Every finding on record at Autumn Court

Based on observation, resident interview, staff interview, and policy review the facility failed to ensure the environment was free from pervasive odors. This had the potential to affect all residents who reside in the facility. The facility census was 48.Findings include:Observation on 08/03/26 at 8:41 A.M. revealed upon entering the facility the building had a strong urine odor that was musty and filled the entire facility.Interview on 08/03/26 at approximately 9:00 A.M. with Social Services (SS #202) verified the strong urine smell throughout the facility. SS #202 stated it is in the carpet that is in the hallways that has been in place for a long time. SS #202 stated they have tried to have the carpets cleaned but the smell remained.Observation on 08/03/36 at 9:40 A.M. revealed the musty urine smell continued to permeate the hallways and into the office area.Interview on 08/03/26 at 12:00 P.M. with Licensed Practical Nurse (LPN #238) verified the urine odor throughout the facility is present. LPN #238 stated that the smell is worse when it is hot outside.Follow-up observation on 08/03/26 at 2:54 P.M. revealed the strong musty urine smell remained in the hallways and permeated the facility.Interview on 08/03/26 at 3:30 P.M. with Resident #43 revealed the facility is too dirty for her. Resident #43 stated there is always poop on the shower room floor. Resident #43 stated the odor in the facility was awful and it smelled like urine all the time.Follow-up observation on 08/04/26 at 8:25 A.M. revealed the musty urine smell remained throughout the facility.Follow-up observation on 08/04/26 at 2:22 P.M. revealed faint musty urine smell remained in the dining room.Follow-up observation on 08/04/26 at 4:10 P.M. revealed musty urine smell remained in the facility. Observation of the back hall shower room had a pile of wet towels on the floor.Follow-up observation on 08/05/26 at 8:36 A.M. revealed an odor of musty urine combined with bleach on the front hallway.Follow-up observation on 08/05/26 at 1:07 P.M. revealed musty urine and feces smell on the back hallway. Musty urine smell on the front hallway was still present but less invasive.Follow-up observation on 08/06/26 at 7:45 A.M. revealed the musty urine smell in the facility was present but less invasive when entering the facility.Follow-up observation on 08/06/26 at 8:07 A.M. revealed the urine smell was stronger on the front hall.Follow-up observation on 08/06/26 at 9:06 A.M. revealed urine smell was noted in the common area outside of the dining room.Review of policy titled Safe and Homelike Environment not dated revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. General considerations to minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaned to housekeeping department.This deficiency represents noncompliance investigated under Master Complaint number 3091772 and Complaint Number 3073164.

Based on medical record review, staff interview and policy review, the facility failed to ensure residents were provided with a nourishing and well-balanced nutritional diet that met their nutritional needs when the stove was unavailable for food preparation and thereafter. This affected all residents reviewed for nourishing and well-balanced meals. The facility identified that all residents received food from the kitchen The facility census was 48. Findings include:Interview on 08/03/26 at 8:18 A.M. with Dietary Manager (DM) #214 revealed a new stove has been in place for approximately two weeks. DM #214 continued to state the facility was without a working stove for approximately a month. Interview on 08/03/26 at 9:14 A.M. with DM #214 revealed there were no saved menus for the time during which the stove was not working, DM #214 stated the menu was written out daily. DM #214 additionally stated Registered Dietitian (RD) #330 would come in every Wednesday and would provide a list of meals that could be warmed in the steamer.Interview on 08/05/26 at 1:20 P.M. with Social Services Director #202 revealed the stove went out during the week of 06/22/26. A new stove was received on 07/06/26. Review of the meal temperature logs for the dates of 06/24/26 through 07/13/26 revealed on 06/24/26 what was planned for dinner included cream of tomato soup, turkey club sandwich, cool corn salad, white Texas sheet cake. What was served included Barbeque shredded beef, potato salad and sugar pie. Lunch on 06/26/26 was planned to be battered dipped [NAME], baked sweet potatoes, cauliflower, dinner roll and apple crisp. What was served included a ham sandwich, chips and cookies. For dinner on 06/26/26 what was planned to be served included beef taco in a soft shell, refried beans, lettuce, tomato, cornbread and chocolate ice cream. What was served for dinner included a turkey sandwich, potato salad and muffins. Lunch on 06/27/26 was planned to be homestyle sloppy joe on a bun, tater tots, broccoli salad and fresh watermelon. What was served was cold chicken sandwich, macaroni salad, chips and a cookie. Dinner on 06/27/26 was planned to be barbecue chicken, pasta salad, corn on the cob, homemade strawberry shortcake. What was served included egg salad sandwiches, coleslaw and watermelon. Lunch on 06/28/26 was planned to be spaghetti with meatballs, tossed salad, garlic bread and frosted cake. What was served included bologna sandwich and coleslaw. It is unclear if a tossed salad, garlic bread and frosted cake was served as no temperature checks were completed. Lunch on 06/29/26 was planned to be fresh ham, pork gravy, roasted red potatoes, asparagus, dinner roll and frosted chocolate cupcake. What was served included turkey sandwich, chips macaroni salad and a cookie. Dinner on 06/29/26 was planned to be oven fried chicken, buttered mashed potatoes, carrot coins biscuit and fruit cocktail. What was served included tuna salad, salad and fruit. Lunch on 06/30/26 was planned was to be roasted turkey, turkey gravy, bread stuffing, green peas, mandarin oranges and a beverage. What was served was a ham or turkey sandwich and chips. It is unclear if the residents were served green peas or mandarin oranges due to no temperature checks completed on those items. Dinner on 06/30/26 was planned to be personal cheese pizza, homemade garden salad and peach crisp. What was served was roast beef sandwiches, chips and tomato soup. Lunch on 07/01/26 was planned to be braised pork shoulder, glazed yams, buttered spinach, cornbread and diced pears. What was served included ham sandwich and chips. It is unclear if the residents were served glazed yams, buttered spinach and cornbread due to no temperature checks completed on those items. Dinner on 07/02/26 was planned to be cream of tomato soup, American grilled cheese sandwich, Italian pasta and apple cobbler. What was served included turkey sandwich, chips and cookies. Dinner on 07/03/26 was planned to be pasta alfredo with Italian sausage, Italian blend vegetables, garlic roll and blushing peaches. What was served included tuna sandwich, chips and applesauce. Dinner on 07/06/26 was planned to be crab/shrimp sandwich, steak fries, lettuce, tomato, onion, pickle and lemon cake. What was served included egg salad sandwiches, three bean salad and pudding. Lunch on 07/07/26 was planned to be [NAME] chicken, white