and when doing PROM Resident #01 has facial grimacing and and starts to cry and scream, and pulling hands away. Interventions included to clean bilateral hands with A.M. and P.M. care, as tolerated. If distress is noted (crying or facial expressions) stop and reapproach as needed. Monitor for signs and symptoms of skin breakdown to bilateral hands. Observation on 04/14/25 at 8:55 A.M. noted Resident #01 seated in a specialized wheelchair with bilateral arms resting dependently at her sides. No washcloths were in place to either hand and both hands fists were closed. Observations on 04/15/25 at 5:46 A.M., 11:43 A.M., 12:42 P.M., 04/16/25 at 5:37 A.M. revealed no washcloths were in place and Resident #01's hands were closed fisted. On 04/16/25 at 10:16 A.M. interview with Certified Nurse Aide (CNA) #569 revealed she assumed care at 6:00 A.M. for Resident #01 and verified no washcloths had been in place to either hand since the beginning of the shift. On 04/16/25 at 11:45 A.M. interview with Licensed Practical Nurse (LPN) #508 verified washcloth rolls had not been in place as ordered by the physician for Resident #01.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure fall interventions were implemented as indicated. This affected one (#24) of three residents reviewed for fall management. The facility census was 73. Findings include: Resident #24's medical record review revealed the resident admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, cerebral infarction, [NAME] lymphoma, hypertension, seizure disorder, abnormal posture, chronic kidney disease stage 3, coronary artery disease, anemia, traumatic subdural hemorrhage without loss of consciousness, and cardiac arrhythmia. According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #24 was assessed with severe cognitive impairment, no recorded refusal of care, utilized a wheelchair for mobility, required substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder. Review of the fall assessment dated [DATE] at 8:06 P.M. noted Resident #24 was found on the floor on the side of the bed. On 03/02/25 at 10:33 P.M. a follow-up fall assessment was completed and indicated new interventions to prevent further injury from falls was implemented. According to progress note dated 03/02/25 at 3:07 A.M., Resident #24 fell out of bed trying to ambulate to the restroom on 03/01/25 and was found sitting on the floor on the side of bed. Resident #24 had no complaints of pain and was assisted with transfer back into bed. Nursing interventions in place included keeping bed in low position, and the call light within reach for assistance. On 03/03/25 at 10:55 A.M. the Interdisciplinary Team progress note documented Resident #24 was found sitting on the floor next to her bed after attempting to ambulate to the bathroom. No injuries were noted and both the physician and family were notified. A new intervention to apply hipsters was implemented. On 03/26/25 a nursing plan of care was revised to address Resident #24's risk for falls/injury related to decreased strength and endurance, generalized weakness, poor balance, and seizures. Interventions included hipsters as tolerated, toileting and repositioning every two hours, taking the resident to the common area when increased anxiety was identified, and encourage the resident to use the call light. Observation on 04/17/25 at 6:37 A.M. noted Resident #24 seated in a wheelchair with her eyes closed. No hipsters were in place. Interview with Licensed Practical Nurse (LPN) #529 at the time of observation verified Resident #24 did not have hipsters applied as indicated. According to facility Accidents and Supervision policy revised 12/27/2023. Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. This included implementing interventions to reduce hazards or risk. Using specific interventions to try to reduce a residents risk from hazards in the environment. Interventions are based on the results of the evaluation and analysis of information about the hazards or risks and are consistent with relevant standards, including evidence-based practice. Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks.

Based on observation, medical record review, resident interview, staff interview, and facility policy the facility failed to ensure timely care and treatment was provided to address incontinence. This affected two (#40 and #63) of five residents reviewed for bowel and bladder incontinence services. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #40 admitted to the facility on [DATE] with the diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, depressed mood, stage 2 pressure ulcer to sacral region and left buttock. dysphagia, and anemia. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #40 was assessed with moderately impaired cognition, range of motion impairments to the bilateral upper and lower extremities, dependency on staff for the completion of activities of daily living including bed mobility and incontience care as Resident #40 was always incontinent of bowel and bladder. Resident #40 was at risk for pressure ulcer development and admitted with two stage two pressure ulcers. On 03/24/25 the nursing plan of care was revised to address Resident #40's episodes of bladder and bowel incontinence. Interventions included to assist Resident #40 with toileting needs, check at regular intervals and change as needed, provide disposable incontinence products, provide peri-care after each incontinence episode and apply house barrier cream after incontinence care. No specific interval of incontinence monitoring was contained in the medical record. Review of the task documentation between 03/19/25 and 04/15/25 recorded Resident #40 to be incontinent daily. However, no frequency of check and change was identified. Observation on 04/15/25 at 5:52 A.M. noted Resident #40 in bed positioned to the right. Continued observation between 5:52 A.M. and 9:14 A.M. noted Resident #40 remained in bed on the right side without repositioning or incontinence checks. On 04/15/25 at 6:04 A.M. interview with Certified Nurse Aide (CNA) #537 revealed she assumed the care for Resident #40 on 04/14/25 at 10:00 P.M. and continued care until 04/15/25 at 6:00 A.M. CNA #537 stated Resident #40 required every two-hour incontinence checks and repositioning and was last provided incontinence care and repositioning at 4:30 A.M. Interview on 04/15/25 at 9:14 A.M. with CNA #554 verified she assumed the care for Resident #40 at 6:00 A.M. and had not checked Resident #40 for incontinence or provided repositioning since assuming care at 6:00 A.M. CNA #554 stated she was unaware when Resident #40 was last checked for incontinence or repositioning. Observation on 04/15/25 at 9:31 A.M. with CNA #554 noted Resident #40 was heavily soiled with urine through an adult brief onto linen covering (chux). Two wound dressings were observed to Resident #40 left upper thigh and left sacrum. 2. Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE] with diagnoses including, dorsopathy, chronic obstructive pulmonary disease, obstructive sleep apnea, abnormal posture, anxiety disorder, depression, hypertension, and fibromyalgia. According to the most current MDS assessment dated [DATE], Resident #63 was cognitively intact, had the ability to make needs known, and had no history of refusing care. Resident #63 had limited range of motion to bilateral lower extremities, required substantial to maximal assistance with activities of daily living, was dependent on staff for bed mobility, was always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. On 12/04/24 a nursing plan of care was revised to address Resident #63 risk for episodes of bowel and bladder incontinence. Interventions included to assist the resident with toileting needs, provide disposable incontinence products, provide peri-care after each incontinence episode and apply in-house barrier cream after each incontinence care. Review of skin assessment dated [DATE] identified a new abnormal skin area with redness and excoriation to the groin. Observation on 04/14/25 at 9:56 A.M. noted Resident #63 in bed. Resident #63 stated she requires every two hour incontinence checks and repositioning and the staff is not providing the care. As a result of not receiving care, Resident #63 stated she developed excoriation and a rash. On 04/15/25 at 5:57 A.M. Resident #63 was observed positioned on her back with eyes closed. Continued observation on 04/15/25 