Every finding on record at Arlington Care Center

Based on observation, interview, and medical record review the facility failed to ensure one, (Resident #37) received timely assistance with facial grooming. This affected one of two reviewed for activities of daily living (ADL). The facility census was 97Findings include:Review of Resident #37's medical record revealed an admission date of 02/05/26. Medical diagnoses include encounter for other orthopedic aftercare, nondisplaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing, need for assistance with personal care, wedge compression fracture of unspecified lumbar vertebrae, chronic kidney disease stage III, Alzheimer's disease, and essential primary hypertension.Review of Resident 37's admission Minimum Data Set (MDS) 3.0 dated 02/11/26 revealed a Brief Interview for Mental Status (BIMS) score which was noted as not completed due to Resident #37 is rarely/never understood. Review of functional abilities note Resident #37 requires substantial/maximal assistance with personal hygiene.Review of Resident #37's bath/shower sheets revealed on 02/07/26, 02/11/26, and 02/21/26, Resident #37 was not shaved, and no reason was noted as to why this was not completed.Observation on 02/23/26 at 11:26 A.M. revealed Resident #37 to be sitting in wheelchair with long facial hair on her chin.Interview with Certified Nursing Assistant (CNA) #113 at 3:37 P.M. confirmed Resident #37 would not be able to verbalize if she wanted her facial hair to be shaved and confirmed Resident #37 did have facial hair on her chin and she would take care of it for her.The facility did not have an activities of daily living policy.

Based on observation, interview, and record review, the facility failed to ensure Resident #102 received services for her vision. This affected one, (Resident #102) of one resident viewed for communication and sensory. The facility census was 97.Findings include: Review of Resident #102's medical record revealed an admission date of 09/25/24 with diagnoses including end stage renal disease, type two diabetes mellitus, hemiplegia and hemiparesis affecting left nondominant side, major depressive disorder, anxiety disorder, and anemia.Review of Resident #102's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and adequate vision.Review of Resident #102's Healthdrive request for service, dated 10/03/24, revealed the resident had requested to be seen by eye care.Review of Resident #102's physician order dated 11/04/25 revealed an order to be treated as needed by podiatrist, dentist, or optometrist.Review of Resident #102's plan of care on 02/25/26 revealed it did not address her vision.Interview on 02/23/26 at 11:18 A.M. with Resident #102 revealed she had blurry vision and she had not seen anyone about it since she came to the facility. She reported she had told multiple people she wanted to see the eye doctor.Interview on 02/25/26 at 2:12 P.M. and 4:32 P.M. with Social Service Designee #135 revealed when residents sign the consent for the eye doctor the form is supposed to get sent to Healthdrive and the resident will get seen by them. She verified Resident #102 had signed this consent form and had not been seen. Social Service Designee #135 reported Resident #102 had not seen the eye doctor since she admitted to the facility and would be signed up to see someone for blurry vision.The facility did not have a policy for ancillary services.

Based on record review, observation, and interview the facility failed to provide timely podiatric care for one, (Resident #79) of two reviewed for activities of daily living (ADL). The census was 97.Findings include:Review of Resident #79 ' s medical record revealed an admission date of 11/21/25. Diagnoses include spinal stenosis lumbar region without neurogenic claudication, wedge compression fracture of T 9-T 10 (thoracic) vertebra subsequent encounter for fracture with routing healing, Type II Diabetes Mellitus with diabetic polyneuropathy, and essential primary hypertension.Review of Resident 79 ' s admission Minimum Data Set (MDS) 3.0 dated 02/05/26 revealed a Brief Interview for Mental Status (BIMS) score of seven. Review of functional abilities revealed Resident #79 required substantial/maximal assistance with putting on/taking off footwear.Review of Resident #79 ' s care plan dated 02/03/26 confirmed Resident #79 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Resident #79 is assisted with all ADL function bathing, transfers, toileting hygiene, foley catheter care, grooming, dressing, and oral care. Resident #79 was able feed self with set up assist, used a wheelchair for mobility needs when out of bed. Goal included all resident ADL's need will be met through the next review date. Interventions included diabetic nail care and grooming (nails, shave, hair) assistance needed and staff to anticipate needs and assist as needed.Review of Resident #79 ' s physician orders confirmed active order placed on 11/22/25 for Podiatry to evaluate feet as indicated for foot care and as needed for diabetic shoes. Further review revealed, an active order placed on 11/22/25 noting diabetic foot care: caregiver to wash, dry, and apply house stock lotion to bilateral feet checking for any skin concerns to foot/toes.Review of Resident#79's medical record revealed he had no documented progress note or evaluation from the podiatrist in his medical record. Review of the completed Podiatry appointments in the facility confirmed Resident #79 was not seen by Podiatry.Observation on 2/23/026 at 11:46 A.M. revealed Resident #79 ' s bilateral feet were exposed revealing long jagged toenails.Interview with 02/25/26 at 9:23 A.M. with the Unit Manager #46 and Assistant Director of Nursing (ADON) #50 confirmed Resident #79 ' s toenails were long and the wound nurse practitioner would trim them the current day.Interview on 02/25/26 at 12:18 P.M. with Social Services Designee #135 confirmed new admissions are advised of ancillary services.There was not an Ancillary services policy in place during the survey.

Based on record review, interview, and facility policy review, the facility failed to obtain weekly weights for Resident #37 who was a new admission and at nutritional risk. This affected one (Resident #37) of two residents reviewed for nutrition. The census was 97.Findings include: Review of Resident #37's medical record revealed an admission date of 02/05/26. Medical diagnoses include encounter for other orthopedic aftercare, nondisplaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing, need for assistance with personal care, wedge compression fracture of unspecified lumbar vertebrae, chronic kidney disease stage III, Alzheimer's disease, and essential primary hypertension.Review of Resident 37's admission Minimum Data Set (MDS) 3.0 dated 02/11/26 revealed a Brief Interview for Mental Status (BIMS) was not completed noting Resident #37 is rarely/never understood. Review of functional abilities revealed Resident #37 required partial/moderate assistance with eating. Further review revealed an admission weight of 132 pounds (lbs).Review of Resident #37's weights revealed an admission weight of 132.4 lbs on 02/06/26 and weight of 119.0 lbs on 02/23/26.Review of Resident #37's nutrition assessment dated [DATE] revealed Resident #37 was on a regular diet with regular texture. Meal intake records less than or equal to(</=) 50 percent (%) heavily assisted/fed by staff, regular diet is adequate but oral (po) is lagging. PO may improve with time and routine post-op noting to monitor.Review of Resident #37's progress note dated 02/23/26 comprised by Dietician #25 noted Resident #37 weight 119.0 lbs representative of a 13.4 lb or 10.1% weight loss since admission.Review of facility weight log for unit C revealed Resident #37 had a weight of 105.0 lbs for week one and weight of 119 for week three. Interview on 02/25/26 at 3:35 P.M. with Dietician #25 confirmed new admissions should be weighed as close to weekly as possible stating she keeps a weight log.Interview on 02/26/26 at 1:51 P.M. with Dietician #25 confirmed Resident #37 should have four weights completed at this point and has only had three completed and she was still unclear of the accuracy of the resident's documented weight.Review of the facility's policy titled, Weight Monitoring dated 02/15/24, newly admitted residents' weight will be monitored as close to weekly as possible for the initial four weeks and at least monthly thereafter. There was not a re-weigh policy in place at the time of the survey.