rice, California blend vegetables, fruited gelatin and a beverage. What was served included turkey and salami sandwiches, potato salad and chips. It is unclear if California blend vegetables and fruited gelatin was served due to no temperature checks completed on those items. Lunch on 07/11/26 was planned to be Chicago style hot dog on a bun, breaded onion rings and lemon cake. What was served included shredded chicken sandwich, cottage cheese and banana. Dinner on 07/12/26 was planned to be open face turkey sandwiches, mashed potatoes with gravy, sauteed spinach, biscuit and blueberry cobbler. What was served included turkey sandwich, chips, pasta salad and ice cream. Dinner on 07/13/26 was planned to be barbeque pork on a bun, baked beans, macaroni salad and homemade strawberry shortcake. What was served included tomato soup, grilled cheese and pudding. Lunch on 07/04/26 was planned to be chicken and dumplings, green beans, corn bread and vanilla mousse. What was served included grilled hot dogs, potato salad, chips and a cookie. Interview on 08/05/26 at 10:02 A.M. with RD #330 revealed the inability to verify if the meals served were equal in nutrition to what was planned. RD #330 stated she would have to see the recipes for each meal to determine if the substitution meals were of equal nutritional value. RD #330 continued to state to determine equal nutritional value she would also need to see the recipes for the meals served to know how many slices of meat were used, if and how many slices of cheese were used and if vegetables were included in the sandwiches. Interview on 08/05/26 at 10:53 A.M. with RD #330 verified the substitute menus were not approved by her prior to serving. RD #330 stated she would come in weekly and review what was served. Review of the policy titled Menu Substitutions Policy undated revealed all substitutions shall be nutritionally comparable and consistent with the resident's care plan, physician orders, and dietary restrictions. Menu Substitutions Policy also states substitutions should be reviewed and signed off by Dietitian.Review of the policy titled Menu Change Policy - Skilled Nursing Facility dated 06/2024 revealed the facility's menus are developed in collaboration with a Registered Dietitian and approved by the Dietary Manager and Administrator. Any change to the posted or planned menu must be intentional, documented, and communicated to residents and staff. Substitutions must be of equal nutritional value and meet resident preferences and dietary restrictions.This deficiency represents noncompliance investigated under Master Complaint number 3091772.

Based on observation, staff interview and policy review, the facility failed to ensure the prescribed menu was followed for two residents (#31 and #17) receiving pureed diet and six residents (#21, #11, #7, #16, #14, and #4) who received mechanical soft diets. The facility census was 48. Findings Include:Observation on 08/04/26 at 11:05 A.M. of mechanical soft lunch preparation revealed [NAME] #204 added twelve slices of bologna meat along with four slices of cheese and one number (#) four scoop (eight ounces) of mayonnaise into a food processor. Interview on 08/04/26 at 11:10 A.M. with [NAME] #204 verified twelve slices of bologna meat were placed into the blender and four slices of cheese. [NAME] #204 shrugged her shoulders when asked why only four slices of cheese were used. [NAME] #204 also stated a #four scoop is equivalent to four ounces. Observation on 08/04/26 at 11:13 A.M. of pureed diet lunch preparation revealed [NAME] #204 added four slices of bologna meat and two slices of cheese to the food processor. [NAME] #204 then added an unmeasured amount of milk and a squirt of thickener to the pureed meat mixture. No mayonnaise was added. The pureed meat mixture was then poured out and separated amongst two plates.Interview on 08/04/26 at 11:18 A.M. with [NAME] #204 verified the pureed meat mixture was not measured when plated. Further interview revealed tomato soup was being given to those with pureed diets due to kitchen staff did not make enough cream of broccoli soup for all 48 residents. Interview on 08/04/26 at 11:47 A.M. with Dietary Manager (DM) #214 verified [NAME] #204 should have used six slices of cheese and twenty-four slices of bologna meat for the mechanical soft meal. Further interview with DM #214 revealed there were no spreadsheets available for the deli sandwich meal. Interview on 08/04/26 at 11:50 A.M. with [NAME] #204 after pureed meals were sent out, verified a sandwich bun was not given to the two residents who were receiving pureed diets. [NAME] #204 also verified there was no replacement for the sandwich bun. Review of the policy titled Portion Control/Spreadsheets, last revised 08/01/24 revealed spreadsheets should be used at each meal for each diet to provide residents with proper portions for each ordered diet. The Portion Control/Spreadsheets policy continues to state, portion control utensils such as scoops, ladles and spoodles shall be used during food preparation and services.This deficiency represents noncompliance investigated under Master Complaint number 3091772.

Based on observation, resident interview, staff interview, and policy review the facility failed to provide a homelike environment and failed to ensure the building was in good repair. This had the potential to affect all residents who reside on the front hallway. The facility census was 48.Findings include:Observation and interview on 08/03/26 at 10:39 A.M. with Resident #43 revealed the sink in the room had been clogged for a week.Observations on 08/03/26 between 11:54 A.M. and 12:06 P.M. revealed the entrance to Resident #7 and #20's doorway had ripped linoleum, the bathroom entrance to the front hall had ripped linoleum, a white substance on the bottom of the doorframe in Resident #9 and #39's room, carpeting in the hallway leading to the door of the front hall shower room was ripped, torn and pulling away from the threshold, the heater in the shower room was missing the cover and in the shower room there was a pile of dirty linens, clothing and a glove on the floor. Interview on 08/03/26 at 12:06 P.M. with Licensed Practical Nurse (LPN #238) verified the ripped linoleum at the doorway entrance to Resident #7 and #20's room and to the entry of the bathroom on the front hall, adding the ripped linoleum could be a trip hazard. LPN #238 also verified the ripped carpet pulling away from the threshold at the entrance of the front shower room, the pile of dirty linens, clothing and the glove on the shower room floor, the missing cover on the shower room heater, and the white substance on the door frame of Resident #9 and #39's room.Review of work orders for the past 12 months revealed no work orders for clogged sinks, ripped linoleum, white substances on doorframes, missing cover for the shower room heater or ripped carpeting. Review of the undated facility policy titled Safe and Homelike Environment, stated the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility that is frequented by residents, including but not limited to resident rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. This deficiency represents noncompliance investigated under Master Complaint number 3091772 and Complaint Number 3073164.

THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PIOR TO THIS SURVEY. Based on closed medical record review, staff interview, paramedic interview, review of the Emergency Medical Services (EMS) run report, review of the hospital records and review of the facility policies, the facility failed to ensure residents were served foods in the physician ordered diet texture to meet individual needs. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes and/or death on 05/02/26 for one (#09) resident when Resident #09, who had a chopped meat diet order, was able to consume a piece of chicken that was not prepared per their physician prescribed diet order. Subsequently, Resident #09 choked, became unresponsive and required staff intervention to perform the Heimlich maneuver (a first-aid method for choking that includes abdominal thrusts), cardiopulmonary resuscitation (CPR), and EMS response to remove the food from the trachea where it was preventing airflow to and from the lungs. Consequently, Resident #09 was hospitalized for 27 days, required gastrostomy tube (G-tube) placement (flexible medical tube inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication) and entered palliative care (specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness) services. This affected one (#09) of three residents reviewed for mechanically altered diets. The facility identified eight (#12, #14, #17, #20, #25, #28, #38, and #40) current residents who had physician ordered mechanically altered diets. The facility census was 49. On 06/15/26 at 4:24 P.M., the Administrator, the Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #501 were notified Immediate Jeopardy began on 05/02/26 when Resident #09, who was under the supervision of Certified Nursing Assistant (CNA) #134 during the dinner meal in the dining room, was able to consume a large piece of chicken that was not prepared per the physician ordered chopped meat diet texture. At approximately 4:50 P.M., CNA #134 observed Resident #09 choking, attempted to assist the resident, and called out for staff assistance. The DON, CNA #134, CNA 137, and CNA #200 attempted the Heimlich maneuver (abdominal thrusts) without success. The resident was moved away from the dining area, nine-one-one (911) was called, staff attempted to stand him up to appropriately perform abdominal thrusts, and Resident #09 became unresponsive. The DON initiated CPR until a faint pulse and agonal breaths (abnormal, involuntary reflex characterized by irregular, gasping, or snoring sounds; it occurs when the brainstem is deprived of oxygen and is not true breathing and does not provide enough oxygen to sustain life) were acquired and the resident was placed in a recovery position on his right side. EMS arrived to transport Resident #09 to the hospital. While attempting to intubate (insertion of a flexible plastic tube into the windpipe to keep the airway open) the resident, EMS discovered the resident had an airway blockage and utilized [NAME] forceps to remove a one-half to one inch by two-inch piece of chicken. Subsequently, Resident #09 was hospitalized from [DATE] until 05/29/26 and required the placement of a G-tube to maintain nutritional status. Resident #09 discharged from the hospital on [DATE] to another facility on palliative care services. Although the Immediate Jeopardy was removed on 05/04/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 05/29/26 when the facility implemented the following corrective actions: -On 05/02/26, CNA #200 called 911 to transport Resident #09 who was transferred to the emergency department (ED) for evaluation/treatment. The resident did not return to the facility. -On 05/02/26, the DON notified Medical Director (MD) #600 of the choking incident. -On 05/04/26, the DON completed a root cause analysis and determined it was unknown how Resident #09 received the unaltered chicken during the dinner meal on 05/02/26. Two possibilities were identified: either the resident was served the incorrect texture by facility staff, or the resident possibly took the chicken that was served to another resident while eating in the supervised dining room. -On 05/04/26, the DON completed dietary assessments for Resident #12, Resident #14, Resident #17, Resident #20, Resident #25, Resident #28, Resident #38, and Resident #40, identified as at risk due to having a mechanically altered diet. No concerns were identified. -On 05/04/26, Social Services Director (SSD) #104 interviewed all residents with a Brief Interview Mental Status (BIMS) score of 13 or higher to ensure there were no concerns regarding diet consistency/texture. No concerns were identified. -On 05/04/26, the Administrator reviewed the facility's policies on therapeutic diets and Cardiopulmonary Resuscitation (CPR). No revisions were needed. -On 05/04/26, the DON, or designee, educated all staff on the facility's policies for therapeutic diets, including ensuring residents received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, and in accordance with his or her goals and preferences. The education included the supervision and monitoring of residents to ensure the correct diet was provided as ordered and supervision to ensure residents only consumed the ordered diet. -On 05/04/26, the Administrator observed dietary staff to ensure the diet consistency on the meal ticket matched the food plated and served to the residents, with no concerns identified. -On 05/04/26, an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held to review the incident and corrective action. In attendance included the Administrator, DON, MD #600, RDCO #501, SSD #104, Business Office Manager (BOM) #100, Human Resources (HR) #103, Dietary Manager (DM) #101, Unit Manager/ Licensed Practical Nurse (UM/LPN) #105, and UM/LPN #107. -Beginning 05/04/26, the DON, or designee, audited meals three times weekly for four weeks to ensure meal tickets reflected the correct diet texture and dietary staff plated the ordered diet. No concerns were identified. -Beginning 05/04/26, the DON, or designee, audited meals three times weekly for four weeks to ensure the correct diet texture was delivered/served/consumed by the residents. No concerns were identified. -Beginning on 05/04/26, the DON, or designee, audited the clinical documentation for three residents a week for four weeks to ensure diet orders matched dietary meal tickets. No concerns were identified. -Interviews on 06/16/26 with Registered Nurse (RN) #200, LPN #126, CNA #136, CNA #138, [NAME] #111, and Dietary Aide (DA) #116 confirmed the facility provided education regarding diet textures, ensuring the appropriate textures were served and consumed, and supervision during mealtimes to ensure residents did not consume diet textures outside of their ordered diet. -Observations on 06/15/26 and 06/16/26 of the lunch meals confirmed the facility verified and served the correct diet textures to each resident. -Review of two (#12 and #14) additional open resident records for physician ordered diet textures revealed no additional concerns. -Review of the facility's corrective action verified audits were completed beginning on 05/04/26 through 05/29/26 to ensure the correct diet texture was delivered/served/consumed by the residents, therapeutic diets matched the meal