between 5:57 A.M. and 8:04 A.M. noted Resident #63 in bed positioned on her back with no repositioning or incontinence checks or care attempted. On 04/15/25 at 6:07 A.M. an interview with Certified Nurse Aide (CNA) 537 revealed she had provided Resident #63 with incontinence care and repositioning at 4:25 A.M. CNA #537 stated Resident #63 is unaware when she is incontinent and needed to be checked and repositioned every two hours. On 04/15/25 at 8:04 A.M. an interview with Resident #63 revealed she had been incontinent of urine and no checks or repositioning had occurred since night shift. On 04/15/25 at 8:41 A.M. an interview with CNA #554 revealed she was looking for incontinent wipes due to Resident #63 being excoriated. CNA #554 stated she did not want to use rough washcloths. At 09:02 A.M. CNA #554 proceeded to check Resident #63 for incontinence. Resident #63 was observed with excoriated perineum including the pan and groin. Resident #63 was incontinent of a large amount of urine and small formed bowel movement. CNA #554 right upper thigh was also excoriated. Two adult incontinence briefs were discovered under the resident and both were soiled. On 04/15/25 at 9:14 A.M. following resident care, interview with CNA #554 verified the check and change at 9:02 A.M. was the first contact CNA #554 had with Resident #63 since assuming care at 6:00 A.M. CNA #554 was unaware when Resident #63 was last checked, changed or repositioned. CNA #554 verified the resident is to be checked and changed every two hours with repositioning. According to the facility policy titled Incontinence, revised 10/26/2023, stated based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00163310.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen was running at the prescribed rate. This affected one resident (#29) reviewed for oxygen therapy. The facility identified 15 residents required the use of oxygen therapy. The facility census was 73. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] with admitting diagnoses of heart failure and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 revealed he was cognitively intact and required the use of oxygen. Review of the care plan revised 02/25 for Resident #29 revealed he was care planned for impaired cardiovascular stated related to heart failure with an intervention for oxygen therapy as ordered. Review of the current physician orders for 04/25 revealed Resident #29 was ordered oxygen at two liters per minute continuously via nasal cannula. Observation on 04/14/25 at 11:51 A.M. of Resident #29 revealed he was sitting in his wheelchair with a portable oxygen tank running at three liters per minute. Interview on 04/14/25 at 11:54 A.M. with Licensed Practical Nurse (LPN) #526 verified oxygen for Resident #29 was running on the portable oxygen tank at three liters per minute and verified the order from the physician was for the oxygen to be running at two liters per minute. Review of the facility policy titled Oxygen Administration, revised 10/23 revealed oxygen is administered under orders of physician.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure alternative and non-pharmacologic interventions were implemented to address pain in accordance with physician orders. This affected one (#177) of two residents reviewed for pain control interventions. The facility census was 73. Findings include: Review of the medical record revealed Resident #177 admitted to the facility on [DATE] with diagnoses including cauda equina syndrome, spinal stenosis lumbar region, abnormal posture, chronic venous hypertension, chronic pain, chronic fatigue, allergy status to unspecified drugs, medications and biological substances, and lumbago with sciatica. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #177 was cognitively intact, was able to make needs known, had limited bilateral lower extremity range of motion, required substantial to maximal assistance with activities of daily living, received scheduled and as needed (PRN) pain medications and had non-medication interventions in place for pain. Review of hospital community referral physician orders dated 04/01/25 noted non-pharmacological wound care instructions to include the application of an ice pack to the surgical incision to help with pain. The ice pack was to be applied 15 to 20 minutes at a time, five to six times daily. On 04/02/25 a nursing plan of care was implemented to address Resident #177 pain related to back surgery, surgical incision, and verbal complaints of pain. Interventions included the following: administer medications as ordered and observe for effectiveness. Offer non-pharmacological interventions to relieve pain and observe for effectiveness. Further review of the plan of care lacked documentation describing specific non-pharmacological interventions. Review of physician orders lacked documentation indicating the ice packs and lacked where and when the ice packs were to be applied. Review of the administration records for Resident #177 lacked documentation regarding the ice packs. Observation on 04/14/25 at 10:00 A.M. noted Resident #177 seated in a wheelchair at the bedside. Interview with Resident #177 stated she was experiencing a pain level of 8 (level zero, no pain and level 10 indicating severe pain) in back, hips, legs. Resident #177 described the pain as a burning sensation. Resident #177 stated she had multiple medication allergies and would like non-pharmacological interventions between scheduled pain medication administrations. The resident stated she had not had any non-pharmacological interventions provided the past two nights. Additional interview on 04/15/25 at 5:54 A.M. with Resident #177 stated she spoke with her surgeon and indicated she was to receive ice applications five to seven times daily for 20 minutes and increased the dose of gabapentin. Resident #177 reported a pain level of 5 at the time of the interview. Resident #177 verified no alternative methods of pain relief were being provided, adding only pain medications have been provided. On 04/15/25 at 2:34 PM Resident #177 was observed in bed requesting an ice pack. Observation on 04/16/25 at 12:50 P.M. of Resident #177 revealed the resident was in bed and reported a pain level of 5 to low back, bilateral hips and lower extremities. Interview with Resident #177 at the time of the observation revealed the resident had not been receiving ice packs between scheduled pain medication to control pain as requested. Continued observation noted disposable ice pack warm to touch at Resident #177 bedside. On 04/16/25 at 12:55 P.M. interview with Certified Nurse Aide (CNA) #551 verified Resident #177 was given an ice pack at 7:00 A.M. CNA #551 confirmed Resident #177 was required to request an ice pack. On 04/16/25 at 1:00 P.M. interview with the Director of Nursing (DON) during review of the medical record for Resident #177 verified the record lacked evidence of ice packs being provided as ordered. In addition, the DON verified no non-pharmacologic intervention related to the application of an ice pack was listed on pain care plan. According to the Pain Management policy revised 10/26/2023. The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00164044.

Based on observation, staff interview, and review of the facility policy, the facility failed to keep the privacy curtain clean in the residents room. This affected one resident (#5) of 24 reviewed for environment. The facility census was 73. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] and an admission diagnosis of dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed he was cognitively impaired and was dependent for all care. Review of the care plan revised 02/25 for Resident #5 revealed he was care planned for behaviors related to dementia of taking his brief off in bed. Observation on 04/15/25 at 1:28 P.M. revealed Resident #5's privacy curtain had several brown stains that were unidentifiable along the bottom of the privacy curtain approximately one third up the privacy curtain and approximately two feet in length. Interview on 04/15/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #569 verified the unidentified brown stains on the privacy curtain of Resident #5. Review of the facility policy titled, Routine Cleaning and Disinfection, revised 02/22 revealed privacy curtains in resident rooms will be changed with visibly dirty by laundering or cleaning with registered disinfectant per managers instructions.