Based on interview and medical record review the facility failed to ensure Resident #13's blood pressure medications were not administered outside of parameters. This affected one resident (#13) of five residents reviewed for unnecessary medications. The facility census was 97.Findings include: Review of Resident #13's medical record revealed an admission date of 09/03/24 with diagnoses including Type Two Diabetes Mellitus, chronic obstructive pulmonary disease, chronic heart failure, and acquired absence of right leg. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Review of Resident #13's plan of care dated 09/13/24 revealed the resident had altered health maintenance related to diagnoses including atherosclerotic heart disease and hypertension. Interventions included administering medications as ordered.Review of Resident #13's physician order dated 09/12/24 revealed an order for Carvedilol tablet 3.125 milligrams (mg) two times a day for hypertension. It was to be held for Systolic blood pressure (SBP) less than 100 millimeters of Mercury (mmHg) or diastolic blood pressure (DBP) less than 80 mmHg. Review of Resident #13's physician order dated 09/16/24 revealed an order for Entresto oral Tablet 49-51 mg one tablet by mouth two times a day for cardiomyopathy. The medication was to be held for SBP less than 110 mmHg, DBP less than 60, or heart rate less than 60 beats per minute (BPM). Review of Resident #13's physician order dated 09/17/24 revealed an order for Torsemide oral tablet 20 mg two tablets by mouth one time a day related hypertension. It was to be held for SBP less than 110 mmHg, DBP less than 60 mmHg, or heart rate less than 60 BPM. Review of Resident #13's Medication Administration Record (MAR) for 02/01/26 to 02/23/26 revealed in the morning Resident #13's DBP was below 60 mmHg on 02/06/26, 02/13/26, and 02/20/26. It was below 80 mmHg on 02/02/26, 02/03/26, 02/04/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/25, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/21/26, 02/22/26, and 02/23/26.Review of Resident #13's MAR and progress notes from 02/01/26 to 02/23/26 revealed Entresto was administered in the morning on 02/06/26, 02/13/26, and 02/20/26 outside of parameters. Torsemide was administered in the morning on 02/06/26 and 02/20/26 outside of parameters. Carvedilol was administered in the morning on all the listed dates outside of parameters. There were no notes indicating the physician was notified or the medication had been approved for administration outside of parameters.Review of Resident #13's MAR for 02/01/26 to 02/23/26 revealed in the evening Resident #13's DBP was below 60 mmHg on 02/04/25, 02/10/26, 02/14/26, 02/15/26, and 02/19/26. His DBP was below 80 mmHg, on 02/02/26, 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/13/26, 02/16/26, 02/18/26, 02/20/26, 02/21/26, 02/22/26, and 02/23/26.Review of Resident #13's MAR and progress notes from 02/01/26 to 02/23/26 revealed Entresto was administered in the evening on 02/04/26, 02/10/26, 02/14/26, and 02/19/26 outside of parameters. Carvedilol was administered in the evening on all listed dates outside of parameters except for 02/05/26 and 02/15/26.Interview on 02/26/26 at 7:19 A.M. with Regional Clinical Manager #87 verified the medications had not been held appropriately according to the ordered parameters. Regional Clinical Manager #87 clarified with the physician the parameters as multiple parameters may have been confusing.The facility had no medication administration policy.

Based on record review, observation, interview and facility policy review, the facility failed to implement safety interventions for Resident #37. This affected one (Resident #37) out three residents reviewed for accidents. The facility census was 103.Findings include:Review of Resident #37's medical record revealed an admission date of 08/31/22 with diagnoses including but not limited Alzheimer's disease, chronic kidney disease, high blood pressure, anxiety, and depression.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had impaired cognition, required assistance from staff to complete activities of daily living (ADL) tasks including personal hygiene care, was incontinent of urine and bowel, and used a wheelchair for mobility.Review of Resident #37's alteration in skin integrity care plan dated 09/09/22 revealed an intervention for geri-sleeves (protective sleeves) to bilateral arms as tolerated and staff to offer and encourage resident to wear long sleeves at bedtime. Further review revealed at risk for falls care plan dated 09/09/22 with interventions including a stop sign to the entry of the bedroom to redirect while unassisted.Review of Resident #37's progress note dated 11/27/25 at 6:00 A.M. revealed Resident #37 had sustained injuries of unknown origin including a superficial laceration to bridge of nose, epistaxis (bloody nose) with small amount of blood draining from bilateral nares, large hematoma to forehead between the eyebrows and skin tears to the left outer hand and base of the right thumb. Resident #37 was sent to the hospital for further evaluation. Further review revealed on 11/27/25 at 9:05 A.M. Resident #37 returned to the facility.Review of Resident #37's progress note dated 11/28/25 at 3:30 P.M. revealed per Resident #37's family request, Resident #37 was moved from the memory care unit to another room on C hallway, with an order to place a Wanderguard (bracelet worn by a resident to alert staff if a resident tries to exit the facility of go into an unsafe area) to the right ankle and to continue 15-minute checks.Review of Resident #37's physician orders dated 12/01/25 to 12/31/25 revealed an order dated 04/29/25 for a stop sign to the entry of the bedroom to redirect the resident while unassisted, and an order dated 11/28/25 for Wanderguard to right ankle expiration 12/2028 to be check every shift for function and placement.An observation on 12/08/25 at 2:00 P.M. revealed Resident #37 was sitting in the wheelchair in her room looking at pictures. There was no stop sign attached to the doorframe or in the doorway to Resident #37's room.An interview on 12/09/25 at 11:55 A.M. with the Director of Nursing (DON) revealed the only intervention implemented for Resident #37 regarding the sustained injuries was to place Resident #37 on 15-minute checks for 24 hours. The DON confirmed there were no further interventions implemented regarding Resident #37's safety.An interview on 12/09/25 at 1:10 P.M. with the DON confirmed there was not a stop sign in the doorway of Resident #37's new room. The DON stated the stop sign intervention was implemented for Resident #37's roommate on the memory unit prior to being moved to the new room.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed upon completion of an investigation, the facility will determine If modifications are needed to prevent similar incidents or injuries from occurring in the future.This deficiency represents non-compliance investigated under Master Complaint Number 2684570.

Based on observations, review of a test tray, resident and staff interview, and policy review, the facility failed to ensure food was served at a palliative and warm food temperature. This affected Residents #11, #77, and #80 and had the potential to affect all residents who received meals from the kitchen except Resident #1 and Resident #99 who were nothing-by-mouth (NPO). The facility census was 94. Findings include: Interview with Resident #77 on 07/08/24 at 11:01 A.M. stated the food was cold. Resident #77 said they have warmers, but they were not using them at all meals. Resident #77 said the breakfast was normally cold. Interview with Resident #80 on 07/08/24 at 11:26 A.M. revealed the food was terrible, not appealing, and cold by the time it gets to them. Resident #80 also said the breakfast was always the same eggs and toast or pancakes and sausage. Interview with Resident #11 on 07/09/24 a 10:19 A.M. revealed the food doesn't agree with her. She said a lot of times the food was cold when they get it. Observation of the tray line was made on 07/11/24 at 8:23 A.M. with Dietary Supervisor #421. The breakfast menu consisted of egg and cheddar bake, donut, and oatmeal. A test tray was requested and Dietary Supervisor #421 took starting temperatures of the food being placed on the test tray on 07/11/24 at 8:23 A.M. Dietary Supervisor #421 confirmed the egg and cheddar bake was 110 degrees Fahrenheit. Dietary Supervisor #421 started a new plate for the test tray with pureed egg and cheddar bake. Dietary Supervisor #421 confirmed the pureed egg and cheddar bake was 150 degrees Fahrenheit, oatmeal was 158 degrees Fahrenheit, and the donut was 92 degrees Fahrenheit on the test tray. The tray was then placed on the meal cart for the K Hall. The test tray left the kitchen on 07/11/24 at 08:28 A.M. Interview on 07/11/24 at 8:28 A.M. with Dietary Supervisor #421 revealed she wants food coming out of hot holding at 145 degrees Fahrenheit or above. Dietary Supervisor #421 also revealed the donut was not a time/temperature controlled for safety (TCS) food product. Observation on 07/11/24 at 8:30 A.M. of the meal cart with the test tray arrived on the K Hall. Interview on 07/11/24 at 8:39 A.M. with Dietary Supervisor #421 revealed she does test trays usually weekly. Dietary Supervisor #421 also revealed she would like the temperature of the food when received by residents at 145 degrees Fahrenheit. Observation on 07/11/24 at 8:41 A.M. of the test tray was served after all other K Hall food trays were served. Observation of the test tray opened on 07/11/24 at 8:41 A.M. with Dietary Supervisor #421. Dietary Supervisor #421 checked the food on the tray and confirmed the food temperatures. The egg and cheddar bake was 123 degrees Fahrenheit, the donut was 94 degrees Fahrenheit, and the oatmeal was 143 degrees Fahrenheit. The food was tasted and the eggs were lukewarm. Interview on 07/11/24 at 09:03 A.M. with Dietary Supervisor #421 revealed the facility has hot plates but they were not currently using carriage pallet warmers under the plates. Dietary Supervisor #421 also revealed the pallet warmer wasn't working and it went down five or six days ago. She said they have to order more parts. Review of the Infection Control - Dietary/Food Handling policy dated March 2016 stated all potentially hazardous food, TCS must be maintained at 41 degrees or less, or at 135 degrees or above, except during preparation, cooking or cooling.

