Every finding on record at Arlington Pointe Care Center

Based on observation, record review, staff interview, and review of facility policy, the facility failed to ensure the food was stored at safe temperatures and failed to ensure food was thawed appropriately. This had the potential to affect all the residents who receive food from the kitchen. The facility identified one resident (#73) who did not receive food from the kitchen. The facility census was 103.Findings include: Observation of the kitchen on 12/15/25 at 8:37 A.M. revealed the freezer door was open. The temperature reading on a thermometer inside the freezer was 50 degrees Fahrenheit (F). Water droplets were forming on the ceiling, and water was dropping on the floor and food items stored on shelves. Ice was formed on the freezers' cooling unit and had formed on boxes of food underneath the unit. Small containers of ice cream and a sponge cake were soft to the touch. In the main part of the kitchen, there eight hamburger patties thawing on a backing rack beside the oven. The hamburger patties were not cooled in any way or under running water. A plate of breakfast sausages, a cup of scrambled eggs, and a plate of breakfast pizzas were on a shelf. The items were not cooled or heated in any way.Interview with Dietary Supervisor (DS) #385 on 12/15/25 at 8:40 A.M. confirmed the freezer door was open and the temperature inside was 50 F. DS #385 stated the freezer may be going through a defrosting cycle.Interview with Dietary Manager (DM) #355 on 12/15/25 at 8:53 A.M. confirmed the findings in the freezer, DM #355 stated he would check with maintenance. DM #355 confirmed food items should be thawed in the refrigerator or under water and food prepared food should be stored under 41 F or above 135 F.Review of facility provided documentation revealed Resident #73 was nothing by mouth (NPO) and did not receive food prepared in the facility's kitchen.Review of the facility policy titled Food Storage Refrigerator/Freezers revised July 2025 revealed temperatures should be 35-40 degrees F for refrigerator and less than zero for freezers.Review of the facility policy titled General Hazard Analysis Critical Control Points Guidelines for Food Safety dated 2023 revealed safe thawing practices included:- Meat, fish and/or poultry should be thawed in a refrigerator in a drip proof container and in a way that prevents cross contamination (on a lower shelf with nothing underneath it). - Completely submerge the item in clean running water (less than 70F) that is running fast enough to agitate and float off loose ice particles.- Thaw the item in a microwave oven using the defrost mode only if it is cooked immediately after thawing.- Thaw as part of the cooking process.

Based on observation of meal preparation, record review, staff interview, and review of recipes, the facility failed to ensure pureed food was prepared by the recipe to ensure nutritional value of the food was maintained. This had the potential to affect six residents (#34, #37, #62, #71, #76, and #116) who the facility identified as being ordered puree diets. The facility census was 103. Findings include: Observations on 12/17/25 at 10:07 A.M. revealed Dietary Supervisor (DS) #385 was completing pureed meal preparation and stated there were currently six residents on pureed diets and would be preparing a little extra food in case needed.DS #385 began with preparing pureed vegetable soup. DS #385 poured vegetable soup into a blender. DS #385 did not measure the amount of soup being put into the blender. DS #385 then proceeded to blend the vegetable soup without adding any extra ingredients including saltine crackers. The facility recipe titled Soup Chunky Pureed Thick revealed the recipe was for 20 servings. The recipe called for one and one-fourth and two cups of chunky vegetable soup, 60 saltine crackers, and one and one-third tablespoon of thickener. Liquid was to be drained from the soup and reserved. Soup ingredients and crackers were to be blended to a fine consistency. Food thickener and reserved liquid was to be added and blended until smooth.DS #385 then prepared pureed onion rings. DS #385 put deep fried onion rings into the blender. DS #385 did not count any onion rings. DS #385 blended the onion rings by adding hot water. DS #385 did not add any other ingredients including milk. The facility recipe titled Onion Rings Pureed Thick revealed the recipe was for 20 servings. The recipe called for 80 onion rings, two cups of two percent white milk, and one-third tablespoon of food thickener. Onion rings were to be blended by adding milk until smooth and adding thickener. DS #385 then prepared pureed grilled ham and cheese sandwiches. DS #385 put 18 ham slices, nine slices of cheese, nine slices of bread and blended together by using hot water. DS #385 did not add any other ingredients or food thickener. Ham and cheese were to be blended with hot water and by adding thickener. Bread was to be pureed separately. The facility recipe titled Sandwich Cheese & Ham Grilled Pureed Thick revealed the recipe was for 20 servings. The recipe called for two pounds and eight ounces of ham, 20 slices of cheddar cheese, five-eighth teaspoon of ham base concentrate, two-thirds cup of hot water, one-fourth cup and one tablespoon, and 40 two-thirds slices of bread. Interview with Dietary Director (DD) #355 and DS #385 on 12/17/25 at 10:30 A.M. confirmed the facility had recipes for pureed food items. Both DD #355 and DS #385 confirmed the recipes were not followed when preparing the pureed vegetable soup, pureed onion rings, and pureed grilled ham and cheese. Both DD #355 and DS #385 confirmed the purpose of using recipes was to maintain the nutritive value of food. Review of the facility's documentation revealed Residents #34, #37, #62, #71, #76, and #116 were ordered puree diets.