Based on medical record review, staff interview, facility documentation review, and facility policy review, the facility failed to ensure an allegation of medication diversion was reported to the Administrator in a timely manner. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a facility document dated 02/19/24 revealed Licensed Practical Nurse (LPN) #324 took a chewable baby aspirin from the over the counter bottle located in the top drawer of medication cart. LPN #324 forgot to take morning aspirin before work. LPN #324 was talked to by the Director of Nursing (DON) as soon as the incident was reported and was instructed to not take over the counter medication off the medication cart again. Further review revealed LPN #324 was very sorry about this mistake and promised to never repeat the mistake again. LPN #324 did not think about how the act could be perceived, and LPN #324 was embarrassed and very sorry. The documented was signed by LPN #324. A telephone interview with LPN #324 on 03/07/24 at 10:37 A.M. stated on 02/19/24 at approximately 9:00 A.M., while preparing medications for Resident #71, she placed a chewable 81 milligram (mg) aspirin tablet in a medication cup and a second chewable aspirin tablet in a second medication cup. LPN #324 verified she proceeded to consume the 81 mg chewable aspirin at the medication cart. When taking the aspirin, Student Nurse (SN) #442 was exiting a resident room behind her and observed LPN #324 take the medication. As a result, later that morning, LPN #324 was counseled by the DON not to take over the counter medications from the medication cart for personal use. No further investigation was conducted and LPN #324 continued to work the remaining shift. Interview with the DON on 03/07/24 at 12:15 P.M. revealed on 02/19/24 an allegation of LPN #324 taking medication from the medication cart was reported to her by Clinical Nurse Instructor Registered Nurse (CNIRN) #438. The DON interviewed LPN #324 on 02/19/24 and was informed by LPN #324 she took a chewable baby aspirin from the over the counter bottle in the top drawer of the medication cart. The DON instructed LPN #324 to not take over the counter medication off the medication cart again. The DON stated no further information was obtained regarding the incident, including an investigation. The DON verified the incident was not reported to the Administrator. Interview with the Administrator on 03/07/24 at 12:17 P.M. revealed no knowledge of the incident on 02/19/24 between Resident #71 and LPN #324. A telephone interview with CNIRN #438 on 03/07/24 at 1:09 P.M. revealed on 02/19/24 at approximately 9:30 A.M., SN #442 reported observing LPN #324 place a pill in a medication cup for a resident and another pill into a second cup. LPN #324 was observed to consume the second cup of medication while standing at the cart. CNIRN #438 reported the incident to the DON and was informed the DON would look into the incident. CNIRN #438 stated no statements were obtained from CNIRN #438 or SN #442. CNIRN #438 also indicated SN #442 did not report the container from which the medication was taken from. No further interactions with the facility occurred regarding the incident. Review of the abuse, neglect, and exploitation policy, revised 01/10/2024, revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be use in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, providing complete and thorough documentation of the investigation, and reporting of alleged violations to the administrator within specified timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00151001.

Based on medical record review, staff interview, facility documentation, and facility policy, the facility failed to ensure an allegation of medication diversion was thoroughly investigated. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a facility document dated 02/19/24 revealed Licensed Practical Nurse (LPN) #324 took a chewable baby aspirin from the over the counter bottle located in the top drawer of medication cart. LPN #324 forgot to take morning aspirin before work. LPN #324 was talked to by the Director of Nursing (DON) as soon as the incident was reported and was instructed to not take over the counter medication off the medication cart again. Further review revealed LPN #324 was very sorry about this mistake and promised to never repeat the mistake again. LPN #324 did not think about how the act could be perceived, and LPN #324 was embarrassed and very sorry. The documented was signed by LPN #324. A telephone interview with LPN #324 on 03/07/24 at 10:37 A.M. stated on 02/19/24 at approximately 9:00 A.M., while preparing medications for Resident #71, she placed a chewable 81 milligram (mg) aspirin tablet in a medication cup and a second chewable aspirin tablet in a second medication cup. LPN #324 verified she proceeded to consume the 81 mg chewable aspirin at the medication cart. When taking the aspirin, Student Nurse (SN) #442 was exiting a resident room behind her and observed LPN #324 take the medication. As a result, later that morning, LPN #324 was counseled by the DON not to take over the counter medications from the medication cart for personal use. No further investigation was conducted and LPN #324 continued to work the remaining shift. Interview with the DON on 03/07/24 at 12:15 P.M. revealed on 02/19/24 an allegation of LPN #324 taking medication from the medication cart was reported to her by Clinical Nurse Instructor Registered Nurse (CNIRN) #438. The DON interviewed LPN #324 on 02/19/24 and was informed by LPN #324 she took a chewable baby aspirin from the over the counter bottle in the top drawer of the medication cart. The DON instructed LPN #324 to not take over the counter medication off the medication cart again. The DON stated no further information was obtained regarding the incident, including an investigation. Interview with the Administrator on 03/07/24 at 12:17 P.M. revealed no knowledge of the incident on 02/19/24 between Resident #71 and LPN #324. A telephone interview with CNIRN #438 on 03/07/24 at 1:09 P.M. revealed on 02/19/24 at approximately 9:30 A.M., SN #442 reported observing LPN #324 place a pill in a medication cup for a resident and another pill into a second cup. LPN #324 was observed to consume the second cup of medication while standing at the cart. CNIRN #438 reported the incident to the DON and was informed the DON would look into the incident. CNIRN #438 stated no statements were obtained from CNIRN #438 or SN #442. CNIRN #438 also indicated SN #442 did not report the container from which the medication was taken from. No further interactions with the facility occurred regarding the incident. Review of the abuse, neglect, and exploitation policy, revised 01/10/2024, revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be use in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, providing complete and thorough documentation of the investigation, and reporting of alleged violations to the administrator within specified timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00151001.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure wound treatments were completed per physician order. This affected one (#24) of three residents reviewed for wounds. The facility census was 66. Findings Include: Review of the medical record revealed Resident #24 admitted to the facility on [DATE]. Diagnoses included hypertension, dementia, anemia, depression, dysphagia, and muscle weakness. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/16/24, revealed Resident #24 was cognitively intact. The resident required assistance from staff for activities of daily living. Review of an interdisciplinary team progress note dated 01/05/24 revealed the wound to the bridge of Resident #24's nose was an area that began as a small open area that the resident continually picked at. Review of Resident #24's physician orders revealed an order dated 08/28/23 through 03/05/24 to cleanse the bridge of the nose with saline, pat dry, and apply the antibiotic Troleandomycin (TAO) topically every day and evening shift. Review of Resident #24's treatment administration record (TAR) for December 2023 through February 2024 revealed the resident did not receive treatment to the bridge of the nose on the evening shift as indicated on 12/02/23, 12/03/23, 12/16/23, 12/17/23, 12/21/23, 12/26/23, 12/30/23, 01/01/24, 01/08/24, 01/09/24, 01/13/24, 01/14/24, 01/18/24, 01/19/24, 01/23/24, 01/27/24, 02/06/24, 02/10/24, 02/13/24, 02/15/24, 02/25/24, or 02/29/24. Interview on 03/07/24 between 11:00 A.M. and 12:30 P.M. with the Director of Nursing (DON) verified Resident #24's treatments were not completed to the bridge of the nose as ordered. The DON confirmed there was no other evidence the treatments were completed. The DON also verified any treatment refusals would have been documented on the TARs. Review of the facility policy titled, Wound Treatment Management, revised 10/26/23, revealed wound treatments would be provided in accordance with physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00151001.