Based on observation, record review, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices in the area of isolation and enhanced barrier precautions (EBP). This affected two residents (#77 and #84) of 24 residents on isolation and/or EBP. Additionally, the facility failed to ensure proper hand hygiene was completed in between contact with each resident while serving meal trays. This had the potential to all nine residents (Resident #198, #86, #30, #199, #200, #74, #72, #63, and #201) residing on the facility's C unit who received a meal tray. The facility census was 94. Findings include: 1. Review of the medical record for Resident #77 revealed an initial admitted [DATE] with the diagnoses including hydronephrosis with renal and ureteral calculous obstruction, artificial openings of urinary tract infection (UTI), and chronic kidney disease. Review of the admission assessment and baseline care plan dated 02/21/24 revealed Resident #77 had a right nephrostomy tube in place. Review of the plan of care dated 03/01/24 revealed Resident #77 was at risk for infection related to right nephrostomy tube. Interventions included to maintain EBP. Review of the resident's monthly physician orders for July 2024 revealed orders dated 02/21/24 to empty nephrostomy drainage bag every shift. On 04/08/24, the order was to maintain EBP every shift. On 07/09/24 at 2:19 P.M., observation of Licensed Practical Nurse (LPN) #324 provide the physician ordered treatment to Resident #77's nephrostomy tube revealed she washed her hands, donned a pair of gloves, removed the old dressing and washed her hands, donned gloves. LPN #324 then cleansed the insertion site with an alcohol pad in a circular motion from the insertion site out. LPN #324 then applied skin prep to the area around the nephrostomy tube insertion site. LPN #324 then placed a T drain sponge on the insertion site and then covered the tube with a 4X4. LPN #324 secured the dressing with a Tegaderm and then washed her hands. LPN #324 failed to wear a gown for personal protective equipment during the procedure for EBP as physician ordered. On 07/09/24 at 2:32 P.M., an interview with LPN #324 verified she did not wear a gown during the treatment of Resident #77's nephrostomy tube and verified a gown should have been worn per physician orders for the use of the EBP. 48568 2. Review of the medical record for Resident #84 revealed an admitted [DATE]. Diagnoses included noninfective gastroenteritis and colitis. Review of Resident #84 physician orders dated 06/26/24 revealed to maintain contact precautions every shift for Methicillin-Resistant Staphyloccous aureus (MRSA) urinary tract infection (UTI). Observation on 07/08/24 at 12:23 P.M. with Licensed Practical Nurse (LPN) #381 revealed LPN #378 entered Resident 84's room with a medication cup and without donning any personal protective equipment (PPE) which included no gloves or gown was donned. Interview on 07/08/24 at 12:23 P.M. with LPN #381 confirmed LPN #378 should have been wearing PPE prior to entering Resident #84's room. LPN #381 said she would do education with LPN #378. Observation on 07/08/24 at 12:23 P.M. revealed there was contact precaution signage on Resident #84's door. The contact precaution sign on the door stated Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Don and Doff procedures were located to the left of the door as you enter. Lastly, PPE required supplies and directions were taped on top of the PPE supply cart that was located to the left of the door before you enter the room. Review of the Standard and Transmission-based Precautions policy dated 03/24/24 revealed the facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC) for transmission based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used. The category of and duration of transmission-based precaution (isolation) will depend upon the infectious agent or organism involved 41271 3. Observation completed on 07/08/24 from 11:20 A.M. to 11:51 A.M. revealed State tested Nursing Assistant (STNA) #320 and #326 passed lunch meal trays to residents residing on the facility's C unit. STNAs #320 and #326 entered and exited multiple resident rooms to deliver their meal tray and helped residents set their meal tray up without the use of hand sanitizer nor were either staff member observed washing their hands. Interview on 07/08/24 at 11:52 A.M. with STNA #320 confirmed she did not complete hand hygiene between delivering lunch meal trays to the residents and claimed she thought hand hygiene only had to be completed after contact with so many residents. STNA #320 was not able to provide the number of residents she could come in contact with before hand hygiene needed to be completed. Interview on 07/08/24 at 11:56 A.M. with STNA #326 confirmed hand hygiene was not completed after delivering meal trays to different residents. STNA #326 stated she knew hand hygiene needed to be completed between contact with each resident, she just forgot to do it. Interview on 07/08/24 12:19 P.M. with the Director of Nursing (DON) revealed staff were to use hand sanitizer every time they enter a resident's room and when they leave a resident's room and to wash their hands when visibly soiled and as needed. Review of the facility policy titled Hand Hygiene dated 11/28/17 revealed staff should perform hand hygiene (even if gloves are used) in the following situations: which included before and after contact with the resident.

Based on observation, record review and interview the facility failed to ensure Resident #24, Resident #58 and Resident #350, who required staff assistance for activities of living (ADL) care received timely assistance with nail care to maintain proper grooming. This affected three residents (#24, #58 and #350) of three residents reviewed for ADL care. The facility identified 71 residents who required assistance with grooming and hygiene. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/10/22 revealed Resident #24 required extensive assistance from one staff for dressing and hygiene. Review of the plan of care, dated 06/10/22 revealed Resident #24 may require assistance with ADLs. Interventions include to provide assistance with bathing and grooming based on resident's needs and abilities. On 08/16/22 at 8:35 A.M. Resident #24's fingernails were observed to appear very dirty, with an unknown dark brown/black substance around the fingernail beds and underneath the resident's fingernails. On 08/16/22 at 8:40 A.M. interview with Licensed Practical Nurse (LPN) #404 confirmed Resident #24's fingernails had an unknown dark brown substance around the nail beds and what appeared to be dried food under the fingernails. 2. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 07/21/22 revealed Resident #58 was severely cognitively impaired, required extensive assistance from one staff for hygiene and bathing and was independent with eating. Review of the plan of care, dated 07/22/22 revealed the resident had a need for assistance with functional abilities including bathing and hygiene. Interventions included staff to assist with activities of daily living (ADL) care as needed. On 08/15/22 at 10:30 A.M. Resident #58 was observed sitting in her wheelchair in her room. Resident #58's fingernails were observed to be long, polished with the nail polish peeling off the tips and nails beds. The fingernails were observed to be light brown with some staining and what appeared to be dirt under the fingernails. On 08/15/22 at 3:31 P.M. Resident #58 was observed in the dining room where fingernail polishing was being completed for residents. Interview at the time of the observation with Activities Aide #490 confirmed the presence of what appeared to be a build-up of dirt underneath Resident #58's fingernails, in addition to the staining. On 08/18/22 at 10:22 A.M. interview with State tested Nursing Assistant (STNA) #494 revealed STNA staff can trim resident fingernails unless the resident was diabetic, then the nurse should do it. STNA #494 revealed there were one or two residents on the unit who request a wet wash cloth each morning to wash up, otherwise they get a bath on scheduled bath days. 3. Review of the medical record revealed Resident #350 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 06/10/22 revealed Resident #350 had intact cognition, required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. However, the resident had a significant change since the assessment, was sent out to the hospital and she now had Hospice services. On 08/15/22 at 9:40 A.M., 11:32 A.M., 2:35 P.M. and on 08/16/22 at 11:28 A.M., 1:36 P.M. and 5:34 P.M. observation revealed the fingernails of Resident #350 were long, jagged, and dirty on both her hands. On 08/16/22 at 5:35 P.M. interview with Licensed Practical Nurse #404 verified the fingernails of Resident #350 were long jagged and dirty. On 08/18/22 at 10:26 A.M. interview with the Director of Nursing revealed the facility did not have a policy on nail care and/or hygiene.