Based on record review, resident interview, and staff interview, the facility failed to provide emergency dental care for a resident. This affected one resident (#55) of three residents (#55, #75, and #98) reviewed for dental services. The facility census was 100. Findings include: Record review for Resident #55 revealed an admitted [DATE]. Diagnoses included gastro-esophageal reflux disease (GERD), major depressive disorder, anxiety disorder, obesity, osteoarthritis, dysphagia, essential primary hypertension, and diabetes mellitus. Review of Resident #55's Minimum Data Set (MDS) assessment, dated 10/25/24, revealed the resident was severely cognitively impaired. Further review of the MDS assessment confirmed Resident #55 required moderate assistance from staff with eating. Review of Resident #55's progress notes revealed on 08/23/24 Resident #55 requested to be seen by the dentist. Further review of the progress notes revealed on 08/28/24, the facility contacted Resident #55's responsible party and notified of the dentist recommendation for dental surgery. The facility stated they will have Resident #55's family sign the consent for dental surgery and the forms will be left at the front desk. Nothing else was documented related to the emergency dental surgery. Review of Resident #55's dental visit note, dated 08/27/24, revealed Resident #55 had an emergency dental consult on 08/27/24 at the facility. Further review of the dental note revealed Resident #55 requested lower dentures following the extraction of the broken teeth. The contracted facility dentist stated Resident #55 had a broken tooth recommended extraction of the broken tooth. Interview on 12/26/24 at 4:13 P.M. with the Director of Nursing (DON) confirmed Resident #55 had a recommendation from the dentist to have her broken tooth extracted. The visit and recommendation from the Dentist was written on 08/27/24. The DON confirmed the facility failed to document any follow up related to Resident #55's tooth extraction. The DON confirmed the facility failed to ensure the emergency visit extraction recommendation for Resident #55 was completed. Interview on 12/26/24 at 4:50 P.M. with Resident #55 confirmed she has a broken tooth that has not been removed. Resident #55 confirmed the broken tooth causes pain at times. This deficiency represents non-compliance investigated under Complaint Number OH00159744.

Based on record review, interviews and policy review, the facility failed to notify a resident's family of a change in condition requiring a resident to go to the hospital. This affected one (Resident #8) of four residents reviewed for change in condition. The facility census was 95. Findings include: Review of the medical record revealed Resident #8 admitted to the facility on [DATE] with diagnoses of elevated white blood cell count, other specified abnormal findings of blood chemistry, cerebral infarction, and post hemorrhagic anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. Review of lab results collected on 04/22/24 at 4:50 A.M. and received on 04/22/24 at 9:32 A.M. revealed Resident #8 had a hemoglobin of 6.9 grams per deciliter (G/DL) Reference range is 11.2-15.7. Review of physician orders dated 04/22/24 at 12:09 P.M. revealed an order for Resident #8 to get a Blood Transfusion at 8:30 A.M. on 04/23/24. Review of Resident #8's nurse's progress notes revealed no documentation on new physician order received for the blood transfusion. There was no documentation the family was notified of the resident being sent out for a blood transfusion. Interview on 05/06/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #733 confirmed there was a recent incident where Resident #8 was sent out to have a blood transfusion on 04/23/22 and the family was not notified. Interview on 05/06/24 at 2:16 P.M. with Director of Nursing (DON) confirmed Resident #8 was sent out for a blood transfusion on 04/23/24, but she thought family had been notified. Review of the policy for Change in Condition dated 11/23 revealed the facility will promptly notify the resident, his/her attending physician, and the resident's sponsor/responsible party in an event of a change in condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00153318

Based on record review and staff interviews the facility failed notify the ordering physician of lab results on a urinalysis with culture that fell outside of the clinical reference range. This affected one (Resident #101) of four residents reviewed for lab services. The facility census was 95. Findings include: Review of the medical record revealed Resident #101 admitted to the facility on [DATE] and discharged from the facility on 04/13/24 with diagnoses of spinal stenosis, lumbar region without neurogenic claudication, and interstitial cystitis (chronic) with hematuria. Review of the Minimum Data Set (MDS) assessment completed on 04/13/24 revealed Resident #101 was cognitively intact. Review of Resident #10's care plan revealed the residnet was at risk for for infection due to immobility, incontinence and surgical site with intervention to monitor lab work. Review of physician orders for Resident #101 revealed an order for a urinalysis with culture dated 03/20/24. Review of laboratory results dated [DATE] revealed Resident #101's urine culture was positive for a Urinary Tract Infection (UTI). The organism identified was enterococcus faecium (VRE) was susceptible to the antibiotics Linezolid and Nitrofurantoin. Review of physician orders revealed an order dated 04/13/24 for Macrobid oral capsule 100 milligrams (mg) (Nitrofurantoin Monohyd Macro) Give 100 mg by mouth two times a day for UTI Vancomycin-resistant Enterococcus VRE for 7 Days. Review of Resident #101 nurse's progress notes revealed on 04/13/24 at 9:43 A.M. the physician was notified Resident #101 had a change in mental status and increased weakness with moderate confusion and was notified urinalysis sensitivity results. Interview on 05/06/24 at 11:56 A.M. with Registered Nurse (RN) #732 confirmed Resident #101 recently had a UTI and she failed to notify the physician of the results of the urinalysis and culture when they came back. Interview confirmed it was approximately 10 days after the results the physician was notified and an antibiotic was initiated on 04/13/24. Interview confirmed the process was to notify the physician immediately if critical or by the end of the day if lab results are out of range. Interview on 05/06/24 at 12:55 P.M. with Licensed Practical Nurse (LPN) #776 confirmed the physician was not notified of the urinalysis until almost 10 days later on 04/13/24 when an antibiotic was initiated. Interview confirmed the physician should be contacted on the day lab results are received if out of range. Interview on 05/06/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed Resident #101 was not started on an antibiotic until 04/13/24 and confirmed there was no documentation showing the physician was aware of the results of the urinalysis until 04/13/24 when the resident had a change in mental status. This deficiency represents non-compliance investigated under Complaint Number OH00153318.