tickets and the meal tickets matched the plated foods with no new areas of concern identified, and staff education was completed. Findings include: Review of the closed medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease without dyskinesia with fluctuations, Type II diabetes mellitus with other skin complication, acute on chronic diastolic heart failure, chronic kidney disease stage III, major depressive disorder, unspecified dementia, impulse disorder, schizoaffective disorder, and dysphagia oropharyngeal phase. Resident #09 was discharged from the facility to the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 04/30/26, revealed Resident #09 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #09 required supervision/touching assistance with eating and received a mechanically altered and therapeutic diet. Review of the Nutritional Assessment, dated 02/18/26, revealed Resident #09 received a mechanically altered and therapeutic diet. Resident #09 ate in the dining room. The ordered diet included a carbohydrate-controlled diet (CCD), chopped meat, thin liquids, and no caffeine. Resident #09 could have toast and grilled cheese. Review of the therapy Diet Communication form, dated 02/19/26, revealed Resident #09 was prescribed a regular texture diet with chopped meats, CCD, and no caffeine. Review of the care plan, dated 09/09/25, revealed Resident #09 had an Activities of Daily Living (ADLs) self-performance deficit due to deconditioning/weakness, impaired mobility, cognitive status, and tremors. Interventions included supervision or touching assistance with eating. Additionally, Resident #09 was identified to be at risk for malnutrition/alteration in nutritional status/dehydration. Interventions included adaptive equipment as ordered: food in separate bowls, weighted silverware, two handled mugs, and a Dycem under bowls. Resident #09 was to be assisted with meals as needed. Review of the daily menu, dated 05/02/26, revealed the lunch meal included barbeque chicken, pasta salad, corn on the cob, and homemade strawberry shortcake. The dinner meal included homestyle sloppy joe on a bun, baked tater tots, broccoli salad, and fresh watermelon. This was the menu served to all residents, altered for texture as needed, unless the resident chose an alternative. Review of Resident #09's dinner meal ticket, dated 05/02/26, revealed the resident received a CCD and chopped meat only diet. The meal ticket did not identify the resident's dinner meal selection or what meal was served to the resident. Review of the nursing progress note dated 05/02/26 at 4:50 P.M. revealed the nurse (DON) was notified Resident #09 was choking in the dining room. Staff responded and attempted the Heimlich maneuver but were unsuccessful. Resident #09 became unresponsive and was moved to the front hall. Staff called 911. Review of the nursing progress note dated 05/02/26 at 5:05 P.M. revealed the writer (DON) initiated chest compressions on the resident. CNA #200 stepped in to assist and took over compressions and was able to regain respirations and a pulse. Review of the nursing progress note dated 05/02/26 at 5:05 P.M. revealed staff were unable to obtain vital signs and CPR was continued. Broccoli was removed from the resident's mouth. The police arrived for assistance. Oxygen was applied at five liters per minute (LPM). Resident #09 regained respirations and a pulse prior to EMS arrival. Vitals were taken and blood pressure (BP) was 210/123 millimeters of mercury (mmHg) [hypertensive crisis], and pulse was 112 beats per minute (elevated heart rate). Review of the nursing progress note dated 05/02/26 at 5:07 P.M. revealed EMS arrived on scene. All appropriate paperwork was sent, including the Medication Administration Record (MAR). Review of the nursing progress note dated 05/02/26 at 9:38 P.M. revealed the facility called the hospital for an update on Resident #09's condition. The resident was intubated in the Intensive Care Unit (ICU). Review of the communication progress note dated 05/04/26 at 9:31 A.M. revealed a telephone update was provided by Resident #09's family. It was reported Resident #09's lungs had improved and they were discussing palliative care. Review of the nursing progress note dated 05/04/26 at 1:54 P.M. revealed, prior to the incident that occurred in the dining room (on 05/02/26), the DON was caring for the resident. Blood glucose was obtained prior to the resident eating dinner. Resident #09 had been sitting in the recliner listing to music and a conversation occurred as to what was playing on the radio, with the resident responding appropriately. Resident #09 did not appear to be in any respiratory distress at the time and was cooperative with the writer. Review of DA #115's witness statement, dated 05/04/26 for the incident on 05/02/26, revealed DA #115 served the dinner trays, including the altered diet plates. DA #115 could not recall what Resident #09 had for dinner. DA #115 did not recall if there was any chicken left over from lunch and recalled serving sloppy joe and broccoli salad or potato salad. Review of Assistant Dietary Supervisor (ADS) #108's witness statement, dated 05/04/26 for the incident on 05/02/26, revealed Resident #09 was served a cut up sloppy joe sandwich and broccoli salad for dinner. ADS #108 denied there was any chicken left over from lunch. Review of CNA #200's undated witness statement for the incident on 05/02/26 revealed CNA #134 stated Resident #09 was choking. CNA #200, along with CNA #134, the DON, agency LPN #201, CNA #137, and CNA #138, attempted the Heimlich maneuver and began back thrusts. Due to the resident being in a high back wheelchair, they attempted to stand him up and the resident became unresponsive. CNA #200 called 911. Staff took Resident #09 out of his wheelchair and the DON initiated CPR. After a few minutes, CNA #200 took over the CPR while the DON secured an oxygen tank. CNA #200 reported she removed broccoli from Resident #09's mouth. Resident #09 was breathing with a pulse and respirations by the time EMS arrived, but the resident was not talking. Review of the EMS report dated 05/02/26 at 4:55 P.M. revealed a call was received for an unresponsive and not breathing male with CPR in progress. At 5:03 P.M., EMS was on the scene. At 5:10 P.M., Paramedic #300 obtained vital signs, with a heart rate of 102 beats per minute (bpm) and oxygen saturation of 83 percent (%). At 5:16 P.M., Resident #09 was enroute to the hospital. While enroute, it was determined the resident's airway reflex was compromised and the decision was made to utilize an invasive airway (intubation). Further review revealed (facility) staff had reported Resident #09 was eating and began choking. The Heimlich maneuver was initiated, and the obstructing item became dislodged. Resident #09 became unresponsive. Upon arrival, Resident #09 was found in a right (side) recovery position with snoring respirations. Staff had placed a nasal cannula at six LPM (oxygen) prior to arrival. Resident #09 was noted to have snoring respirations and the cardiac monitor revealed supraventricular tachycardia (abnormally fast heartbeat) with oxygen saturation in the 70s (normal, healthy oxygen levels range from 95% to 100%) with ventilation assistance. Following a failed