Based on observation, record review and interview the facility failed to ensure Resident #37 was provided timely and adequate assistance with eating, a nutritional diet was provided as ordered and meal intakes were documented for Resident #37 who was identified to have a significant weight loss in one month. This affected one resident (#37) of five residents reviewed for nutrition. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the dietary assessment, dated 07/06/22 at 1:06 P.M. revealed Resident #37 was on a regular diet with finger foods because she would not use silverware. The assessment revealed the meal should provide approximately 2473 calories and 95 grams of protein daily. The resident feeds herself with poor intakes of approximately 25-50 percent of most meals documented. Her current body weight was 140 pounds (lbs) with a body mass index of 21.9, which was her normal weight status. Resident #37 was at high risk for nutritional decline per the nutritional risk assessment tool. The dietitian recommends offering 120 milliliters (ml) house supplement twice daily to provide an additional 480 calories and 20 grams of protein. Also add 60 ml of house liquid protein supplement daily to provide 202 calories and 30 grams protein for wound healing and provide diet as ordered with the goal of greater than 50 percent of meals consumed. Monitor intakes, supplement acceptance, weight and skin integrity. Review of the plan of care, dated 07/06/22 revealed Resident #37 had a potential for alteration in nutrition and hydration related to finger foods (she refused all silverware), supplements related to poor intakes and pressure wounds. Interventions included to provide assistance with meals as needed, encourage family to bring in favorite foods from home, honor food preferences, medications as ordered, monitor consistency of diet ordered, obtain food preferences, provide diet as ordered, provide supplement as ordered, weights as ordered, and dietitian referral as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/07/22 revealed Resident #37 had severely impaired cognition, required total assistance from one staff member for dressing and personal hygiene, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for eating. The assessment revealed the resident weighed 140 lbs. Review of July 2022 meal intake records for Resident #37 revealed there was no documentation of her meal intakes for breakfast on 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/19/22, 07/21/22, 07/23/22, 07/26/22 or 07/31/22. There was no documentation of her meal intakes for lunch on 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/19/22, 07/21/22, 07/23/22, 07/26/22 or 07/31/22. There was no documentation of her meal intakes for dinner on 07/02/22, 07/06/22, 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/12/22, 07/13/22 07/14/22, 07/16/22, 7/17/22, 07/19/22, 07/21/22, 07/23/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22, 07/30/22 or 07/31/22. Review of the weights in the electronic medical record (in Point Click Care) revealed Resident #37 weighed 140 lbs on 07/06/22. There was not an admission (07/01/22) weight documented. She weighed 131.6 lbs on 07/14/22, 135.5 lbs on 07/21/22, 134.9 lbs on 07/27/22, 133.4 lbs on 08/04/22 and 131.7 lbs on 08/16/22 which reflected a 5.6 percent weight loss. Review of the August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of August 2022 meal intake records for Resident #37 revealed there was no documentation of meal intakes for breakfast on 08/04/22 or 08/06/22. There was no documentation of meal intakes for lunch on 08/04/22, 08/05/22, 08/06/22 or 08/07/22. There was no documentation of meal intakes for dinner on 08/03/22, 08/04/22, 08/05/22, 08/06/22, 08/07/22, 08/12/22 or 08/13/22. Review of the breakfast diet slip, dated 08/17/22 revealed resident's slip documented a regular diet, finger foods and four ounces health shake. On 08/17/22 at 8:35 A.M. State tested Nursing Assistant (STNA) #406 was observed to hand Resident #37's breakfast tray to Licensed Practical Nurse (LPN) #405 who was in the resident's room. LPN #405 set the tray on the round table in the corner of the room. The resident was in bed. LPN #405 left the resident's room and closed the door. Continued observation from 8:35 A.M. to 9:39 A.M. revealed no staff member had gone into the room of Resident #37 to provide assistance to her with the meal and the meal tray was not positioned in front of her to eat. At 9:39 A.M. STNA #406 was observed to enter the resident's room to assist with the meal. At 10:10 A.M. STNA #406 came out of the room with Resident #37's meal tray and indicated she had only eaten her donut. The tray had scrambled eggs, bacon, toast, a donut, a carton of milk, which was unopened, a bowl of fruit loops, a four-ounce glass of orange juice, which was half gone, and a four-ounce glass of heath shake which still had the lid on it. STNA #406 indicated the resident does not like eggs and stated she had told the kitchen, but they kept sending her eggs. In addition, STNA #406 verified scrambled eggs were not a finger food. Review of the week two menu (dated 08/15/22) revealed on Wednesday for lunch the residents who were to get finger foods were to receive three ounces of veal bites, four ounces of pasta, four ounces of the Key West vegetable blend, four ounces carton of milk, and eight ounces of water. On Wednesday 08/17/22 at 12:05 P.M. observation of the lunch trays revealed they arrived to the unit at this time. STNA #406, who was passing trays, left the tray for Resident #37 on the meal cart in the hallway. Continuous observation from 12:05 P.M. to 12:58 P.M. revealed the lunch tray for Resident #37 remained on the meal cart in the hallway. At 12:58 P.M. STNA #406 took the meal tray for Resident #37 into the resident's room. The meal tray had a ground meat sandwich, green beans, Cheetos puffs, a four ounces carton of milk and a four-ounce glass of water. On 08/17/22 at 12:58 P.M. interview with STNA #406 revealed it was taking her a little longer to feed the four residents on the unit because the other nursing assistant had gone home at 12:00 P.M. and it was just her on the unit. On 08/17/22 at 1:40 P.M. interview with Dietitian #481 revealed the facility does give scrambled eggs as a finger food so the resident would have a variety of options for breakfast. Also, they wound give green beans instead of the Key West blend because they believe the green beans were easier to hold on to then the Key West blend which tends to get mushy when cooked. She indicated the cook gave the Cheetos puffs in place of the pasta and verified this was not an appropriate substitution. She indicated the alternate sandwich was a chicken patty and the resident does not like chicken, so the cook put ground meat on a bun for her. She did not know why she did not get the veal patty because she was a regular diet not a mechanical soft. She stated she did not do the menus, so she did not know why they gave Cheetos instead of pasta. On 08/17/22 at 2:55 P.M. interview with Dietary Manager #462 revealed Resident #37 should not have gotten the ground meat sandwich. She stated the cook must have put it on the wrong tray. She stated Resident #37 could have had the veil and pasta. The Cheetos puffs should not have been a replacement for the pasta but an extra on her tray. On 08/18/22 at 1:45 P.M. interview with Dietitian #481 revealed meal intakes were an important part of her nutritional assessment and determined what intervention she initiated. She stated if no meal intakes were documented she would have to go talk to the staff to know how much the resident was consuming at meals.