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper bed mobility assistance to a dependent resident resulting in a avoidable fall. This affected one (#19) of three resident falls reviewed. Facility census was 66. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include multiple sclerosis, type II diabetes, pseudobulbar affect, major depressive disorder, mild cognitive impairment, osteoarthritis, dementia, hypertension, attention and concentration deficit, difficulty walking, and anxiety disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 11/01/23, revealed she had a severe cognitive impairment. Resident #19 required partial/moderate assistance with rolling from left to right. Review of Resident #19 fall incident report and progress notes, dated 11/23/23, revealed State tested Nursing Aide (STNA) #101 was assisting Resident #19 with moving in bed by herself. STNA #101 informed the nurse that she was rolling Resident #19 in bed and her arm went over the side of the bed and she then rolled off the bed. Resident #19 fell and hit her head against the wall, before falling to the floor. She was sent to the hospital for evaluation; the only injury was a bump above her left eye. Review of Resident #19 care plan, dated 07/31/23 to 12/22/23, revealed she was to have one person assistance for bed mobility. Interview with Administrator on 12/22/23 at 12:45 P.M. confirmed STNA #101 was assisting Resident #19 in her bed when Resident #19 fell from her bed. The Administrator confirmed when they did an investigation related to this fall, STNA #101 admitted she had been drinking until very late the night before, and then came to work still hungover. She stated she was not drunk, but was not herself either. Review of facility Fall Prevention Program, dated 01/01/22, revealed each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall was defined as an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The facility utilizes a standardized risk assessment for determining a resident's fall risk. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. Each resident's risk factors and environmental hazards will be evaluated when developed the resident;s comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed. When any resident experiences a fall, the facility will assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Master Complaint Number OH00148996 and Complaint Number OH00148867.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility corrective action documentation, and policy review, the facility failed to ensure a resident with an indwelling urinary catheter had orders for the placement and received associated care with maintenance of the drainage system. This affected one (#1) of three residents reviewed for indwelling urinary catheters. The census was 70. Finding include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, metabolic encephalopathy, acute lymphadenitis, autoimmune encephalitis, muscle weakness, depression, hypertension, dysphagia, anxiety disorder, and Alzheimer's disease. Review of a nursing admission assessment dated [DATE] revealed Resident #1 was dependent with toileting and elimination with assistance. There was no documentation an indwelling urinary catheter was in place. Review of a nursing admission evaluation completed on 06/08/23 revealed Resident #1 was documented with a Foley catheter (indwelling urinary catheter) in place. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and was always incontinent of bowel and bladder. There was no documentation an indwelling urinary catheter was in place. Review of a urinary continence evaluation dated 06/14/23 revealed Resident #1 was incontinent of bladder since admission. Further review revealed there was no indwelling urinary catheter in place. Review of the MDS assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and utilized an indwelling urinary catheter. Further review of Resident #1's medical record lacked a physician order, a supporting diagnosis, or documentation of urinary catheter care and maintenance for the placement of an indwelling urinary catheter. On 08/25/23 at 9:06 A.M., interview with Licensed Practical Nurse (LPN) #200 stated, on 07/16/23, a state tested nurse aide (STNA) made notification Resident #1 was non-responsive and had a elevated pulse rate. LPN #200 contacted emergency medical services (EMS), and the resident was subsequently sent to the hospital emergency room for evaluation. LPN #200 confirmed Resident #1 had a urinary indwelling catheter in place at the time of discharge which had been in place during the resident's admission to the facility. On 08/25/23 at 9:45 A.M., interview with the Director of Nursing (DON), during review of Resident #1's medical record, confirmed the resident had an indwelling urinary catheter in place at the time of admission and until discharge on [DATE]. The DON confirmed there was no documentation contained in the medical record which indicated the indwelling urinary catheter was in place, a supporting diagnosis or physician order for the use of the indwelling catheter, or documentation of maintenance and care. The DON indicated the facility discovered the missing documentation and initiated corrective action. Review of the facility catheterization policy, dated 01/01/22, revealed the use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter and balloon, and frequency of change (if applicable). As a result of the deficient practice the facility has implemented corrective action as of 08/18/23 as follows: On 07/18/23, the DON conducted a visual room to room audit for indwelling (Foley) urinary catheters. On 07/20/23, all nurses were in-serviced by staff development on the facility policy for Foley catheters to include residents with Foley catheters have orders with type, size, and an appropriate diagnosis, have Foley catheter care orders each shift, and tasks for Foley catheter care each shift. On 07/24/23, weekly audits were completed by the DON or designee on admissions and readmissions to the facility Monday through Friday for four weeks to validate if a resident admitted with a Foley catheter had orders with type, size, and diagnosis, and Foley catheter care each shift. The audits concluded on 08/18/23 with no concerns noted. On 08/25/23 at 10:25 A.M., interview with LPN #200 and at 10:35 A.M. with Registered Nurse (RN) #300 confirmed attending indwelling catheter in-service training and were knowledgeable of the in-service topics. On 08/25/23, review of two (#2 and #3) current resident's medical records and observation of catheter care and maintenance verified effectiveness of the corrective action. This deficiency represents non-compliance investigated under Complaint Number OH00144734.

Based on medical record review and staff interview, the facility failed to ensure there was documented evidence contained in the medical record to include the placement and care of an indwelling urinary catheter. This affected one (#1) of three residents reviewed for indwelling urinary catheters. The census was 70. Finding include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, metabolic encephalopathy, acute lymphadenitis, autoimmune encephalitis, muscle weakness, depression, hypertension, dysphagia, anxiety disorder, and Alzheimer's disease. Review of a nursing admission assessment dated [DATE] revealed Resident #1 was dependent with toileting and elimination with assistance. There was no documentation an indwelling urinary catheter was in place. Review of a nursing admission evaluation completed on 06/08/23 revealed Resident #1 was documented with a Foley catheter (indwelling urinary catheter) in place. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and was always incontinent of bowel and bladder. There was no documentation an indwelling urinary catheter was in place. Review of a urinary continence evaluation dated 06/14/23 revealed Resident #1 was incontinent of bladder since admission. Further review revealed there was no indwelling urinary catheter in place. Review of the MDS assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and utilized an indwelling urinary catheter. Further review of Resident #1's medical record lacked a physician order, a supporting diagnosis, or documentation of urinary catheter care and maintenance for the placement of an indwelling urinary catheter. On 08/25/23 at 9:06 A.M., interview with Licensed Practical Nurse (LPN) #200 stated, on 07/16/23, a state tested nurse aide (STNA) made notification Resident #1 was non-responsive and had a elevated pulse rate. LPN #200 contacted emergency medical services (EMS), and the resident was subsequently sent to the hospital emergency room for evaluation. LPN #200 confirmed Resident #1 had a urinary indwelling catheter in place at the time of discharge which had been in place during the resident's admission to the facility. On 08/25/23 at 9:45 A.M., interview with the Director of Nursing (DON), during review of Resident #1's medical record, confirmed the resident had an indwelling urinary catheter in place at the time of admission and until discharge on [DATE]. The DON confirmed there was no documentation contained in the medical record which indicated the indwelling urinary catheter was in place, a supporting diagnosis or physician order for the use of the indwelling catheter, or documentation of maintenance and care.