Based on observation, staff interview and review of facility policy, the facility failed to provide proper infection control measures to prevent the potential infection during wound care. This affected one Resident #31 out of three Residents (#17, #26, #31) reviewed for wound care. The facility census was 94. Findings include Review of Resident #31 revealed an admitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set assessment (MDS) dated [DATE] revealed resident #31 had impaired cognition. Further review of the MDS assessment revealed resident required extensive assistance and supervision for activities of daily living (ADLs). Review of the physician orders for Resident #31 dated 08/31/22 revealed resident was ordered to receive her left lateral ankle cleansed with normal saline (NS), apply [MEDICATION(S)] (wound gel for moisture) and covered with bordered gauze every other day and as needed (PRN) for skin integrity. Observation of wound care on 09/09/22 at 11:10 A.M. revealed licensed practical nurse (LPN) #164 washed her hands and applied gloves prior to providing care to Resident #31. Observation revealed LPN #164 approached Residents #31 while she was seated in her wheelchair, and LPN #164 used both gloved hands to reposition her scrub pants and squatted down in front of resident to provide wound care to Resident #31's left lower leg. Observation revealed LPN #164 used her gloved hands to pull up Resident #31's left pants leg, removed Resident #31's non-skid sock and then removed resident's soiled dressing. Continued observation revealed LPN #164 followed the physician order by cleansing the left lateral ankle with NS, applied [MEDICATION(S)] wound gel, and covered the wound with a bordered gauze. However, at no time during the removal of the soiled dressing and any time during cleaning the wound or redressing the wound did LPN #164 change her gloves or wash her hands. Interview on 09/09/22 at 11:19 A.M. interview with LPN #164 confirmed she did not wash her hands or change her gloves during or after the removal of soiled wound bandages, cleaning of the wound, or redressing of the wound. LPN #164 stated she should have washed her hands following the removal of the soiled dressings and prior to the wound care and applying the new wound dressing. Review of the facility policy titled, General Infection Control, dated 03/09/22, stated all staff will follow proper infection control measures to prevent the spread of infection. Further review of the policy revealed, All staff will perform hand hygiene, c. after handling contaminated equipment or supplies. This is an incidental finding identified during a complaint survey completed on 09/10/22.

Based on medical record review, observations, staff interviews, review of a facility policy, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore the proper personal protective equipment when entering the room of a resident who was in quarantine for COVID-19. This affected one (Resident #188) and had the potential to to affect all 92 residents in the facility. The facility census was 92. Findings include: Review of Resident #188's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #188's admission assessment, dated 07/19/22, revealed Resident #188 was not cognitively impaired and required assistance of one staff with care. Resident #188 was placed in quarantine (transmission based precautions) due to a recent hospital stay and possible exposure to COVID-19. Observation on 07/18/22 at 10:00 A.M. revealed Housekeeper #53 entered Resident #188's room while wearing a surgical mask which was pulled below her nose. Housekeeper #53 went in and out of Resident #188's room twice. Observation on 07/18/22 at 12:14 P.M. revealed State tested Nursing Assistant (STNA) #16 was delivering meal trays and went in Resident #188's room while only wearing a surgical mask and without donning an isolation gown. Interview with Housekeeper #53 on 07/18/22 at 10:05 A.M. verified Resident #188 was in quarantine and she did not wear the correct personal protective equipment (PPE) while in Resident #188's room. Housekeeper #53 verified her mask was not in the correct position. Interview on 07/18/22 at 12:20 P.M., with STNA #16 verified he/she was not wearing proper PPE while entering Resident #188's room. Review of the facility policy titled COVID-19, revised 02/2022, revealed residents in quarantine require transmission based precautions and should be cared for by staff wearing full PPE. Review of the CDC guidelines, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 02/02/22, revealed healthcare personnel caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator).

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the physician was notified of a weight gains as ordered. This affected two (Resident #26 and #62) out of six residents reviewed for notification of change. The facility census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed Resident #26 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderate cognitive impairment. Review of the care plan for Resident #26 revealed Resident #26 had potential for or alteration in cardiac output/arrhythmia/cardiorespiratory distress related to her coronary artery disease, [CONDITION(S)], hypertension, congestive heart failure, and [CONDITION(S)]. The interventions included monitoring vital signs and weights as ordered. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated staff were to notify the physician if Resident #26's weight gain was greater than five pounds in three days. Resident #26's weight was to be obtained in the morning. Review of Resident #26's weight records revealed Resident #26 weighed 167.5 pounds on 06/27/22 and weighed 176.6 pounds on 06/30/22 which reflected a 9.1 pound weight gain from 06/27/22 to 06/30/22. Further review of the weight records revealed Resident #26 weighed 167.4 pounds on 07/07/22 and weighed 177 pounds on 07/09/22 which reflected a 9.6 pound weight gain from 07/07/22 to 07/09/22. Interview with the Director of Nursing (DON) on 07/21/22 at 2:31 P.M. verified the physician was not notified of Resident #26's weight gains on 06/30/22 (9.1 pounds) and 07/09/22 (9.6 pounds). Review of the policy titled Procedure for Weight Loss/Gain Monitoring, reviewed 11/2021, revealed weight changes were monitored by nursing and the dietitian or diet tech. It indicated the resident, the resident's physician and the resident's sponsor/responsible party are notified of significant weight change. 2. Review of the medical record for Resident #62 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #62 dated 07/01/22 revealed the resident had impaired cognition. Review of the plan of care for Resident #62 dated 10/06/21 revealed the resident had the potential for an alteration in cardiac function related to hypertension and [CONDITION(S)] fibrillation. Interventions included administer medications as ordered, assess for [CONDITION(S)], and monitor vital signs and weights as ordered. Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order stated to obtain daily weights and call the doctor with a weight gain of three pounds in one day or more than five pounds in one week. Review of the medical record for Resident #62 revealed no weights were obtained on 07/14/22 and 07/15/22. The weight recorded on 07/13/22 was 149.4 pounds (lbs.) and on 07/16/22 was 159 lbs. Resident #62 experienced a weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Review of the progress notes for Resident #62 revealed there was no evidence the facility notified the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing (DON) confirmed no daily weights were obtained on 07/14/22 and 07/15/22 for Resident #62. The DON also confirmed the order for daily weights was current and that the order specified to notify the doctor with a three-pound weight gain in a day or five pounds in a week. The DON also confirmed there was no notification to the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22.