Based on observation, record review and interview the facility failed to ensure Resident #37 had oxygen on to maintain her oxygen saturation above 90 percent as ordered. This affected one resident (#37) of eight residents who were ordered oxygen on unit one. Finding include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum data Set (MDS) 3.0 assessment, dated 07/07/22 revealed Resident #37 had severely impaired cognition, required total assist from one staff member for dressing and personal hygiene, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for eating. Review of the August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/15/22 at 11:58 A.M. Resident #37 was observed without oxygen on as ordered. Interview with State tested Nursing Assistant #401 at the time of the observation verified Resident #37 did not have her oxygen on as ordered. On 08/16/22 at 1:33 P.M. and 4:32 P.M. and on 08/17/22 at 8:35 A.M. Resident #37 was observed without oxygen in place. On 08/17/22 at 8:35 A.M. interview with Licensed Practical Nurse (LPN) #405 verified Resident #37 did not have her oxygen on as ordered. LPN #405 obtained an oxygen saturation from Resident #37 at this time and the resident's oxygen saturation level was 89 percent on room air. LPN #405 placed oxygen Resident #37 and her oxygen saturation came up to 91 percent.

Based on observation, record review and interview the facility failed to ensure food items were properly stored and prepared to prevent contamination and/or food borne illness. The facility also failed to maintain the kitchen food preparation countertops, equipment and distribution carts in a sanitary manner. This had the potential to affect all 106 residents who received food and/or beverages from the kitchen. Findings include: 1. On 09/16/21 at 11:27 A.M. observation of the kitchen revealed the pureed food preparation area to have multiple dried substances on the walls, countertops, the base of a blender and the base of a food processor. The countertops and blender were observed to have crumbs of a hard, dried yellow substance resembling eggs, and scattered unknown black substance resembling coffee grounds. The walls, countertops and food processor were observed to have splashes of an unknown dried red substance. The trash can near the area was noted to be full and without a lid. Interview on 09/16/21 at 11:30 A.M. with Registered Dietitian (RD) #203 confirmed the presence of the dried food and other debris in the food preparation area, on the walls, blender, food processor and countertops. RD #203 also confirmed the trash can did not have a lid. The dietitian failed to produce a cleaning schedule at the time of the interview. Review of the facility policy titled Infection Control-Dietary/Food handling, revised 05/2015 revealed guidelines should be followed for the safe preparation, storage and handling of perishable food and proper environmental cleaning. 2. On 09/16/21 at 2:00 P.M. Dietary Personnel #205 was observed preparing cake batter and pouring the batter into pans, on a three tier cart. Further observation of the three tier cart revealed dried orange and red splashes encrusted onto the first, second and third shelves of the cart. The cart also had an unknown light brown substance on the first and third shelves and large specks of an unknown black substance that resembled dirt on the bottom shelf. RD #203 obtained a clean white wet cloth and wiped the cart. Some of the substances were easily removed with the cloth which was then observed to be brown in color. Part of the orange and red splashes that were dried onto the cart, were not able to be wiped clean with the cloth. Additional observations of the walk in refrigerator, revealed three open half gallon cartons of milk. None of the cartons of milk had an open date on them. In one of the cartons of milk, the milk appeared to be light brown in color near the top of the milk, that could be seen through the plastic container. When the milk was moved, it was observed to be curdled and chunky. The cartons of milk were undated. Debris and trash in the form of empty splenda packets and an empty drinking cup with drops of a white liquid in the bottom, were removed from a shelf in the walk-in refrigerator by Dietary Supervisor #204 at the time of the observation, as well as the three cartons of spoiled milk. Additionally, the walk in refrigerator contained an open, undated box of coleslaw, an undated pitcher of tomato juice, and a container of prepared jello, dated 09/09/21 and 09/12/21. Observation of the dry food storage area on 09/16/21 at 2:10 P.M. revealed an open, undated bag of fried onions sitting on a box. Interview with Dietary Supervisor #204 on 09/16/21 at 2:15 P.M. confirmed the opened items were undated and threw them out. Dietary Supervisor #204 revealed she was not sure when the jello was made and threw it away. Dietary Supervisor #204 and RD #203 shared they do not date everything when it was opened, if the manufacturer's date was present on the container. RD #203 revealed she was in charge of ensuring outdated foods were thrown out and stated she usually checked the refrigerator once per month. Review of the daily cleaning schedule for the month of September 2021 revealed a rotating schedule of items to be cleaned in the kitchen. The log was incomplete and lacking initials indicating all cleaning tasks were completed as assigned. Interview on 09/16/21 at 2:15 P.M. with Dietary Supervisor #204 confirmed the daily cleaning schedule log was incomplete and the lack of evidence that sanitation of the kitchen areas were completed. Review of the facility policy titled Infection Control-Dietary/Food handling, revised 05/2015 revealed guidelines should be followed for the safe preparation, storage and handling of perishable food and proper environmental cleaning. 3. On 09/18/21 at 6:32 A.M. Cook #220 was observed preparing for breakfast in the kitchen. Cook #220 was observed to be wearing gloves when he opened the walk-in refrigerator with his gloved hand, entered the refrigerator and exited with a box he set on the counter. Cook #220 then entered the dry storage area and exited with another package he set on the counter. Cook #220 started labeling cartons with a marker, at the counter, then proceeded to enter and exit the walk-in refrigerator again. Cook #220 had not removed his gloves or washed his hands throughout the observation. At this time, Cook #220 opened a package of food with the same gloved hands and poured the contents into a pot that was on the stove. Cook #220 then went into the dry storage area again and removed another package. On 09/18/21 at 6:35 A.M. interview with Cook #220 revealed he should remove his gloves and wash his hands anytime he touches raw meat or other food. When asked, Cook #220 was agreeable he should also change his gloves and wash his hands after touching the refrigerator door handle and prior to handling food. Cook #220 then confirmed he touched the walk-in refrigerator door hand multiple times and then proceeded to prepare food without changing his gloves or washing his hands. Review of the facility policy titled Infection Control-Dietary/Food handling, revised 05/2015 revealed guidelines should be followed for the safe preparation, storage and handling of perishable food and proper environmental cleaning. This deficiency substantiates Complaint Number OH 582.

Based on observation, record review, Centers for Disease Control (CDC) guidance, facility policy and procedure review and interview the facility failed to ensure staff wore appropriate personal protective equipment (PPE) including N95 masks/respirators and face shields, while providing direct care to two residents (#105 and #70) during the Coronavirus (COVID-19) pandemic and while the facility was in outbreak status (facility staff or residents had recently tested positive for COVID-19) to prevent the spread of infection including COVID-19. This had the potential to affect all 106 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #105 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed the resident required extensive assistance of two staff for transfers and bed mobility. Interview on 09/18/21 at 5:48 A.M. with Licensed Practical Nurse Supervisor (LPN) #219 revealed the facility has had multiple recent staff cases of COVID-19 and the facility was in outbreak status which required all staff to wear N95 masks. On 09/18/21 at 6:10 A.M. State tested Nursing Assistant (STNA) #217 was observed assisting Resident #105 to reposition in bed. STNA #217 was observed to be wearing a face mask that was resting below her nose and was not fully covering her mouth and nose. The STNA did not have any type of eye protection in place. During an interview with STNA #217 on 09/18/21 at 6:12 A.M. STNA #217 confirmed she was not wearing any type of eye protection/face shield. STNA #217 confirmed she was wearing a face mask that was falling below her nose. STNA #217 revealed she could not get the mask to stay up above her nose. The STNA also verified she was supposed to be wearing an N95 mask/respirator but stated she couldn't because it hurt her face. STNA #217 reported management staff were aware she was not able to wear an N95 but she had not been offered another type of N95 or other alternate PPE. 2. Review of the medical record for Resident #70 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment, dated 06/30/21 revealed the resident required extensive assistance of two staff for bed mobility and toileting. On 09/18/21 at 6:55 A.M. STNA #217 and STNA #216 were observed exiting Resident #70's room without proper PPE. STNA #217 was observed to be wearing a face mask improperly (below her nose). STNA #216 was observed to be wearing a face shield resting high on her head, like a sun [NAME]. The face shield was not completely covering the mouth, nose or eyes of STNA #216. An interview with STNA #216 at the time of the observation confirmed the face shield was not being worn properly. STNA #216 indicated she could not wear her face shield properly because she gets too hot. An interview with STNA #217 at the time of the observation confirmed she was wearing her face mask below her nose. On 09/18/21 at 8:45 A.M. interview with the Administrator confirmed recent staff cases of COVID-19 and the facility being in outbreak status. The Administrator confirmed all staff should be wearing N95 masks and face shields when providing direct care to residents. The Administrator further revealed they do have two staff who cannot tolerate N95 masks and had provided a physician note to that affect. The Administrator further revealed STNA #217 had not provided any information from her physician related to PPE use. Review of the Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the COVID-19 pandemic, dated 09/10/21 revealed health care professions (HCP) working in facilities located in an area with substantial to high community transmission should implement universal use of PPE including N95 if working in an area where multiple risk factors are present, such as a patient who is unvaccinated and unable to use source control. Additionally, eye protection should be worn during all patient care encounters. Review of the CDC Covid-19 Integrated County View Seven Day Metric for Licking county (the county in which the facility is located) revealed community transmission to be high with a 13.77% positivity rate. Review of the facility policy titled Standard and Transmission Based Precautions, dated 11/28/17 revealed the facility would take appropriate precautions, including isolation to prevent transmission of infectious agents. The facility would use standard approaches as defined by the CDC for universal and transmission based precautions. This deficiency is an incidental finding to Complaint Number OH 582.