intubation attempt, airway visualization with a King Vision (portable laryngoscope) revealed a large mass of chicken in the trachea. Chicken was removed from the trachea using [NAME] forceps (angled instruments primarily used for removing foreign bodies from the airway) on one attempt and intubation attempt was made and the laryngeal tube was placed to aid in ventilation support. EMS transferred care to the hospital at 5:44 P.M. Review of the Emergency Department (ED) physician note dated 05/02/26 revealed Resident #09 presented to the ED via EMS after an episode of choking. EMS reported that at approximately 4:55 P.M., the resident began choking and the facility attempted the Heimlich maneuver, which was unsuccessful. Resident #09 was taken to the hallway where the facility initiated CPR and reported the resident was given approximately three minutes of chest compressions before the patient came back. EMS stated Resident #09 was unresponsive when they arrived. Resident #09 had agonal breathing and was initially supraventricular tachycardia on the monitor and was initially placed on five liters of oxygen via nasal cannula before deciding to intubate with low oxygen saturation. EMS reported when initially intubating the resident, a large mass of chicken was found and removed. EMS reported they also noticed blood and some vomit in the airway. EMS successfully intubated the resident on the second try with no problems. EMS reported Resident #09's oxygen saturation before intubation was in the 50's, which they were able to get up to 84% within 15 breaths after intubation. EMS administered 20 milligrams (mg) of etomidate (short-acting general anesthetic and sedative) and five mg of Versed (benzodiazepine used to help patients relax) before intubation and another 2.5 mg of Versed after intubation. EMS reported the resident never became responsive. Upon physical examination, Resident #09 had diminished breath sounds, tachypnea (abnormally rapid, shallow breathing), and respirations were with controlled ventilation (mechanical ventilator that assumes total control over a patient's respiratory cycle). Resident #09 was unresponsive to painful stimuli and had a Glasgow Coma Score of three (the lowest possible score, indicating a state of complete, unresponsive unconsciousness, representing a deep coma). Resident #09 was admitted to the hospital in critical condition with diagnoses of choking episode, hypoxemia (abnormally low levels of oxygen in the blood), and unresponsiveness. Review of the hospital chest X-ray results dated 05/02/26 revealed Resident #09 had diffused bilateral airspace disease. A follow-up chest X-ray dated 05/02/26, revealed extensive parenchymal opacity (areas that appear white where it should normally look dark) throughout the lungs, which could reflect acute respiratory distress syndrome (life-threatening medical emergency where severe, widespread inflammation causes fluid to leak directly into the alveoli [air sacs in the lungs responsible for oxygen exchange]), edema, or pneumonia. The X-rays showed no concerning intubation results. Review of a hospital speech therapy evaluation dated 05/13/26 revealed the mechanical ventilator was extubated on 05/12/26. After evaluation, speech therapy recommended Resident #09 remain NPO (nothing by mouth). Review of a hospital speech therapy evaluation, dated 05/18/26, revealed a speech modified barium swallow study was completed with recommendations for Resident #09 to remain NPO. Resident #09 presented with pharyngeal dysphagia. Review of a case management note dated 05/26/26 revealed on 05/22/26, a new skilled nursing facility/nursing facility (SNF/NF) referral was sent, and palliative care was set up for the new facility. discharge date to the new SNF/NF was planned for 05/29/26. Review of the hospital surgical note, dated 05/26/26, revealed Resident #09 had a laparoscopic assisted G-tube placement performed. An interview on 06/15/26 at 8:53 A.M. with CNA #134 revealed she was providing resident supervision in the dining room during the dinner meal on 05/02/26 when Resident #09 began choking. CNA #134 stated she was sitting approximately four to five feet from the resident. CNA #134 stated, at first, the resident was coughing and she grabbed a glove and encouraged him to spit it out. CNA #134 stated Resident #09 was a larger male, in a customized wheelchair, and she was unable to get her arms around him, so she gave him back blows and called out for help. The DON came and they tried to perform the Heimlich maneuver with no success. CNA #134 stated they moved the resident out of the dining room and attempted to stand him up when he became blue and unresponsive. CNA #134 stated they laid him on the ground and CPR was initiated. CNA #134 stated there was some broccoli in his mouth that came out. CNA #134 verified the resident should have had cut up meats and breads due to not having natural teeth or dentures. CNA #134 stated she did not know what Resident #09 had for dinner on 05/02/26. An interview on 06/15/26 at 10:38 A.M. with the DON revealed at the time of the incident, she was in the nurses' station with the other nurse. The DON verified all staff responded to the incident. Due to the resident's high back wheelchair, the staff were unable to perform the Heimlich maneuver and when they attempted to stand Resident #09, he went unresponsive. The DON stated they checked for a pulse and breaths, and he had none, so she initiated CPR and an aide called 911. The DON stated she was doing chest compressions and then CNA #200 took over. Resident #09 achieved a faint pulse and agonal breaths. The DON stated Resident #09 was placed in recovery position on his side and EMS arrived shortly after and took over care of the resident. An interview on 06/15/16 at 10:56 A.M. with Director of Rehabilitation (DOR) #550 verified Resident #09 was on a regular texture diet with chopped meats. A telephone interview on 06/15/26 at 11:33 A.M. with Paramedic #500 revealed that upon entering the facility, Resident #09 was on his right side in the recovery position with snoring respirations and was receiving oxygen through a nasal cannula at six LPM. Paramedic #500 stated that if the facility did everything they had reported on scene, then they did everything that they could have done for Resident #09 related to the choking incident. Paramedic #500 stated while enroute to the hospital, Resident #09 continued to have difficulty breathing and he quickly assessed the resident and determined he needed to intubate. Paramedic #500 stated after opening up his airway, he immediately noted there was a large object obstructing his airway and used [NAME] forceps to pull out a piece of chicken that was approximately one half inch to one inch wide by two inches long. Paramedic #500 stated the resident may have attempted to chew the chicken, but it definitely was not chopped into small cubes or pieces, adding that it was a fairly decent size piece of chicken that was lodged between the resident's vocal cords and his trachea. Paramedic #500 verified there was no evidence Resident #09 had consumed sloppy joe or broccoli, as indicated on the menu for the dinner meal. An interview on 06/15/26 at 11:55 A.M. with CNA #137 revealed Resident #09 was eating at the table just