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of guidance from the Centers for Disease Control (CDC) and Prevention website related to; preparing for Coronavirus Disease 2019 (COVID-19), assessment tool for nursing home preparedness, infection prevention and control (IPC) recommendations, responding to COVID 19 for nursing homes and health care facilities, and duration of isolation, surveyor observations, medical record reviews, staff interviews, review of daily census sheets, state health department staff interviews, review of facility staffing schedules, review of facility emails, review of facility infection control line listing for COVID-19 testing of residents, review of the facility list of COVID-19 positive residents, review of facility list of residents on transmission based precautions, review of staff COVID-19 test results, review of State Staffing Tool, review of staff training, review of facility policy regarding isolation, and review of facility policy for COVID-19, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 including; developing an infection control policy to mitigate the spread of COVID-19, providing dedicated staff for the COVID-19 isolation units, ensuring staff with symptoms of COVID-19 reported these symptoms and did not work, ensuring staff were wearing proper Personal Protective Equipment (PPE) while working on or entering the COVID-19 isolation unit, ensuring residents identified to be on isolation and/or quarantine were not allowed to exit their rooms into the hallway and if doing so were wearing a mask, and posting signage at the entrance of the isolation units identifying the proper PPE to be worn upon entering. This resulted in Immediate Jeopardy for nine residents (#106, #137, #140, #141, #142, #143, #144, #146, and #147) who tested positive after staff working both the COVID-19 isolation unit and non-COVID-19 units provided their care and for five residents (#105, #107, #113, #115, and #118) who tested positive for COVID-19 when State tested Nurse Aide (STNA) #204 did not report her COVID-19 symptoms and worked for three days before testing positive for [MEDICAL CONDITION]. Additionally, eight residents (#117, #127, #128, #131, #151, #153, #159, and #160) who were COVID-19 negative were placed in Immediate Jeopardy when one resident (#118) on isolation due to testing positive for COVID-19 was observed in the hallway with no mask on, one resident (#131) under quarantine for exposure to COVID-19 was observed to be ambulating the length of the hall to exit the facility to smoke, one resident (#159) under quarantine was observed to be sitting in the doorway of her room with no mask on, staff working the COVID-19 isolation unit continued to provide care to residents on non-COVID-19 units, and staff were observed not using proper PPE when on the COVID-19 isolation unit. The facility also failed to develop an infection control policy to mitigate the spread of COVID-19 once a staff member or resident tested positive for [MEDICAL CONDITION]. This lack of development of current infection control policies and implementation of current infection control practices placed all 56 residents at risk for hospitalization , complications and/or death related to the facility's COVID-19 outbreak. Furthermore, the facility failed to post the proper signage at the entrance of the COVID-19 isolation unit which directed persons on the proper PPE to apply prior to entering the isolation unit. The facility census was 56 residents, which included 54 residents in house and two COVID-19 positive residents (#107 and #115) who were hospitalized . On 09/17/20 at 2:26 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/21/20 when the facility completed setting up a COVID-19 isolation unit on the 400 Hall without changing their staffing model to identify dedicated staff to work only on this unit. The facility had been allowing staff to work between both the COVID-19 isolation units and the non-COVID-19 units during their daily shift and weekly assignments. The Immediate Jeopardy continued 08/29/20 when STNA #204 reported having worked with symptoms of COVID-19 she had not reported to the facility. On 09/01/20, STNA #204 tested positive for COVID-19. During observations on 09/14/20 and 09/15/20, staff were not wearing proper PPE including gloves and appropriate eye protection when on the COVID-19 positive unit, Resident #118, who was identified to be on isolation due to being COVID-19 positive, was observed to exit his room into the hall without a mask on, Resident #131, who was identified to be on quarantine transmission based precautions for COVID-19 exposure, was observed ambulating the length of the hall to the facility exterior to smoke, and Resident #159, who was identified to be under quarantine for COVID-19 exposure, was observed sitting at the door of her room, facing the hallway, without a mask on. As of 09/14/20, the facility had a census of 56 residents. Since the outbreak, 46 residents tested positive for COVID-19 and 20 were considered recovered, eight residents continue to test negative, with four of the eight negative residents on quarantine for exposure to COVID-19. Two residents were currently hospitalized and on bed hold status. The Immediate Jeopardy was removed on 09/21/20 at 5:35 P.M. when the last resident was removed from an isolation status on the COVID-19 unit and the facility implemented the following corrective actions: · On 09/17/20, the DON educated STNA #204 to report any signs and symptoms of COVID-19 upon reporting to work. · On 09/17/20, the Administrator provided education to Residents #159 and #131 to stay in their rooms and wear a mask if they exited the room. Both residents had masks available in the room for use. · On 9/17/20, the DON educated all staff to encourage/remind residents to wear masks for source control when exiting rooms and to encourage residents to stay in their rooms while on quarantine. · On 09/17/20, the Administrator placed signs on the isolation unit doors notifying persons not to enter unless a N95 mask and goggles were applied per CDC guidance. · On 09/17/20 and 09/18/20, the DON and Regional Director of Clinical Services completed an audit of facility staff use of proper PPE. · On 09/17/20, the DON and Administrator reviewed the facility action plan with the Medical Director through an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting. · On 09/17/20, the Administrator contacted the local health department to review the QAPI action plan. · On 09/18/20, the DON and Regional Director of Clinical Services educated all staff on CDC guidelines for cohorting residents. · On 09/18/20, the Staff Development Coordinator/Infection Prevention nurse educated direct care staff on proper PPE usage for transmission-based precautions. · On 09/18/20, the DON and Regional Director of Clinical Services educated all staff on signs and symptoms of COVID-19, the importance of immediately reporting any signs and symptoms during the screening process, and self-monitoring for signs and symptoms. · On 09/18/20, the DON and Regional Director of Clinical Services educated all staff on the CDC guidelines for wearing the proper PPE to include gloves, N95 mask, face shield/googles, and an isolation gown upon entering the room of a resident on transmission based isolation for COVID-19. · Interview on 09/20/20 at 9:24 P.M. with STNA #209 verified receiving education on either 09/17/20 or 09/18/20 via telephone clarifying isolation precautions when providing care to COVID-19 positive residents. · On 09/21/20 at 5:35 P.M., the last resident on isolation for COVID-19 was released from isolation and there are currently no COVID-19 positive residents residing in the facility. · On 09/22/20, the Regional Director of Clinical Services educated the staff scheduler and all nurses regarding the use of dedicated staff on the positive COVID-19 isolation unit. · Review of the medical record for 20 current residents (#105, #106, #107, #111, #112, #115, #117, #118, #122, #127, #128, #131, #134, #135, #136, #150, #151, #154, #157, and #158) and five former residents (#161, #162, #163, #164, #165) were