Based on medical record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASSAR) and notify the state mental health authority for residents with new mental health diagnoses. This affected two residents (#35 and #83) out of three residents reviewed for PASSAR's. The facility census was 92. Findings include: 1. Review of the medical record for Resident #35 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASSAR for Resident #35 dated 02/18/19, revealed psychotic disorder was not included in the assessment. Review of the medical record for Resident #35 revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #35 revealed the facility did not complete a significant change PASSAR for Resident #35 following Resident #35's new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/19/22 at 2:47 P.M. with Admissions Director (AD) #37 confirmed no significant change PASSAR was completed for Resident #35 after the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the medical record for Resident #83 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASSAR for Resident #83 dated 08/29/19, revealed no psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #83 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #83 revealed the facility did not complete a significant change PASSAR for Resident #83 following Resident #83's new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/19/22 at 2:47 P.M. with Admissions Director #37 confirmed no significant change PASSAR was completed for Resident #83 after Resident #83 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure daily weights were completed as ordered. Additionally, the facility failed to timely implement interventions and reassess a resident with severe weight loss. This affected two (Resident #62 and #83) out of three residents reviewed for nutrition. The facility census was 92. 1. Review of the medical record for Resident #62 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #62 dated 07/01/22 revealed the resident had impaired cognition. Review of the plan of care for Resident #62 dated 10/06/21 revealed the resident had the potential for an alteration in cardiac function related to hypertension and [CONDITION(S)] fibrillation. Interventions included administer medications as ordered, assess for [CONDITION(S)], and monitor vital signs and weights as ordered. Review of the active physician orders for Resident #62 revealed an order with a start date of 10/27/21 for daily weights. The order stated to obtain daily weights and call the doctor with a weight gain of three pounds in one day or more than five pounds in one week. Review of the medical record for Resident #62 revealed no weights were obtained on 07/14/22 and 07/15/22. The weight recorded on 07/13/22 was 149.4 pounds (lbs.) and on 07/16/22 was 159 lbs. Resident #62 experienced a weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Review of the progress notes for Resident #62 revealed no documented reason regarding why Resident #62's weight was not obtained on 07/14/22 and 07/15/22. There was no evidence the facility notified the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Resident #62 did not experience any distress or negative outcome related to the failure to weigh the resident daily and report the weights. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing (DON) confirmed no daily weights were obtained on 07/14/22 and 07/15/22 for Resident #62. The DON also confirmed the order for daily weights was current and that the order specified to notify the doctor with a three-pound weight gain in a day or five pounds in a week. The DON also confirmed there was no notification to the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. 2. Review of the medical record for Resident #83 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set assessment for Resident #83 dated 07/05/22 revealed the resident had an impaired cognition. No significant weight loss or gain was noted for Resident #83 on the assessment. Review of the plan of care for Resident #83 dated 01/27/22 revealed Resident #83 was at risk for potential nutritional problems related to therapeutic diet. Interventions included providing diet as ordered, monitoring weight monthly and as needed, and providing and serving supplements as ordered. Review of the medical record for Resident #83 revealed a weight on 06/08/22 of 210 lbs. A weight of 194.3 lbs. was obtained on 07/11/22. Review of the physician orders for Resident #83 from 07/11/22 to 07/19/22 revealed no orders to monitor Resident #83's weight more frequently or to obtain a reweigh for Resident #83. Review of the medical record for Resident #83 revealed a weight of 199 lbs. was obtained on 07/19/22. Review of the dietary notes for Resident #83 dated 07/20/22 revealed Resident #83 would be started on a nutritional supplement twice daily to help with weight gain. Review of the medical record for Resident #83 revealed no nutritional interventions were implemented after Resident #83 was found to have experienced a severe weight loss on 07/11/22 until 07/20/22 when Resident #83 was started on a nutritional supplement twice daily to help with weight gain. Interview on 07/19/22 at 4:20 P.M. with Registered Dietitian (RD) #121 confirmed no reweigh had been completed on Resident #83 after identifying that he experienced a severe 15.7 lb. (7.47 percent) weight loss from 06/08/22 to 07/11/22. RD #121 stated that she would have typically recommended Resident #83 be reweighed to determine the accuracy of the weight and had no explanation as to why Resident #83 was not reweighed. RD #121 also stated that she had not made the recommendation or requested an order be put in to reweigh Resident #83. Review of the facility policy titled Procedure for Weight loss/gain monitoring dated 11/2021, revealed the facility failed to implement their policy. The dietician or dietician technician, in coordination with the interdisciplinary team evaluate the weight change and make appropriate recommendations for unplanned weight changes as necessary to meet resident's goals for care.