Based on staff interview, resident interview, family interview, review of resident council meeting minutes, observations, and medical record review the facility failed to provide adequate staffing to provide needed assistance to a resident who required staff assistance with personal care. This affected one of three residents reviewed for incontinence (Resident #48) with the potential to affect all residents in the facility. The facility census was 110. Findings include: Review of the medical record for the Resident #48 revealed an initial admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #48's bowel and bladder assessment dated [DATE] revealed she had stress incontinence of urine related to obesity and was always continent of her bowel. The assessment also revealed the resident needed moderate assistance to ambulate/transfer to the toilet due to her need for assistance with transfers, orthopedic injuries/fractures, and pain. The comments revealed staff was to assist the resident to the toilet every two to three hours and as needed. Incontinence care was to be provided as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had adequate vision and hearing, had clear speech that was understood, and she understood verbal communication. She was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15 (no cognitive impairment) and no behaviors. She required extensive assistance of one to two staff members for transfers, bed mobility, toileting, and dressing. She was independent with eating and required supervision and set up for personal hygiene. She was occasionally incontinent of her bladder but always continent of her bowels. Review of the plan of care dated 07/19/21 revealed Resident #48 had a fluctuating alteration in elimination due to requiring the assistance of one to two staff members for toileting. Interventions included providing incontinence care as needed. Review of Resident #48's documented bowel movements revealed from 08/04/21 through 09/01/21, the resident was incontinent of bowels on two occasions (08/24/21 and 09/01/21). Review of Resident Council meeting minutes for 06/30/21 revealed there were concerns with call lights not being answered timely resulting in delayed care. Observation on 09/02/21 at 11:28 A.M. revealed Resident #48 was sitting on the toilet, bowel movement noted on the recliner, the pillow on the back of the chair, within the resident's adult brief, and all over the resident's buttocks and upper legs. Interview on 09/02/21 at 11:29 A.M. with State tested Nurse Aide (STNA) #200 revealed Resident #48 was normally continent. She stated she was unsure how long Resident #48's call light was on before transferring her into the bathroom. She confirmed the resident was incontinent and she was gathering supplies for incontinence care. She stated that she was the only aide for both the E and F hall, making it difficult, when she was in residents' room, to know when a call light was going off. Observation on 09/02/21 at 11:30 A.M. incontinence care provided by Licensed Practical Nurse (LPN) #201 and STNA #200 for Resident #48 revealed the resident was embarrassed that she was incontinent. Interview on 09/02/21 at 11:45 A.M. with Family Member #202 reported it took an hour for Resident #48 to get assistance to the bathroom on 09/02/21 from her recliner. She reported that Resident #48 was used to being independent and not relying on anyone. Family Member #202 confirmed Resident #48 was incontinent of her bowels in her recliner and reported feeling embarrassed. She also reported that the aides turn off Resident #48's light and informed the resident they would return to provide care and the resident had to continue to wait for care. Interview on 09/02/21 at 11:47 A.M. with Resident #48 revealed she could only hold her bowels for so long. She reported feeling embarrassed that she was incontinent of her bowels and had bowel movement in her recliner, all over her, and on her pillow that was behind her back. She confirmed had she not had to wait over an hour for assistance to the bathroom she would not have been incontinent. She reported the facility does not have enough staff, so it takes them sometimes over an hour to assist her with care. She also reported the aides telling her every day they were short staffed and only had one aide for two hallways. Interviews on 09/02/21 at 12:08 P.M., 12:11 P.M., 12:27 P.M., and 12:34 P.M., with Dietician #203, Housekeeper #207, Housekeeper #204, and STNA #206 revealed call light wait time being longer now that staffing was low and open positions were not filled. Staff reported unanimously, their short staffing was reflected on their prolonged response time to resident care and other duties. Interviews on 09/02/21 at 12:18 P.M.,12:23 P.M., 12:26 P.M., 12:36 P.M., 12:36 P.M., 12:36 P.M., 2:53 P.M., and 2:59 P.M. with six residents (who wished to remain confidential) revealed concerns related to lengthy call light wait times resulting in prolonged time for provision of care. Interviews on 09/02/21 at 3:01 P.M. with Family Member #209 and Family Member #210 revealed concerns related to insufficient facility staffing. The family members stated resident care was prolonged because of the facility being short staffed and staff members often reminded the residents and families, they were short staffed. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed under prevention and identification of the policy the facility would deploy sufficient staff to meet the needs of the residents. This deficiency substantiates Complaint Number OH 375.