completed. Although the Immediate Jeopardy was removed on 09/21/20, 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 is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Review of the daily census sheet dated 08/19/20 verified the facility initiated a COVID-19 isolation unit on the 400 Hall, which was completed by the end of the day on 08/21/20 when all resident COVID-19 test results were obtained. The COVID-19 isolation hall housed Residents #117, #121, #123, #124, #125, #126, #130, #132, #133, #134, #135, #145, #148, and #162. Review of daily staffing schedules revealed daily from 7:00 A.M. to 11:00 P.M., one nurse was assigned to the 400 Hall and Rooms #500, #502, #504, #506, and #508. From 11:00 P.M. to 7:00 A.M., one nurse was assigned to work on the 400 Hall and 500 Hall. The daily schedule for 08/21/20 revealed Licensed Practical Nurse (LPN) #305 was assigned to residents on the 400 Hall COVID-19 isolation unit and the residents on the 500 Hall. STNA #214 was scheduled to provide care for residents on the COVID-19 isolation unit and the 500 Hall. On 08/22/20 and 08/23/20, LPN #306 worked the 400 Hall and the even rooms on the 500 Hall from 7:00 A.M. to 7:00 P.M., LPN #307 worked both the COVID-19 isolation unit and the 500 Hall from 7:00 P.M. to 7:00 A.M., and STNA #214 was assigned both the 400 Hall and the 500 Hall for first shift and half of second shift. On 08/22/20, STNA #216 worked the 400 Hall and 500 Hall for half of second shift and the third shift. On 08/24/20, LPN #308 worked the 400 Hall and the even rooms on the 500 Hall from 7:00 A.M. to 7:00 P.M. and LPN #307 worked both the COVID-19 isolation unit and the 500 Hall from 7:00 P.M. to 7:00 A.M. STNA #202 and STNA #201 worked the 400 Hall and the 500 Hall on first shift, STNA #213 worked both the 400 Hall and 500 Hall on second shift and half of third shift, and STNA #217 worked the 400 Hall and 500 Hall for half of third shift. On 08/25/20, LPN #308 worked the 400 Hall and the even rooms on the 500 Hall from 7:00 A.M. to 7:00 P.M., LPN #307 worked both the COVID-19 isolation unit and the 500 Hall from 7:00 P.M. to 7:00 A.M., and STNA #214 and STNA #203 worked the 400 Hall and 500 Hall on first shift. Additionally, on 08/25/20 staff who had previously worked the 400 Hall COVID-19 isolation unit were scheduled to work on non-COVID-19 halls which included; LPN #305 worked on the 100 Hall and 200 Hall, STNA #216 worked on the 100 Hall, and STNA #211 worked on the 500 Hall. There was no evidence the facility had made any changes to their staffing model to ensure dedicated staff were assigned to the COVID-19 isolation unit. Review of the State Staffing Tool for 08/21/20 through 08/25/20 revealed the facility met the state minimum direct care staff hours of 2.5 per resident for all seven days. On 08/21/20, the facility staffing was at 2.86 hours per resident of direct care staff, on 08/22/20 the staffing was at 3.14 hours, on 08/23/20 the staffing was at 3.22 direct care hours, 08/24/20 the staffing was at 3.34 direct care hours, and on 08/25/20 the facility staffing was at 2.96 direct care hours per resident per day. Review of the COVID-19 Outbreak Line Listing and resident record review revealed on 08/25/20, five residents (#111, #112, #122, #158, and #164) on the 500 Hall were tested for COVID-19. On 08/27/20 the facility received positive test results for all five residents. Review of the medical record for Resident #111 revealed an initial admission date of [DATE] and re-entry on 04/05/20. [DIAGNOSES REDACTED]. Resident #111 was tested for COVID-19 on 08/25/20 and received a positive result on 08/27/20. Review of the medical record for Resident #112 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident # 112 was tested for COVID-19 on 08/25/20 and received a positive result on 08/27/20. Resident #112 resided on the 500 Hall from 08/20/20 to 08/25/20. Review of the medical record for Resident #122 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #122 was tested for COVID-19 on 08/25/20 and received a positive result on 08/27/20. Review of the medical record for Resident #158 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #158 was tested for COVID-19 on 08/25/20 and received a positive result on 08/27/20. Review of the medical record for Resident #164 revealed an admission date of [DATE] and re-entry on 09/18/20. [DIAGNOSES REDACTED]. Resident #164 was tested for COVID-19 on 08/25/20. Resident #164 was hosptalized on [DATE] due to pneumonia of the left lower lung and COVID-19 rule out. Resident #164 was tested for COVID-19 on 08/26/20 at the hospital and received a positive result on 08/27/20. Review of daily staffing schedules on 08/26/20 revealed LPN #302 worked 7:00 A.M. to 7:00 P.M. and LPN #307 worked from 7:00 P.M. to 7:00 A.M., with both assigned to residents on the 400 Hall COVID-19 isolation unit and the residents on the 500 Hall. STNA #218 was scheduled to provide care for residents on the COVID-19 isolation unit and the 500 Hall from 2:00 P.M. to 10:00 P.M. On 08/27/20, 08/28/20, 08/31/20, and 09/01/20, LPN #306 was assigned to residents on the 400 Hall COVID-19 isolation unit and the residents on the 500 Hall from 7:00 A.M. to 7:00 P.M. On 08/27/20, 08/28/20, and 09/01/20, LPN #305 worked the COVID-19 isolation unit and the 500 Hall from 7:00 P.M. to 7:00 A.M. and was scheduled on 08/29/20 from 11:00 P.M. to 7:30 A.M. to provide care for residents on the 100 Hall and 200 Hall. On 08/28/20, STNA #201 was assigned both the 400 Hall COVID-19 isolation unit and the 500 Hall for first shift. On 08/28/20, STNA #214 was assigned to work on the 400 Hall COVID-19 isolation unit and the 500 Hall from 6:00 A.M to 2:00 P.M. On 08/29/20 and 08/30/20, STNA #214 was assigned residents on the 400 Hall COVID-19 isolation unit and the 500 Hall for both first and second shifts. On 08/29/20, LPN #302 was scheduled to work the 200 Hall and odd rooms on the 500 Hall after working on the 400 Hall COVID isolation unit on 08/26/20. On 08/29/20 and 08/30/20 from 7:00 A.M. to 7:00 P.M., LPN #308 was scheduled to work the 400 Hall COVID-19 isolation unit and the 500 Hall. On 08/29/20, 08/30/20, and 08/31/20 from 7:00 P.M. to 7:00 A.M., LPN #307 was scheduled to work the 400 Hall COVID-19 isolation unit and the 500 Hall. There was no evidence the facility had made any changes during this time to their staffing model to ensure dedicated staff were assigned to the COVID-19 isolation unit. Review of the daily census revealed by the end of the day on 08/28/20, the facility began utilizing the 100 Hall as a second COVID-19 isolation unit. Review of the daily staffing schedules documented the first shift and second shift nurses assigned to the 100 Hall COVID-19 isolation unit were also assigned care of residents in Rooms #200, #201, #202, and #203. The third shift nurse assigned to the 100 Hall COVID-19 isolation unit was also assigned the care of all residents for the 200 Hall. Review of the staffing schedules from 08/28/20 through 09/03/20 revealed this staffing model for the nurses was not altered once the 100 Hall became a COVID-19 isolation unit. Between 08/28/20 and 09/03/20, the nurse on each shift who was assigned the 100 Hall COVID-19 isolation unit was also assigned the care of non-COVID-19 residents on the 200 Hall. Additionally, on 08/29/20, STNA #221 was assigned to work both the 100 Hall COVID-19 isolation unit and the 200 Hall for the first shift. At 2:00 P.M., STNA #221 switched to the care of non-COVID-19 residents on the 500 Hall. On 08/31/20, STNA #220 was assigned both the 100 Hall isolation unit and the 200 Hall for the first shift. On 09/02/20, the daily staffing sheet showed the Administrator worked both the 100 Hall COVID-19 isolation unit and the 200 Hall from 2:00 P.M. until 9:00 P.M. Review of the State Staffing Tool for 08/26/20 to 09/01/20 revealed the facility met the state minimum direct care staff hours of 2.5 per resident for every day except on 09/01/20. On 08/26/20 the facility had 3.16 hours of direct care per resident, on 08/27/20 the staffing was at 2.92 direct care hours, on 08/28/20 the staffing was 2.90 direct care hours, on 08/29/20 the facility had 2.79 direct care hours per resident, on 08/30/20 the staffing was 2.54 direct care hours, for 08/31/20 the staffing was 2.89 direct care hours, and for 09/01/20 the staffing was at 2.45 direct care hours per resident per day. Review of the COVID-19 Outbreak Line Listing and resident census revealed nine residents who resided on the 500 Hall tested positive after staff working on the COVID-19 isolation unit provided their care. This included Resident #147 who resided on the 500 Hall, was tested on [DATE] and received positive results on 09/04/20 and Resident #140 who resided on the 500 Hall, was tested on [DATE], and received positive results on 09/03/20. On 09/04/20 testing of all