Based on observations, staff interviews, review of the facility's policy, review of the online resources from Centers for Medicare and Medicaid (CMS), review of the COVID-19 Nursing Home data website, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in the facility to prevent the spread of Coronavirus (COVID-19). This had the potential to affect all 63 residents residing in the facility. Findings include: Observations during the initial facility tour with Director of Nursing (DON) on 01/26/21 at 8:45 A.M. through 9:16 A.M. revealed numerous direct care staff members with no eye protection in place. Observation of the dedicated COVID-19 unit (end of 400 hallway) during the initial tour revealed State tested Nursing Aide (STNA) #42 was observed to be inside the COVID-19 unit with no eye protection in place and Residents #5's door was open. Interview with STNA #42 at same time indicated she forgot to put her eye protection on when she entered the unit. Interview with DON at same time verified STNA #42 did not have eye protection in place while she worked inside the COVID-19 unit. During an observation/tour of laundry on 01/26/21 at 10:10 A.M. revealed Director of Housekeeping/Laundry #10 was observed in resident care areas with eyeglasses on and no proper eye protection in place. Interview at the same with Director of Housekeeping/Laundry #10 time verified she had her eyeglasses on and no proper eye protection in place while being in resident care areas. Housekeeping/Laundry #10 stated she was not aware she had to have additional eye protection in place besides her eyeglasses. During an observation of the facility's PPE stock on 01/26/21 at 10:14 A.M. with STNA #43 revealed the facility had sufficient amount of PPE which included face shields and goggles for eye protection, N95 masks, gowns and shoe coverings. STNA #43 stated the facility was not in a crisis strategy related to PPE equipment. Observation of the B Wing nurses desk on 01/26/21 at 10:28 A.M. revealed Licensed Practical Nurse (LPN) #30 was at the nurse's desk with no eye protection in place as Resident #40 sat in a wheelchair directly at the nurse's desk with no mask in place. Interview with LPN #30 immediately afterwards verified she did was not wearing eye protection and Resident #40 did not have a facemask in place as they were less than six feet from each other. LPN #30 stated she forgot to put eye protection on this morning at the beginning of her shift. During continued observations of B-wing revealed STNA #40 completed tasks on the unit with no eye protection in place. Continued observation revealed STNA #40 retrieved a surgical mask from the nurse's desk, bent down to Resident #40 and placed the surgical mask on resident as resident coughed while STNA #40 was observed to have no eye protection in place. Interview with STNA #40 on 01/26/21 at 10:32 A.M. verified she provided direct care to Resident #40 with no eye protection in place. STNA #40 stated she forgot her eye protection at home. During an observation of A-wing on 01/26/21 at 10:51 A.M. revealed STNA #41 completed tasks on the 100-hallway with no eye protection in place. Observation of A-wing also revealed Registered Nurse (RN) #20 completed tasks in resident areas with no eye protection in place. Continued observation of A-wing revealed Resident #10, who the facility identified as being in quarantine due to a new admission was sitting in the common area dining room directly across from the nurse's desk with no mask in place. Further observation at 11:01 A.M. revealed STNA #41 retrieved a surgical mask and attempted to put a mask on Resident #10 with no eye protection in place. Interview with STNA #41 on 01/16/21 at 11:02 A.M. verified she completed various resident tasks and attempted to put a facemask on Resident #10 with no eye protection in place. STNA #41 indicated Resident #10 was in quarantine due to being a new admission. STNA #41 stated staff placed Resident #10 in the dining area due to his wandering activities. During continued observations of the A-wing on 01/26/21 at 11:04 A.M. revealed RN #21 completed tasks with prescription eyeglasses in place with plastic side coverings attached over the arms of her glasses. Interview with RN #21 at the same time verified she did not have proper eye protection in place. RN #21 stated she thought the side pieces attached to her glasses were enough eye protection. Interview with RN #21 indicated Resident #10 was on quarantine due to being a new admission. RN #21 also stated Resident #10 wondered due to confusion and was a fall risk and staff placed him in the common dining room to watch him. During an observation of lunch trays being served on the 400 hall of A wing on 01/26/21 at 11:45 A.M. revealed Therapy Staff #5 was in Resident #10's room sitting at a table with the resident completing a therapy session. Therapy Staff #5 was observed to be wearing a disposable gown, eyeglasses with plastic shields attached to arms of her glasses and Resident #10 was observed with no mask in place. During continued observation of Resident #10's room at 11:54 A.M. revealed STNA #41 entered Resident #10's room to deliver a lunch tray with no protective gown in place. Further observation revealed STNA #41 sat down at the table with Resident #10 and started assisting resident with feeding. Interview with STNA #41 at 12:20 P.M. indicated she had to cue and occasionally assist Resident #10 with eating. STNA #41 verified she did not have a protective gown in place while she provided direct care to Resident #10. STNA #41 stated she was only required to wear a protective gown when she did personal care such as showers or incontinence care. During an observation of the COVID-19 unit on 01/26/21 at 12:27 P.M. revealed STNA #41 was in the unit with no eye protection in place and the door to Resident #5's room was open. Interview at same time with STNA #41 indicated she took her PPE off and forgot to put it back on. During an observation of the COVID-19 testing for facility staff in A wing on 01/26/21 at 1:02 P.M. revealed Dietary Aide #8 was observed in the resident common area with a homemade cloth mask on. Observation revealed STNA #43 and Human Resources #9 checked Dietary Aide in for testing. Interview with STNA #43 and Human Resources #9 at the same time verified Dietary Aide #8 had a homemade cloth mask while being in the resident common area. STNA #43 stated she did not notice the homemade cloth mask. Review of the COVID-19 Nursing Home data website (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg) of the most recent county positivity rates revealed the facility's county percent positivity in prior fourteen days was coded the color red indicating substantial community transmission. 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. Review of the Centers for Medicare and Medicaid Services (CMS) memo titled Nursing Home Guidance, dated 04/02/20, revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control. Review of the CDC's COVID-19 guideline titled Responding to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed to determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Review of the CDC's COVID-19 guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID 19 Pandemic (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), dated 07/15/20, revealed Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. Staff should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient encounters and wear an N95 or equivalent or higher-level respirator, instead of a facemask. Guidance recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection, revealed as a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. Patients should wear a facemask or cloth face covering to contain secretions during transport. If patients cannot tolerate a facemask or cloth face covering or one is not available, they should use tissues to cover their mouth and nose while out of their room. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions, put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, put on clean, non-sterile gloves upon entry into the patient room or care area, and put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The guideline also indicates if worn properly, a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control). Review of the CDC's guidance on eye protection (https://www.cdc.gov/niosh/topics/eye/eye-infectious.html) revealed prescription eyeglasses are not considered eye protection and the use of prescription safety glasses with side protection are available, but do not protect against splashes or droplets as well as goggles. Review of the facility's policy titled COVID-19, dated 08/01/20, revealed the facility will follow the most recent CDC recommendations. Policy also indicated new admissions will be placed in quarantine for 14 days and monitored for signs and symptoms of COVID-19 and residents in quarantine will received care and services in their rooms. The policy also indicated the facility will follow standard and transmission-based precautions which included eye protection for all residents in the quarantine unit and staff were required to wear PPE according to CDC guidelines. Staff shall don respirator, eye protection and gown upon entry to patient room or care area.