Based on observation, record review, facility policy review and interview the facility failed to implement adequate infection control guidelines for residents in quarantine to prevent the spread of COVID-19. This affected six residents (#7, #30, #53, #58, #71 and #90) and had the potential to affect all 20 residents residing on the J and K halls. The facility census was 93. Findings include: On 12/16/20 at 11:44 A.M. Housekeeper #125 was observed taking clean laundry into Resident #7's room on the J-hall. There were signs on Resident #7's room stating droplet and contact precautions were to be followed. Housekeeper #125 came out of Resident #7's room, removed a personal protective gown that was worn in the resident's room and laid it on top of the stand that contained clean personal protective equipment (PPE). Housekeeper #125 removed her face shield and placed it on the stand with the used gown. Housekeeper #125 donned a clean gown and applied new gloves, and put face shield back on without first cleaning it. Housekeeper #125 then carried the used gown down to the end of K-hall to put it in a bag to be sent to laundry. There was a container with a lid inside Resident #7's room for soiled laundry. Housekeeper then started to pass clean laundry to another resident. Housekeeper #125 verified he had not changed gloves after carrying the used gown down the hall. Review of the signs posted on the door to Resident #7's room revealed Droplet Precautions: everyone must clean their hand before entering and when leaving the room. It also revealed face protection was to be removed before exiting the room. Another sign posted revealed Contact Precautions: everyone must clean their hands before entering and when leaving the room. Providers and staff must also put on gloves before room entry, discard gloves before room exit, put on gown before room entry, and discard gown before room exit. A sign was also posted for donning and doffing PPE. A notation revealed if facilities were implementing reuse or extended use of PPE they would need to adjust their donning and doffing procedures to accommodate those practices. On 12/16/20 at 11:56 A.M. Housekeeper #125 was observed to exit Resident #58's room still wearing the gown that was worn into the resident's room. Housekeeper #125 opened the drawers to the stand containing PPE to get a new gown. Housekeeper #125 placed her face shield on top of stand containing PPE. Housekeeper #125 removed the gown worn into Resident #58's room and placed it on the floor. Housekeeper #125 then took a clean gown and unfolded it. The clean gown touched the floor and the gown that had been put on the floor. Housekeeper #125 did not remove her mask. Housekeeper #125 placed her face shield back on without first cleaning it. Housekeeper #125 picked the gown up off the floor and carried it from J-Hall to K-hall. On 12/16/20 at 12:09 P.M. interview with STNA #152 revealed she cleaned her face shield often due to sweating. However, STNA #152 revealed she did not clean her face shield after exiting the rooms of those residents in quarantine. STNA #152 revealed face shields and masks only had to be changed on the COVID-19 units. On 12/16/20 from 12:25 P.M. through 1:15 P.M. STNA #152 and STNA #153 were observed passing meal trays to Resident #7, #30, #53, #58, #71 and #90. These six residents were identified to be in quarantine. STNA #153 did not change her gown after entering Resident #7, #30, #58, or #90's room. STNA #152 and #153 did not remove or clean their face shields between each resident. On 12/16/20 at 1:03 P.M. interview with STNA #154 revealed gowns were to be changed after being in isolation rooms and when going from one unit to another. On 12/16/20 at 1:05 P.M. interview STNA #153 revealed they no longer had to change gowns unless they were soiled. STNA #153 verified this included when entering/exiting isolation rooms and non-isolation rooms. On 12/16/20 at 2:30 P.M. interview with the Administrator verified staff should be removing their gowns and gloves before exiting a quarantine room. In addition, a surgical mask was to be worn over the N95 mask and the surgical mask was to be discarded before leaving the resident's room. The Administrator agreed face shields should be cleaned after being in a quarantine room. Review of an in-service held in November 2020 revealed all staff, including Housekeeper #125, STNA #152 and STNA #153, were trained in N95 extended re-use guidelines, COVID-19-Extended Use of Eye Protection, donning and doffing of PPE for COVID-19, and novel coronavirus prevention and response. Review of facility policy titled COVID-19 Transmission Based Precautions Best Practice dated 11/2020 revealed suspected but not confirmed COVID-19 infected residents would have a contact and droplet transmission-based precautions signs at the residents doorway in addition to PPE donning and doffing instructions. A private room with a private bathroom was recommended. When care was provided for suspected COVID-19 residents, PPE included a gown, respirator with surgical mask over the respirator, eye protection, and gloves. The gown, surgical mask and gloves would be changed, and eyewear sanitized in between caring for each suspected resident. The respirator could remain in place between caring for each suspected resident as long as it was covered by a surgical mask and not visibly soiled. This deficiency substantiates Complaint Number OH 153.

Based on observation, interview, and record review, the facility failed to ensure food/beverage containers were stored correctly, the dishwasher functioned according to manufactures guidelines, and food/beverage were dated and labeled. This had the potential to affect all 115 residents who receive meals from the kitchen. The census was 115. Findings Include: 1. Observation of the kitchen dry storage room on 10/28/19 at 8:45 [NAME]M. revealed three bowls and four beverage pitchers stored face up and uncovered. Interview with Dietary Director #432 on 10/28/19 at 8:45 [NAME]M. verified the three bowls and four beverage pitchers were stored incorrectly. Observation of the kitchen dry storage room on 10/30/19 at 9:13 [NAME]M. revealed two coffee containers and a clear pitcher stored face up and uncovered. Interview with Dietary Supervisor #40 on 10/30/19 at 9:13 [NAME]M. verified the two coffee containers and clear pitcher were stored incorrectly. 2. Observation of the dishwasher on 10/28/19 at 8:55 [NAME]M. revealed the dishwasher wash tank temperature was 131 degrees Fahrenheit, the rinse tank temperature was 140 degrees Fahrenheit, and the final rinse temperature was 184 degrees Fahrenheit. Interview with Dietary Director #432 on 10/28/19 at 8:55 [NAME]M. verified the dishwasher was a hot water sanitizing dishwasher and the wash tank temperature did not reach 150 degrees Fahrenheit and the rinse tank temperature did not reach 160 degrees Fahrenheit. Observation of the dishwasher on 10/28/19 at 10:40 [NAME]M. revealed the dishwasher wash tank temperature was 148 degrees Fahrenheit, the rinse tank temperature was 148 degrees Fahrenheit, and the final rinse temperature was 191 degrees Fahrenheit. Interview with Dietary Supervisor #40 on 10/28/19 at 10:40 [NAME]M. verified the dishwasher was a hot water sanitizing dishwasher and the wash tank temperature did not reach 150 degrees Fahrenheit and the rinse tank temperature did not reach 160 degrees Fahrenheit. Observation of the dishwasher on 10/30/19 at 10:39 [NAME]M. revealed the dishwasher wash tank temperature was 139 degrees Fahrenheit. Interview with Registered Dietitian (RD) #320 on 10/30/19 at 10:39 [NAME]M. revealed the dishwasher was switched to a chemical sanitizing dishwasher and verified the dishwasher was tank temperature did not reach 140 degrees Fahrenheit. Review of the dishwasher manufacture guidelines dated 10/07/13 revealed when the dishwasher is set up for hot water sanitizing, the wash tank temperature minimum temperature is 150 degrees Fahrenheit, the minimum pumped rinse tank temperature is 160 degrees Fahrenheit, and the minimum final sanitizing rinse temperature is 180 degrees Fahrenheit. Further review of the dishwasher manufacture guidelines revealed when the dishwasher is set up for chemical sanitizing, the wash tank temperature minimum temperature is 140 degrees Fahrenheit, the pumped rinse tank temperature is 120 degrees Fahrenheit, the final rinse minimum temperature is 120 degrees Fahrenheit, and the sanitizer required is 50 parts per million of available chlorine. 3. Observation of the unit one refrigerator on 10/30/19 at 2:15 P.M. revealed an undated open container of nectar thick lemon flavored water. Interview with Unit Manager #165 on 10/30/19 at 2:15 P.M. verified the nectar thick lemon flavored water was not dated as to when it was opened. Observation of the unit two refrigerator on 10/30/19 at 2:18 P.M. revealed resident salsa that was undated and not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:18 P.M. verified the salsa was a residents and was not dated or labeled with the residents name. Observation of the unit three freezer on 10/30/19 at 2:20 P.M. revealed frozen beef and peppers that was not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:20 P.M. verified the frozen beef and peppers was a residents and was not labeled with the residents name. Observation of the unit four freezer on 10/30/19 at 2:24 P.M. revealed a pint of vanilla ice cream that was not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:24 P.M. verified the pint of vanilla ice cream was a residents and was not labeled with the residents name. Review of the policy titled Food Storage- Labeling and Dating last revised (MONTH) (YEAR) revealed all food must has a date that includes the month/day/year on the package indicating the date in which it entered the facility, items must be dated after opening with an Open date and a Use by Date, and pre-thickened water's use by date is 10 days after opening. Review of the policy titled Use and Storage of Food Brought in by Family and Visitors last revised 04/16/18 revealed food items that are already prepared by families or visitors brought in must be labeled and dated.