residents was conducted with positive results received on 09/09/20 for seven additional residents (#106, #137, #141, #142, #143, #144, and #146) who resided on the 500 Hall and tested positive after staff working the COVID-19 isolation unit also provided their care. Review of the laboratory [DIAGNOSES REDACTED]-CoV-2 document for STNA #204 revealed the sample was collected on 08/28/20 and reported positive for COVID-19 on 09/01/20 at 7:27 A.M. During an interview on 09/15/20 at 4:05 P.M., STNA #204 revealed submitting a routine COVID-19 test on 08/28/20 and receiving positive results on 09/01/20. On 09/01/20, STNA #204 reported working and finding out during the shift she was positive. STNA #204 reported she had been exhibiting symptoms of a headache, shortness of breath, and body aches for three days prior to the positive results. STNA #204 believed it was a sinus infection and thought because she had no fever, she was not contagious. STNA #204 verified she did not report the symptoms to the facility when working the three days. STNA #204 stated when scheduled on the 100 Hall COVID-19 isolation unit she will also assist residents on the 200 Hall non-COVID unit as needed throughout the shift. Review of the daily staffing schedules revealed STNA #204 was scheduled to work the 100 Hall and 200 Hall on 08/29/20 and the 100 Hall on 08/30/20 and 09/01/20. During an additional interview on 09/23/20 at 1:20 P.M., STNA #204 revealed the facility asked STNA #204 to sign a statement stating she had lied about her previous interview of working with symptoms. STNA #204 stated she refused to sign a statement and quit. STNA #204 verified symptoms began on 08/29/20; however, she thought she was experiencing symptoms of allergies [REDACTED]. STNA #204 was informed on 09/01/20 at approximately 3:30 P.M. during the shift that she was positive for COVID-19. STNA #204 reported the Administrator and DON had told her due to not having a fever she was fine to continue to work. Review of the COVID-19 Outbreak Line Listing and resident census revealed Resident #105 resided on the 100 Hall, was tested for COVID-19 on 08/31/20, and received positive results on 09/02/20, after STNA #204 worked his hall. On 09/04/20, all facility resident testing was conducted with positive results received on 09/09/20 for four additional residents (#107, #113, #115, and #118) on the 200 Hall where STNA #204 worked while exhibiting symptoms of COVID-19 and where staff who had worked on the 100 Hall COVID-19 isolation unit also provided care during their shifts from 08/28/20 through 09/03/20. During an interview on 09/14/20 at 9:11 A.M., the Administrator and DON revealed at the beginning of the COVID-19 infection outbreak staffing was sufficient. The Administrator stated the facility was not always able to provide dedicated staff and staff were instructed to care for non-COVID-19 residents then COVID-19 positive residents if possible. When leaving the COVID-19 unit to go to another area, staff were required to take off PPE, wash their goggles or shield, and change their gown. Review of the facility provided list of COVID-19 positive residents, dated 09/14/20, revealed Resident #101, #102, #134, and #135 were COVID-19 positive. Observation on 09/14/20 at 10:05 A.M. and 10:10 A.M. of signage on the COVID-19 isolation unit doors revealed the sign to read Stop. Doors are to remain closed at all times. A second signage was posted which read See nurse before entering. During an interview on 09/14/20 at 10:45 A.M., LPN #300 revealed being scheduled both the COVID and non-COVID hall throughout the shift. LPN #300 revealed the medication pass begins with the non-COVID-19 hallway and will go to the COVID-19 isolation unit. LPN #300 stated after medication pass for the COVID-19 isolation unit she will return to the non-COVID unit. LPN #300 verified STNA #203 was assigned the 400 Hall COVID-19 isolation unit and the 500 Hall non-COVID unit on this date. During an interview on 09/14/20 at 11:16 A.M., STNA #203 revealed being assigned to both the 400 Hall COVID-19 isolation unit and the 500 Hall on this date. STNA #203 verified it is necessary to go back and forth between the 400 Hall COVID-19 unit and the 500 Hall throughout the day to meet residents' needs. Observation on 09/14/20 at 11:37 A.M. revealed Activity Staff #212 to enter the 100 Hall COVID-19 isolation unit without wearing eye protection. Activity Staff #212 was observed standing in the COVID-19 isolation unit talking briefly with staff working on the unit. The doors to resident Rooms #104, #106, and #107 were all open. During an interview on 09/14/20 at 11:39 A.M., Activity Staff #212 verified being in the COVID-19 isolation unit and not wearing eye protection. Observation on 09/14/20 at 1:10 P.M. revealed Registered Nurse (RN) #303 exiting the room of Resident #146 and #147, who were positive for COVID-19, with no gloves or eye protection in use. Signage on the door of the room read The following should be worn prior to entering the room including mask, gown, gloves, and googles. During an interview on 09/14/10 at 1:12 P.M , RN #303 stated she had only been hanging a saline bag for the resident, therefore gloves were not necessary. RN #303 also stated she was wearing eyeglasses and a face shield or eye goggles were not necessary. Observations on 09/14/20 at 1:15 P.M., immediately following the interview, revealed RN #303 doffed the gown she was wearing while still inside the isolation unit and not discard it. RN #303 left the isolation unit with the gown tucked under her right arm and walked to the left into the non-COVID area of the building. At 1:17 P.M., RN #303 knocked on the room of Resident #150 and #151, who were both negative for COVID-19. RN #303 was not wearing a gown and no longer had the gown in hand. Review of the Transmission Based Precaution list provided by the facility on 09/15/20 revealed four residents (#131, #153, #159, and #160) who have tested negative were on transmission-based precautions for possible exposure. The list also verified residents on transmission-based precautions who were positive for COVID-19. The list included Resident #105, #106, #118, #134, and #135. Review of medical record for Resident #118 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #118's lab results revealed a specimen for a COVID-19 test was collected on 09/04/20 and reported positive on 09/09/20. Physician orders [REDACTED].#118 in transmission-based precautions related to positive COVID-19 status. Resident #118's care plan revised on 08/21/20 verified Resident #118 wanders in the hall due to [MEDICAL CONDITION]. Review of the progress note for Resident #118, dated 09/10/20, revealed a call was placed to the Ohio Department of Heath to seek guidance on the resident remaining outside of the COVID-19 positive unit. It was reported if the resident was treated with the same isolation precautions as inside the facility's COVID-19 isolation unit and was not a known wanderer, then the resident was considered contained and isolated. If the resident does begin to try and exit the room or have a change in wandering status, he should then be moved inside the COVID-19 unit. Observation on 09/15/20 at 3:42 P.M., 4:12 P.M., 4:19 P.M., and 4:20 P.M. revealed Resident #118 standing in the doorway of his room with the door open. Across the doorway there was a mesh stop sign banner. Resident #118 was observed to bend under the banner, step into the hallway, look at the banner and step back in the resident room. The resident was not wearing a mask. No staff were observed in the area except on the last occasion when LPN #304 was observed in the same hallway. LPN #304 did not appear to notice Resident #118 in the hall. During an interview on 09/15/20 at 4:42 P.M., LPN #304 verified Resident #118 wanders in the hall and at times into the doorway of other resident rooms. Review of medical record for Resident #131 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A safe smoking evaluation was completed on 03/04/20 for Resident #131 which indicated the resident may smoke independently and unsupervised in the designated smoking area. Resident #131's care plan, initiated on 03/16/20, revealed the resident prefers not to wear his mask when out of his room or prefers to wear the mask inappropriately. Review of physician orders, dated 08/17/20, placed Resident #131 on transmission-based precautions related to suspected COVID-19 status. Review of the resident's COVID-19 test results revealed the resident tested negative on 09/09/20 and 09/13/20. During an interview on 09/14/20 at 12:04 P.M., LPN #302 revealed Resident #131 leaves his room to smoke, traveling through the hall to the smoking area. LPN #302 revealed she often obtains Resident #131's vitals while he is in the hallway as well. Observation on 09/15/20 at 3:43 P.M. revealed transmission-based precaution