outside the dining room during the first dinner meal tray pass, explaining there were two meal passes. She was assisting another resident and not in the dining room at that time. CNA #137 stated that near the time when the second dinner meal trays were delivered, CNA #134 announced that Resident #09 was choking and to get the nurses. CNA #137 verified the Heimlich maneuver was attempted but unsuccessful and she called out to CNA #200 to call 911. Resident #09 became unresponsive, so they put him on the floor and initiated CPR. CNA #137 stated broccoli came out of his mouth. CNA #137 stated after the incident she checked Resident #09's meal tray and observed a whole piece of chicken with approximately two bites taken out of it. CNA #137 stated she reported to the DON that Resident #09 had a whole piece of chicken on his tray. A follow-up interview on 06/15/26 at 12:34 P.M. with the DON verified staff reported to her that Resident #09 had a whole (not chopped) piece of chicken on his meal tray after the incident. An interview on 06/15/26 at 12:39 P.M. with Regional Dietary Director (RDD) #499 verified Resident #09 had an order for chopped meat, which could have been altered mechanically or chopped by hand with pieces no larger than one-half of an inch. An interview on 06/15/26 at 12:59 P.M. with DM #101 verified on 05/02/26, chicken was served as an alternate menu item for the dinner meal. An interview on 06/15/26 at 1:06 P.M. with ADS #108 verified Resident #09 received chopped chicken for the dinner meal on 05/02/26. ADS #108 stated Resident #09 may have requested a second piece of chicken, which was not unusual, but could not confirm this or, if the resident received another piece of chicken, if it was chopped. A telephone interview on 06/15/26 at 2:43 P.M. with CNA #138 revealed she worked on 05/02/26 and checked Resident #09's dinner tray following the choking incident. CNA #138 verified there was a whole piece of chicken on his meal tray, adding Resident #09 should have had chopped meat and sometimes took food off of other resident's meal trays. An interview on 06/16/26 at 7:15 A.M. with RDCO #501 revealed the facility was unable to identify who Resident #09's tablemates were on the day of the choking incident to determine if they had chicken the resident could have possibly taken. RDCO #501 explained they did not have assigned tables and residents sat wherever they chose to. Review of the facility policy titled, Therapeutic Diets, dated August 2023, revealed the policy was to assure residents received and consumed foods in the appropriate form and/or the nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. Review of the facility policy titled, Supporting Activities of Daily Living, reviewed 04/28/25, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the care plan, including appropriate support and assistance with dining. A resident's ability to perform ADLs would be measured using clinical tools including the MDS. The MDS definition of supervision included oversight, encouragement, or cueing. This deficiency represents non-compliance investigated under Complaint Number 3031000.

Based on observation, staff interview, and review of the dishwasher manufacturer's guidelines, the facility failed to ensure the dishwasher washed and rinsed dishes at temperatures specified by the manufacturer's guidelines. This had the potential to affect all 48 residents who received food from the kitchen. The facility census was 48. Findings include: Observation on 10/16/24 at approximately 11:00 A.M. revealed the dishwasher labeled with Machine Operational Requirements with a wash temperature of 120 degrees Fahrenheit (F) minimum and a rinse temperature of 120 degrees F minimum. Further observation revealed Dietary Director (DD) #114 running one cycle of the dishwasher and the was temperature reached 80 degrees F during the wash and a rinse temperature of 88 degrees F. Concurrent interview with DD #114 revealed the dishwasher was a low-temperature machine and should wash and rinse at approximately 100 degrees F and 110 degrees F respectively. Two additional wash cycles were run, and the dishwasher temperatures peaked at a wash temperature of 88 degrees F and a rinse temperature of 95 degrees F. Continued interview with DD #114 confirmed the manufacturer's guidance for wash and rinse temperatures were mounted on the dishwasher and indicated the minimum temperature for each were 120 degrees F. Interview on 10/16/24 at 11:26 A.M. with DD #114 and concurrent review of the Dish Machine temperature log for October 2024 revealed the dishwasher water temperature was documented three times daily and most documented temperatures were 100 degrees F wash and 110 degrees F rinse. DD #114 stated he would contact the dish machine company regarding the dishwasher temperatures not reaching manufacturer's temperature recommendations. Review of the Dish Machine temperature log for August 2024 revealed the dishwasher water temperature was documented three times daily (breakfast, lunch and dinner) and all documented temperatures were 100 degrees F wash and 110 degrees F rinse except dinner on 08/02/24 and lunch on 08/29/24 when the documented temperatures were 100 degrees F wash and 100 degrees F rinse, and lunch and dinner on 08/30/24 when the documented temperatures were 90 degrees F wash and 110 degrees F rinse. Review of the Dish Machine temperature log for September 2024 revealed the dishwasher water temperature was documented three times daily and all documented temperatures were 100 degrees F wash and 110 degrees F rinse except dinner on 09/26/24, 09/27/24, and 09/29/24 when the documented temperatures were 100 degrees F wash and 100 degrees F rinse.

Based on observation, resident interview, staff interview, and policy review, the facility failed to maintain a comfortable temperature throughout the facility. This affected 18 residents (#9, #10, #13, #15, #16, #17, #19, #22, #24, #29, #32, #33, #35, #36, #40, #42, #43, and #45) by the uncomfortable temperatures in the facility. Additionally the facility failed to maintain a clean and sanitary environment. This affected three residents (#8, #19, and #43) of 16 residents reviewed for environment. The facility census was 48. Findings include: 1. Observation and interview on 10/16/24 at 11:38 A.M. with Resident #33 revealed the heater not working or on at this time. Heater elements appear to be old and in disrepair. Cold air observed coming from the windows. Resident #33 stated his room was cold and he was cold last night. Resident #33 wanted his heater fixed. Interview and observation on 10/16/24 at 11:45 A.M. with Regional Director of Facility Management (RDFM) #156 confirmed their temperature gun showed a room temperature ranging from 60-65 degrees Fahrenheit (F) in Residents #33 and #22's room. Interview and observation on 10/16/24 at 12:02 P.M. with Resident #29 stated she was cold. Resident #29 was observed sitting on her bed with a winter coat on. Observation and interview on 10/16/24 at 2:48 P.M. with Maintenance Director #133 confirmed the facility's temperature gun showed the following room temperatures: Resident #42 and #36's room was 67.4 degrees F, Resident #16 and #40's room was 63.3 degrees F, the front hallway was 60.9 degrees F, Residents #15, #19 and #10's room was 64.4 degrees F, Residents #17, #29, #13, and #24's room was 64.9 degrees F, Residents #43 and #9's room was 69.0 degrees F, Resident #32 and #35's room was 65.3 degrees F, and the dining room was 69.0 degrees F. Maintenance Director #133 stated the air conditioning was still on in the facility. Observation and interview on 10/17/24 at 8:38 A.M. with Resident #45 revealed the resident was sitting outside their room with jacket on. Resident #45 stated it is warmer today than it was yesterday. Interview on 10/17/24 at 8:44 A.M. with Resident #10 revealed the resident stated it is warmer in the facility today than it was yesterday. Resident #10 stated a few days back it was really cold in the facility. Review of the policy titled Quality of Life-Homelike Environment revised May 2017 revealed the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71 degrees F to 81 degrees F). 