Based on observation, medical record review, [MEDICAL CONDITION] exposure control plan review, infection control log review, manufacturer guidelines review, policy review and interview, the facility failed to ensure residents received [MEDICAL CONDITION] testing upon admission and failed to ensure a sanitary environment. This affected one (Resident #79) of five residents reviewed for immunizations and two of four units within the facility. The facility was 115. Findings include: 1. Medical record review revealed Resident #79 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Review (MAR) dated (MONTH) 2019 revealed no evidence a mantoux [MEDICATION NAME] skin test was given upon admission. Review of the undated [MEDICAL CONDITION] Exposure Control Plan revealed due to the increasing incidence of [MEDICAL CONDITION] and the potential for nosocomial (facility acquired) transmission of the disease to residents and employees, the facility adopted a [MEDICAL CONDITION] exposure control plan. This plan included to administer a mantoux [MEDICATION NAME] skin test to every resident upon admission. Review of the electronic Immunization record revealed no evidence the resident was administered a mantoux upon admission. Review of the immunization history revealed the last mantoux administered to Resident #79 was on 03/15/14. On 10/30/19 at approximately 3:30 P.M., interview with the Director of Nursing (DON) stated the facility was notified of a limited availability of [MEDICATION NAME] sometime in (MONTH) 2019 and it was determined at that time that residents deemed at low risk were to be checked for symptoms of [MEDICAL CONDITION]. The DON stated it was unknown when the shortage began or resolved itself, and verified there was no evidence a mantoux was administered to Resident #79 upon admission on 06/10/19. Review of the pharmacy email dated 10/30/19 at 3:38 P.M. revealed the availability of [MEDICATION NAME] (mantoux) and [MEDICATION NAME] (diluted [MEDICATION NAME]) would be limited between the dates of 06/14/19 to 09/17/19. On 10/31/19 at 8:09 [NAME]M., interview with the DON verified the pharmacy did not notify the facility of the limited availability of [MEDICATION NAME] or [MEDICATION NAME] until 06/14/19, the resident was admitted on [DATE] and should have been administered a mantoux upon admission. The DON further stated Resident #79's nurse did not administer the mantoux upon admission because she did not realize this was the facility policy. 2. Review of the undated policy: Housekeeping Guidelines revealed routine cleaning of horizontal surfaces including floors were to be cleaned daily with an acceptable hospital grade disinfectant/germicide. Review of the Infection Control Logs dated (MONTH) 2019 to (MONTH) 2019 revealed no increased incidence of gastrointestinal or skin infections. On 10/30/19 at 12:34 P.M., interview with Housekeeper (HSKP) #264 revealed resident rooms and common area floors were mopped with a mixture of a neutral floor cleaner and water on Monday, Wednesday and Friday. HSKP #264 stated on Sunday, Tuesday, Thursday and Saturday the rooms and common area floors were mopped with only water. At the time of the interview, HSKP #264 showed the surveyor a posting in the Unit 1 Housekeeping Room revealing which days staff was to clean the floors with only water. HSKP #264 stated if the floor was visibly dirty she would use bleach spray on the soiled area prior to mopping the area. HSKP #264 stated isolation rooms including the floors were cleaned with bleach products. On 10/30/19 at 1:57 P.M., observation with Laundry and Housekeeping Supervisor (LHS) #176 verified Unit 1 and Unit 2 housekeeping rooms had a posted floor cleaning schedule to use water only to mop the floors on Sunday, Tuesday, Thursday and Saturday. LHS #176 removed the postings during the observation, verified the floors were to be washed with floor cleaner daily and stated last year the facility practice of using only water to clean the floors was discontinued. On 10/30/19 at 2:42 P.M., interview with the DON stated there were no known trends or patterns of infections on Unit 1 or Unit 2. On 10/31/19 at 2:55 P.M., interview with the Administrator verified the State Scentastic Neutral Cleaner was a general cleaner and deodorizer only. Review of the State Scentastic Neutral Cleaner dated (YEAR) revealed the neutral cleaner was safe for use on finished floors, dilute product according to existing floor soils and apply using traditional mopping equipment. There was no evidence the cleaner was a hospital grade disinfectant/germicide.

Based on medical record review, meal card review, observation and interview, the facility failed to ensure a resident on fluid restrictions was monitored. This affected one (Resident #79) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Medical record review revealed Resident #79 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the quarterly Dietary Assessment Narrative dated 10/23/19 revealed Resident #79 had a good intake, received a low concentrated sweet/regular diet with no nutritional [DIAGNOSES REDACTED]. Review of the dietary Meal Card dated 10/31/19 revealed the following fluids to be delivered for each meal: Breakfast included eight ounces (equivalent to 236 ml) of 2% milk, eight ounces (oz) of orange juice and eight (oz) of water. Lunch included eight (oz) of 2% milk, eight (oz) of chocolate milk, eight (oz) of ice tea and eight (oz) of water. Dinner included eight (oz) of 2% milk, eight (oz) of ice tea and eight (oz) of water. Review of the non-electronic and the electronic medical record revealed no evidence Resident #79's total daily fluid intake was being documented or monitored for compliance. Review of the care plan: Potential for Alteration in Nutrition and Hydration related to [DIAGNOSES REDACTED]. On 10/29/19 at 9:36 [NAME]M., a water pitcher and various beverages were observed in the resident's room. On 10/31/19 at 1:08 P.M., interview with the Director of Nursing verified physician orders [REDACTED]. On 10/31/19 at 3:00 P.M., interview with unit manager Licensed Practical Nurse (LPN) #421 verified Resident #79 had an ordered fluid restriction and the facility was not monitoring how much the resident was drinking. LPN #421 stated the resident signed a risk and benefit due to non-compliance with the fluid restriction but verified the facility should still have been implementing the fluid restriction, monitoring intake, documenting refusals and non-compliance and contacting the physician as needed. Further interview revealed there was no breakdown of the amount of fluid nursing and dietary was allotted and dietary alone was offering (2360 ml) fluids with meals which exceeded the ordered daily fluid restriction.

Based on medical record review and interview, the facility failed to implement interventions to restore or maintain bowel function. This affected one (Resident #75) of two residents reviewed for bladder and bowel incontinence. The facility census was 115. Findings include: Medical record review revealed Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge assessment Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #75 was moderately impaired for daily decision-making and was continent of bowel. Review of the quarterly MDS assessments dated 09/20/19 and 10/02/19 revealed Resident #75 was frequently incontinent of bowel with no toileting program. Review of the readmission Bowel/Bladder assessment dated [DATE] revealed Resident #75 required limited assistance with ambulation and transfers and staff was to assist with incontinence as needed. Review of the care plan: Alteration in elimination revised 10/05/19 revealed Resident #75 was continent of bowel, required staff assist with toileting needs and was at risk for constipation. Interventions included to monitor bowel movements every shift, provide incontinence care as needed and monitor for a pattern if resident able to participate. On 10/31/19 at 3:39 P.M., interview with State tested Nurse Aide (STNA) #218 stated she has noted a decline in the resident's continence status and has told the nurse. STNA #218 stated every couple hours the resident was asked if she needed to go to the bathroom but no specific times to her knowledge. STNA #218 also stated the resident is both continent and incontinent now and will sometimes let staff know when she needs to use the bathroom. On 10/31/19 at approximately 4:30 P.M., interview with the Director of Nursing verified Resident #75 had a decline in bowel continence with no intervention and the care plan was not accurate for the resident's continence status.

Based on review of the medical record and staff interview the facility failed to monitor and document the status of the resident's [MEDICAL TREATMENT] access cite. This affected one resident (#216) of one resident reviewed for [MEDICAL TREATMENT]. Facility census was 115. Findings include Review of the medical record revealed Resident #216 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident # 216 required extensive assistance for activities of daily living. No swallowing disorders were identified. Review of the care plan revealed a focus areas for [MEDICAL TREATMENT] with appropriate interventions including to monitor the [MEDICAL TREATMENT] fistula every shift. Interview on 10/31/19 at 11:30 [NAME]M. with Registered Nurse (RN) #165 revealed staff checked Resident #216's fistula dressing when returning to the facility following [MEDICAL TREATMENT]. The dressing remained in place for one day. Staff checked the thrill and bruit of the fistula each shift and documented the check on the resident's treatment administration record (TAR). A physician order [REDACTED]. RN #165 verified no order was in place to check the bruit and thrill every shift. Review of the facility's policy titled [MEDICAL TREATMENT] Management, dated 10/11/18, revealed physician orders [REDACTED]. The care plan included assessment and care of the access site.