signage on Resident #131's door and PPE present outside the door. Observation on 09/15/20 at 4:21 P.M. revealed Resident #131 ambulating the length of the hallway toward the exit door. Resident #131 was wearing a blue medical mask. Observation on 09/15/20 at 4:32 P.M. revealed transmission-based precaution signage on the door and PPE outside the door of Resident #159's room. Resident #159, who was identified on the transmission-based precaution list as positive for COVID-19, was observed in the hallway outside of the room without a mask on. During an interview on 09/16/20 at 1:20 P.M., STNA #207 revealed staff often work on the COVID-19 positive unit and return to non-COVID-19 areas of the building to provide care. STNA #207 reported floating between an isolation unit and non-isolation unit occurred on every shift, but especially on third shift. Review of an email on 09/16/20 at 5:25 P.M. from the Administrator verified the facility cannot provide evidence the staff worked differently than noted on the schedule. The Administrator verified the staff have been trained to work from clean to dirty and have been trained in proper donning and doffing of PPE. Review of an email on 09/17/20 at 1:25 P.M. from the DON verified from 7:00 P.M. to 11:00 P.M. nurses work the 400 Hall and even room numbers on the 500 Hall. From 11:00 P.M. to 7:00 A.M. the same nurse is responsible for all the 400 Hall COVID-19 isolation unit and the 500 Hall residents. The DON stated staff were aware to start from the non-COVID-19 unit and work their way towards the COVID-19 unit as much as appropriate care allowed. During an interview on 09/20/20 at 9:24 P.M., STNA #209 verified caring for COVID-19 positive and non-COVID-19 residents on the same shift. STNA #209 acknowledged leaving a contaminated area and going to a non-contaminated area to meet the needs of residents on a regular basis. STNA #209 stated there was no clarification on how it should be done and did what she felt was best. During an interview on 09/21/20 at 3:36 P.M., STNA #218 verified caring for both residents diagnosed with [REDACTED]. STNA #218 revealed staff scheduled on the COVID-19 isolation unit were expected to stay on the unit but it was common for staff to go back and forth between the isolation and non-isolation unit to assist with transfers of residents. Review of an email forwarded from the Administrator on 09/21/20 revealed on 08/27/20 at 8:10 A.M. Infectious Disease Control Consultant #500 provided a brief overview of recommendations and points discussed during the Tele-Infection Control Assessment and Response (Tele-ICAR) virtual visit help on 08/26/20. The first recommendation listed was regarding eye protection and provided a link recommending having eye protection in areas with moderate to sustained community spread. Interview on 09/22/20 at 8:15 A.M. with Infectious Disease Control Consultant #500, from the state health department, verified contact with the (TRUNCATED)

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, policy review and investigation review, the failed to ensure Resident #01 was provided with appropriate assistance and intervention during a transfer from the toilet to the wheelchair. This resulted in actual harm when State tested Nurse Aide (STNA) #200 attempted to transfer Resident #01 alone when the resident became weak and had to be lowered to the floor causing right tibial and fibular fractures. The facility also failed to ensure Resident #01 was assessed by the nurse for injury prior to being moved from the floor to the wheelchair. This affected one (Resident #01) of three residents reviewed for accidents. The facility census was 61. The deficient practice was corrected on 08/21/19 when the facility implemented the following corrective actions: · On 07/24/19, STNA#200 was suspended, then terminated on 07/26/19. · On 07/24/19, the Director of Nursing (DON) implemented all nursing staff in-service training on the use of gait belts with all non-mechanical lift transfers, review of the Kardex before providing care and review of the accident policy not to move an injured victim until being examined. The training was completed on 07/26/19. · On 07/29/19, the DON completed an audit of 10 transfers a week for four weeks to ensure staff were following resident Kardex per plan of care for transfers. The monitoring was completed on 08/21/19 and no concerns were identified Findings include: Resident #01 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #01's care card with admission date of [DATE] identified the intervention of two person assistance with all transfers. On 09/20/18 the fall prevention plan of care was revised as the resident was at risk for falls related to balance deficits, confusion , gait/balance problems. Interventions included, assist with mobility, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, encourage rest periods as needed to avoid overtiring, evaluate medication regimen with physician and pharmacist as needed, physical therapy (PT) to evaluate and treat as ordered or as needed (PRN), two person transfer for all transfers. On 05/04/19 a fall assessment scored the resident at risk and indicated fall prevention interventions were required. According to the Minimum Data Set (MDS) assessment dated [DATE] the resident was severely cognitively impaired, dependent on staff for the completion of activities of daily living, required the physical assistance of two staff for transfer and bed mobility, utilized a walker for locomotion, and was incontinent of bowel and bladder. Nursing notes dated 07/24/19 at 2:45 P.M. revealed Licensed Practical Nurse (LPN) #300 was called to Resident #01's room. The resident was sitting in the wheelchair with the right leg swollen and very painful. STNA #200 reported that she was transferring the resident in the bathroom and her legs buckled. STNA #200 lowered the resident to the floor then she and STNA #201 picked the resident up from the floor, placed the resident in the wheelchair and proceeded to summon LPN #300. LPN #300 had STNA #200 get the unit manager, and call an ambulance for transportation to the hospital. The resident was subsequently sent to the emergency room . Review of hospital documentation dated 07/24/19 documented X-ray results identified a right comminuted tibial and fibular fractures with displacement and impaction. Orthopedic physician evaluation noted a right shin deformity, with anterior abrasion and ecchymosis. Orthopedic intervention included reducing the fracture and splinting the residents right lower extremity. The resident was admitted to the hospital and did not return to the facility. According to the facility investigation dated 07/24/19, STNA #200 was suspended pending investigation and employment terminated on 07/26/19 due to failing to follow facility policy. It was determined STNA#200 did not use a gait belt when transferring Resident #01 and failed to follow the plan of care using two staff during the transfer. This resulted in Resident #01 sustaining an injury. STNA#200 statement dated 07/24/19 documented standing Resident #01 in the bathroom when both legs buckled and STNA #200 lowered the resident to the floor. Resident #01's right leg was under the resident and STNA#200 left the resident to get STNA #201 to assist with placing the resident to the wheelchair. STNA #200 documented not using a gait belt. During interview on 11/13/19 at 11:07 [NAME]M., LPN #300 stated on 07/24/19, STNA #200 summoned her to Resident #01's room. Upon entry to the room, Resident #01 was up in a wheelchair. The resident's right leg was very painful and swollen. STNA #200 stated she had lowered the resident to the floor in the bathroom during a transfer. LPN #300 confirmed STNA #200 and STNA #201 had transferred Resident #01 from the floor of the bathroom to the wheelchair before LPN #300 could assess the resident for injury. Interview with the Director of Nursing (DON) on 11/13/19 at 11:30 [NAME]M. confirmed STNA #200 failed to provide care planned interventions including two person assistance and gait belt application during a transfer and failed to summon the nurse before moving the resident from the floor of the bathroom to the wheelchair. Review of the facility policy titled Facility Fall Protocol, revised (MONTH) (YEAR), documented based on the assessment an initial care plan is developed and implemented address identified risk. Interventions for direct care givers should be placed on the certified nurse aide (CNA) care card (Kardex) or similar format. Review of the facility policy titled Accident and Incident, revised 12/01/18, revealed when assisting accident victims staff are to render immediate assistance and keep the resident as comfortable as possible. Do not move the victim until he/she has been examined for possible injuries. This deficiency substantiates Complaint Number OH 148.