37452 2. Observation on 10/15/24 at 10:03 A.M. revealed Resident #19's privacy curtain had a dried brown stain over an approximately three by six inch area, in a noticeable section of the curtain. During the observation, Resident #19 stated he had had an episode of bowel incontinence on the day prior, and feces had stained the curtain. Further observations on 10/16/24 at 8:45 A.M., at 11:56 A.M. and again at 4:33 P.M. revealed the dried feces was still present on Resident #19's privacy curtain. Interview on 10/16/24 at 4:33 P.M. with STNA #141 confirmed the noticeable dried brown feces stain on Resident #19's privacy curtain. The aide stated soiled privacy curtains were to be changed as needed. Interview on 10/17/24 at 9:55 A.M. with the Administrator confirmed staff were to let housekeeping know if a privacy curtain was soiled and required a change. Additional interviews on 10/17/24 at 11:29 A.M. with Housekeeping Aide #118 and at 11:53 A.M. with Housekeeping Director #119, further confirmed aides were to let housekeeping staff know if a privacy curtain was soiled and requires a change. 3. Observation on 10/16/24 at 12:13 P.M. revealed the room shared by Residents #43 and #8, had excessive spiderwebs in a corner from the floor to the ceiling, with debris scattered throughout the web and on the floor. Immediately following the observation, the excessive spider webs were confirmed by Regional Director of Clinical #157 and the Director of Nursing. Interview on 10/17/24 at 11:49 A.M. with Resident #43 stated they were relieved the spider webs were being addressed. Review of a policy titled Routine Cleaning and Disinfection, last reviewed August 2023, revealed the facility shall ensure provision of routine cleaning in order to provide a safe, sanitary environment and to prevent the development and transmission of infections. The policy stated curtains in resident rooms, shall be changed when visibly dirty and the cleaning of walls will be conducted when visibly soiled. Review of a policy titled Homelike Environment, last revised May 2017, revealed the facility shall provide a clean, sanitary environment.

Based on observation of medication administration, staff interview, and policy review, the facility failed to ensure the medication cart was secured at all times when unattended. This had the potential to affect all residents but three residents. The facility reported all residents were cognitively impaired and all but three residents were independently mobile or able to self-propel in a wheelchair. The facility census was 48. Findings include: Observation on 10/16/24 at 7:47 A.M. revealed Licensed Practical Nurse (LPN) #154 prepared medication at the medication cart which was parked adjacent to the dining room with the drawers facing away from the seating area. There was a half wall approximately two to two and one half feet high, between the cart and the actual dining room. During the observation, there were approximately ten to twelve residents in the surrounding area, with some residents arriving and departing breakfast service. After preparing medication for Resident #18, LPN #154 failed to lock the cart, walked away, and sat for approximately two minutes, in a chair next to the resident on the other side of an approximately five foot diameter round table. The nurse was facing in the direction of the cart which was approximately ten feet away, separated by the half wall and the round table. While administering medication to the resident, LPN #154 was observed to be focused on and looking at the resident. Additionally, this surveyor observed that while the nurse was seated, the nurse's view of the drawers were obscured considering the position of the cart, and the nurse would have been unable to see if a resident in a wheelchair approached the unlocked drawers. Interview immediately following this observation with LPN #154, confirmed the nurse walked away from the unlocked medication cart for approximately two minutes and was not fully attentive to the cart, despite the cart itself being within view. LPN #154 acknowledged the facility's population of residents with cognitive, mental, and behavioral health concerns, increased the need to ensure the cart was secure, and especially since the unlocked drawers were not within sight when she was seated at the table. Interview on 10/17/24 at 12:17 P.M. with the Director of Nursing confirmed medication carts were to be locked when out of sight or otherwise unattended. Review of a policy titled Medication Dispensing System, undated, revealed medication carts are to always be locked when out of sight or unattended.

Based on observation, staff interview, medical record review, and review of policy for medication administration, the facility failed to practice appropriate hand hygiene during medication administration. This affected two residents (Residents #13 and #15) of three residents observed for medication administration. The facility census was 48. Findings include: Observation on 10/16/24 at 7:35 A.M. revealed Licensed Practical Nurse (LPN) #132 prepared 13 oral medications for Resident #13 by punching them from a punch card and/or removing them from a multi-dose container. During this preparation, LPN #132 touched each of the 13 tablets with bare skin while removing the medications from the packages and placing each them in the medication cup. LPN #132 then administered the medications to Resident #13. Observation on 10/16/24 at 7:41 A.M. revealed LPN #132 prepared six oral medications for Resident #15 by punching them from a punch card and/or removing them from a multi-dose container. During this preparation, LPN #132 touched each of the six tablets with bare skin while removing the medications from the packages and placing them in the medication cup. LPN #132 then administered the medications to Resident #15. Immediately following this second observation, interview with LPN #132 confirmed the nurse touched 13 medications for Resident #13 and six medications for Resident #15 with bare skin during preparation. Interview on 10/17/24 at 12:17 P.M. with the Director of Nursing confirmed nurses were not to touch medications with bare hands at any time. Review of a policy titled Medication Dispensing System, undated, revealed it directed the administering staff person, to not touch the medication when opening a bottle or unit dose package.