Based on medical record review, staff interview and review of the facility's policy, the facility failed to notify a resident's family/representative of a change in condition. This affected one resident (#100) of three residents reviewed for notification of change. The facility census was 78. Findings include: Medical record review for Resident #100 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the nursing notes for Resident #100, dated 11/05/20 at 2:14 P.M., revealed a blood pressure medication was not given due to a low blood pressure reading of 75/48. The resident was placed in a Trendelenburg's position (head lower that feet), skin color was ashen (gray in color), oral membranes were dry and sticky, refused fluids and supplements. Pressure ulcer dressing was changed and noted with red and yellow tissue in wound bed. The wound had an odor. The nursing note dated 11/05/20 at 2:18 P.M. revealed the resident had a large amount of brown watery stools containing mucous and blood. The supervisor was notified. On 11/05/20 at 2:29 P.M., it was noted the resident had an improved blood pressure reading, skin was natural, warm and dry. The nurse will continue to monitor, supervisor and upper management was notified. There was no indication the resident's family/representative was notified of the change indication noted on 11/05/20. Interview with Director of Nursing (DON) on 12/01/20 at 6:48 P.M. verified the resident's nursing notes was silent for documentation that the family member/representative for Resident #100 was notified. The DON verified the resident's family/representative should have been notified regarding a change in condition. Review of the facility's policy titled Change in Condition, dated 01/2020, revealed the facility will immediately inform the resident, the resident's physician and the residents legal responsible party when the following occurs: the resident is involved in an accident or incident which results in injury and had the potential for requiring physician intervention. This deficiency substantiates Complaint Number OH 236.

Based on observation, staff interview, Centers for Disease Control (CDC) recommendations, and review of facility infection control policy, the facility failed to develop a policy based on current CDC recommendations and implement infection control policies and procedure regarding the re-use of filtering facepiece respirators (FFRs). The facility did not have any current cases of COVID 19 for staff or residents. This had the potential to affect all 80 residents of the facility. Findings include: A tour of the facility was conducted with the Director of Nursing (DON) on 10/22/20 at 10:35 A.M. While touring the facility nursing and ancillary staff present on resident unit were observed wearing N95 FFRs with a surgical mask over them. During the tour the DON was queried as to how many N95 masks were provided to staff, and how often and at what interval were they re-used. The DON stated that staff were permitted to wear the same N95 mask for a week of shifts at a time. Interview with Registered Nurse (RN) #17 on 10/27/20 at 1:30 P.M. revealed the nurse was wearing the same N95 mask three days/shifts in a row i.e. the same mask for the work week. Interview with State tested Nurse Aide (STNA) #78 on 10/27/20 at 3:41 P.M. revealed the STNA was wearing the same N95 mask for three days/shift in a row within the same work week. She reported that this was the policy that was conveyed to her by supervisory/administrative nursing staff. Interview with Licensed Practical Nurse (LPN) #80 on 10/28/20 at 6:30 A.M. revealed that staff were permitted to wear the same N95 mask for three days/shifts in a row, and that was what she did. Review of facility policy titled Re-use and Extended use of Personal Protective Equipment (PPE) to prevent exhausting supply during COVID-19 nation shortage revealed the facility permitted staff to re-use the same N95 particulate respirator for one standard workweek i.e. five 8 hour shifts or three 12 hour shifts. The policy did not allow for a 72 hour period between uses for the same mask. Interview with the Administrator and DON on 10/28/20 at 12:20 P.M. confirmed the facility policy specified that staff could wear the same N95 mask three 12 hour shifts in a row, or five 8 hours days in a row. The communicated they were not using a new one each day as they were conserving the mask as they were having trouble getting them from their usual sources. Follow-up interview with the DON on 10/28/20 at 2:55 P.M. revealed the facility was having difficulty obtaining a uninterrupted supply of N95 masks. The DON shared the facility was not able to get N95 masks in sufficient quantity from their usual vendor, and the County emergency management agency was not shipping them out either. There were no resident cases of COVID-19 in the facility at the time of the survey. Review of Center for Disease Control guidelines and recommendation for Coronavirus Disease 2019 under the section titled Strategies for Optimizing the Supply of N95 Respirators updated 06/28/20 included the following: Re-use refers to the practice of using the same N95 respirator by one Health Care Provider (HCP) for multiple encounters with different patients but removing it (i.e. doffing) after each encounter. This practice is often referred to as limited reuse because restrictions are in place to limit the number of times the same respirator is reused. It is important to consult with the respirator manufacturer regarding the maximum number of donnings or uses the recommend for the N95 respirator model. If no manufacturer guidance is available, data suggest limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin. N95 and other disposable respirators should not be shared by multiple HCP. CDC has recommended guidance on implementation of limited re-use of N95 respirators in healthcare settings. For pathogens for which contact transmission is not a concern, routine limited reuse of single-use disposable respirators has been practiced for decades. For example, for [MEDICAL CONDITION] prevention, a respirator classified as disposable can be reused by the same provider as long as the respirator maintains its structural and functional integrity. If reuse must be implemented in times of shortages, HCP could be encouraged to reuse their N95 respirators when caring for patients with [MEDICAL CONDITION] disease first. Limited re-use of N95 respirators when caring for patients with COVID-19 might also become necessary. However, it is unknown what the potential contribution of contact transmission is for [DIAGNOSES REDACTED]-CoV-2, and caution should be used. Re-use should be implemented according to CDC guidance. Re-use has been recommended as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics. During times of crisis, [MEDICATION NAME] limited re-use while also implementing extended use can be considered. It may also be necessary to re-use N95 respirators when caring for patients with [MEDICATION NAME] or [DIAGNOSES REDACTED], although contact transmission poses a risk to HCP who implement this practice. Ideally, N95 respirators should not be re-used by HCP who care for patients with COVID-19 then care for other patients with [MEDICATION NAME], [DIAGNOSES REDACTED], and [MEDICAL CONDITION], and vice versa. Respirators grossly contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients should be discarded. HCP can consider using a face shield or facemask over the respirator to reduce/prevent contamination of the N95 respirator. HCP re-using an N95 respirators should use a clean pair of gloves when donning or adjusting a previously worn N95 respirator. It is important to discard gloves and perform hand hygiene after the N95 respirator is donned or adjusted. The surfaces of a properly donned and functioning National Institute for Occupation Safety and Health (NIOSH)-approved N95 respirator will become contaminated with pathogens while filtering the inhalation air of the wearer during exposures to pathogen laden aerosols. The pathogens on the filter materials of the respirator may be transferred to the wearer upon contact with the respirator during activities such as adjusting the respirator, improper doffing of the respirator, or when performing a user-seal check when redonnng a previously worn respirator. One effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to COVID-19 patients a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for [DIAGNOSES REDACTED]-CoV2 ([MEDICAL CONDITION] that caused COVID-19). HCP should still treat the respirator as though it is still contaminated and follow the precautions outlined in CDC's re-use recommendations.

Based on record review and staff interview, the facility failed to update the resident's care plan to include a post- fall intervention ordered by the resident's physician. This affected one (Resident #3) of three resident reviewed for staffing issues. The census was 95. Findings include: Review of the record revealed Resident #3 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was cognitively impaired and required extensive assist of two staff with activities of daily living. Review of nurse progress notes dated 10/28/18 revealed the resident sustained [REDACTED]. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of interdisciplinary team progress note dated 10/31/18 revealed Resident #3's physician ordered one one one supervision from 10/29/18 through 10/31/18 as a post-fall intervention following Resident #3's fall on 10/28/18. Review of fall risk care plan for Resident #3 initiated 10/24/18 revealed the resident's care plan did not include the post-fall intervention for one on one supervision from 10/29/18 through 10/31/18 as ordered by the resident's physician. Interview with Registered Nurse (RN) #40 on 11/13/18 at 12:47 P.M. confirmed that Resident #3's physician gave an order for [REDACTED]. Interview with the Director of Nursing on 11/13/18 at 4:37 P.M. confirmed the care plan for Resident #3 did not not include the post fall intervention for one on one supervision.

Based on record review, staff interview, and policy review, the facility failed to ensure the medical record included documentation of provision of one on one supervision per the physician's orders [REDACTED].#3) of three residents reviewed for staffing concerns. The census was 95. Findings include: Review of the record revealed Resident #3 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was cognitively impaired and required extensive assist of two staff with activities of daily living. Review of nurse progress notes for dated 10/28/18 revealed resident sustained [REDACTED]. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of interdisciplinary team progress note dated 10/31/18 revealed Resident #3's physician ordered one one one supervision from 10/29/18 through 10/31/18 as a post-fall intervention following Resident #3's fall on 10/28/18. Further review of the medical record for Resident #3 revealed the record did not include documentation of the one on one supervision provided as a post fall intervention as ordered by the resident's physician for 10/29/18 through 10/31/18. Interview with Registered Nurse (RN) #40 on 11/13/18 at 12:47 P.M. confirmed that Resident #3's physician gave an order for [REDACTED].#40 confirmed Resident #3's medical record did not include documentation of the one on one supervision provided as a post intervention as ordered by the resident's physician for 10/29/18 through 10/31/18. Interview with the Director of Nursing on 11/13/18 at 4:37 P.M. confirmed the medical record for Resident #3 did not not include documentation of the post fall intervention for one on one supervision. Review of undated policy titled Charting and Documentation revealed all observations and services performed must be documented in the resident's clinical record.

Based on observation, staff interview and policy review, the facility failed to ensure foods in the coolers and freezer were dated, were not expired, and stored in closed containers. This had the potential to affect all 93 residents of the facility who were identified as receiving meals from the kitchen. Findings included: Observations of the kitchen on [DATE] at 6:31 P.M., revealed the following areas of concern: 1. The walk in cooler contained undated side salads, and bowls of cottage cheese. 2. The walk in cooler had a bag of tortillas with a use by date of [DATE], and a plastic container of shredded carrots with a use by date of [DATE]. 3. The walk in freezer had unsealed bags left open to air, of hamburger patties, chicken breasts, and breaded steaks. 4. The dry storage room had two racks of rolls with use by dates of [DATE], two racks of rolls with use by dates of [DATE], a box of individual servings of thickened orange juice, with a use by date of [DATE], and two boxes of individual cartons of thickened dairy beverage, with a use by date of [DATE]. All the areas of concern were verified with Dietary Cook #27 on [DATE] at 7:00 P.M. Review of policy titled Food Storage dated [DATE], revealed all foods stored in the refrigerator should be dated, all foods stored in the freezer should be covered, and the date of preparation for food may not exceed the use by date.

Based on record review and facility staff interview, the facility failed to follow physician recommendations for one (#31) of five residents reviewed for unnecessary medications. The facility census was 93. Findings included: Record review revealed Resident #31 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], cancer of the ovary, [MEDICAL CONDITION], dementia with behavioral disturbance,and anxiety disorder. Further review of the record revealed the resident was moderately cognitively impaired. Review of Resident #31's history and physical dated 03/27/18, revealed the resident was currently prescribed [MEDICATION NAME] (anti-depressant) and [MEDICATION NAME] (Anti- psychotic). A recommendation was made to consult with psychiatry. There was no evidence in the resident's record an appointment had ever been made, or that the resident had ever been seen by psychiatry. Interview with Unit Manager #35 on 06/20/18 at 2:55 P.M., confirmed Resident #31 had not been seen by psychiatry, or was she on the current list to be seen. The Unit Manager further revealed the physician probably just missed seeing the resident, as he had been at the facility in April.

Based on medical record review, observation, resident and facility policy review, staff interviews, the facility failed to provide safe storage of self administered medications for one (#80) of one residents reviewed for self administration of medications. This had the potential to affect two (#343 and #77) residents on the 400 hall who the facility identified as being independently mobile and cognitively impaired. Findings included: Review of resident #80 medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #80's medication orders dated 06/03/18 revealed the resident had an order for [REDACTED]. Interview and observation with Resident #80 on 06/20/18 at 11:50 A.M., confirmed the resident's inhaler was on the bedside table, and the resident confirmed his inhaler was always kept on his bedside table. During an interview on 06/21/18 at 9:45 A.M., with Registered Nurse (RN) #25 confirmed Resident #80 kept his inhaler on his bedside table, or sometimes in the bed side drawer. RN #25 confirmed the resident did not have access to a secured locking drawer to keep the inhaler in. Review of the Self-Administration of Medications Policy, (undated) revealed, self-administered medications must be stored in a safe manner. If safe storage is not possible in the resident's room, the medication will be stored with the nursing staff in a medication cart or medication room, and nursing will transfer the unopened medication to the resident when the resident requests them.

Based on medical record review, observation, and staff interview, the facility failed to provide dental services for one (#3) of two residents reviewed for dental services. The facility census was 93. Findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 06/18/18 revealed Resident #3 was cognitively impaired. Observation and interview on 06/18/18 at 9:14 A.M., revealed Resident #3 did not have any teeth visible. Resident #3 revealed she did not have teeth. She stated she used to have dentures, however they did not fit her anymore. She further revealed she had never seen a dentist since being admitted to the facility and would like to have dentures. Interview on 06/21/18 at 10:09 A.M., with Registered Nurse Case Manager (RNCM) #16 revealed residents were supposed to be set up on admission with a dental visit. RNCM #16 verified Resident #3 had not seen a dentist since admission to the facility.

Based on medical record review, observation, resident and staff interview, the facility failed to maintain one resident's wheelchairs in a safe working condition. This affected one (#57) of four residents reviewed for environmental concerns. The facility census was 93. Findings included: Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #57 on 06/19/18 at 10:20 A.M., revealed the armrest of resident's wheelchair was ripped, exposing a portion of foam insulation, approximately eight inches in length. Interview with State tested Nurse Aide (STNA) #10 on 06/19/18 at 10:25 A.M., confirmed the armrest of Resident #57's wheelchair was ripped, exposing the foam insulation underneath, and it needed repaired. Interview with Maintenance Director #52 confirmed the maintenance department had received no requests regarding repairs to Resident #57's wheelchair.