Based on observation, staff interview, and review of production recipes, the facility failed to ensure pureed foods were prepared properly. This affected one (#5) of one resident who received pureed food in the facility. The facility census was 48. Findings include: Observations beginning on 10/16/24 at 10:48 A.M. revealed [NAME] #109 receiving guidance from Dietary Director (DD) #114 regarding the preparation of one pureed portion of the noon meal. Interview with DD #114 revealed the noon meal consisted of beef pot roast, vegetable blend, mashed potatoes, and pumpkin pie. [NAME] #109 pureed and plated each food item separately. Observation of the pureed beef pot roast revealed a thick liquid with several small pieces of what appeared to be ground beef. Observation of the pureed vegetable blend appeared to be thin soup with several large pieces of vegetables. Observation on 10/16/24 at 11:55 A.M. revealed Resident #5 in the dining room received her noon meal tray with pureed items which included beef pot roast and vegetable blend. Interview and observation on 10/16/24 at 11:56 A.M. with DD #114 confirmed the vegetables delivered to Resident #5 were in a thin liquid with nearly intact pieces of vegetables. DD #114 confirmed the vegetables were not blended to a pureed texture and removed Resident #5's plate and explained he needed to re-prepare her meal. Telephone interview on 10/16/24 at 1:14 P.M. with Speech Therapist (ST) #158 revealed she had identified concerns with modified food textures, pureed and mechanical soft, at the facility and brought it to the facility's attention. ST #158 stated staff was receptive to re-education and training to ensure food textures were modified appropriately. Follow-up interview on 10/17/24 at 3:43 P.M. with DD #114, and concurrent review of the guidelines for preparing the pureed beef pot roast, revealed the pureed pot roast provided to Resident #5 during the noon meal on 10/16/24 was not pureed to a smooth texture. DD #114 stated he would have pureed it further but believed the lack of intervention by the surveyor indicated the texture was appropriate. Review of the Production Recipe for Vegetable Blend Mixed Pureed Thick, dated 03/31/21, revealed vegetables and melted margarine should be added to the food processor and processed until smooth in texture. Review of the Production Recipe for Beef Roast Pot Pureed Thick, dated 03/26/21, revealed beef pot roast and prepared broth should be added to the food processor and processed until smooth in texture.

Based on review of personnel files, record review, and staff interview, the facility failed to ensure newly hired State tested Nurse Aides (STNA) received specialty behavioral training. This had the potential to affect all 48 residents in the facility. Findings include: Review of the personnel file for STNA #142 revealed a hire date of 08/07/24. The file contained no evidence STNA #142 received training on mental health behaviors. Review of the personnel file for STNA #148 revealed a hire date of 08/15/24. The file contained no evidence STNA #148 received training on mental health behaviors. Interview and concurrent review of personnel files on 10/17/24 at 1:49 P.M. with Human Resources Director (HRD) #120 confirmed the facility provided no formal specialized training for mental health behaviors for newly hired staff. HRD #120 further confirmed STNA #142 and STNA #148 did not receive specialized training for mental health behaviors. Review of the Facility Assessment, dated 07/15/24, revealed the facility was a secure building, specializing in mental health behaviors.

Based on medical record review, staff and resident interviews, review of self reported incident (SRI's, and policy review, the facility failed to ensure a resident was free from physical abuse. This affected one (#28) out of four residents reviewed for abuse. The facility census was 46. Findings include: Review of the medical record for the Resident #28 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder, bipolar type, major depression, diabetes mellitus, anxiety disorder, bipolar disorder, and epilepsy. Review of the medical record for Resident #28 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/19/21, indicated Resident #28 was cognitively intact and required supervision for bed mobility, transfers, toileting, and ambulation. Further review of the MDS, revealed Resident #28 had behaviors towards others. Review of the medical record for Resident #28 revealed a progress note dated 12/12/22 at 6:50 P.M. which stated Resident #28 walked to the front lounge and went to sit down in a chair that Resident #10 said was hers. The note stated Resident #28 sat in the chair anyway and Resident #10 came over and grabbed Resident #28 around the neck and choked her. Review of the medical record for Resident #28 revealed a progress note dated 12/13/22 at 5:40 A.M. which stated Resident #28 denied any discomfort and the redness to Resident 28's neck had resolved. Further review of the medical record revealed an Interdisciplinary Team note (IDT) note dated 12/13/22 at 8:23 A.M. which stated the Resident #28 was on the receiving end of choking by another resident. The IDT note stated Resident #10 and #28 were separated and assessed for injuries. The IDT note stated Resident #28 did not want to press charges. Review of the medical record for Resident #28 revealed a progress note dated 12/14/22 at 3:03 P.M. which stated Resident #28 complained of a sore throat and had difficulty swallowing and Resident #28 voiced being fearful. Review of the medical record for Resident #10 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder, bipolar disorder, and schizophrenia. Review of Resident #10's quarterly MDS dated [DATE] revealed the resident had a BIMS of nine out of 15. Resident #10 requires supervision with transfers, walking in room, walking in corridor and locomotion on unit. Resident #10 is independent with locomotion off unit. Resident #10 is coded for having delusions. Resident #10 has no behaviors. Review of the medical record for Resident #10 revealed care plans to address the resident's psychosocial well-being related to anxiety with interventions to monitor and document problems. The medical record for Resident #10 contained a care plan that stated Resident #10 has verbal and physical aggression related to schizophrenia, bipolar disorder, and delusions. Interventions included document mood, redirect resident, remove resident from public area if having behaviors towards others due to residents' anger and poor impulse control. Review of the medical record for Resident #10 revealed she was sent to hospital for a psychiatric evaluation on 12/14/22 due to behaviors and returned to the facility 12/20/22. Review of a facility SRI dated 12/12/22 which stated Resident #10 walked over to Resident #28 and put her hands around Resident #28's neck and started choking her. Per the SRI, Resident #10 stated she told Resident #28 not to go to that chair. The SRI continued to state Resident #28 was upset and crying after the incident. The report stated staff separated the residents, Resident #28 was assessed by the nurse, and the police department was notified. Interview on 12/27/22 at 11:46 A.M. with Resident #28 stated that one (#10) resident recently hurt her but stated that resident was sent to the hospital due to her behaviors. Resident #28 stated staff responded promptly to the incident with Resident #10. Resident #28 stated she was fearful Resident #10 would attack her again now that she was back in the facility. Resident #28 stated she was told to stay away from the Resident #10 but Resident #28 stated that would be hard to do because they both walk around the facility. Interview on 12/27/22 at 12:44 P.M. with Director of Nursing (DON) stated she completed the abuse investigation for the incident of Resident #10 choking Resident #28. DON stated Resident #10 stated she was upset with Resident #28 for sitting in the chair and she walked over to Resident #28 and started choking Resident #28. DON stated the immediate intervention was to separate the residents and then to conduct frequent checks on each resident. DON stated the incident was witnessed by two staff members. DON confirmed there was no documentation to support the facility staff conducted frequent checks on Resident #10 and Resident #28. DON stated Resident #10 and Resident #28 have been in the lounge area at the same time since the above incident but have not had any other incidents. Interview on 12/27/22 at 3:04 P.M. with Administrator stated Resident #28 was instructed to stay away from Resident #10 when in the lounge area. Further review of SRI's with the Administrator confirmed there have been four other resident-to-resident altercations involving Resident #28 and #10 since July 2022. The Administrator confirmed there was a SRI involving Resident #28 and #10 dated 07/09/22, 07/30/22, 07/31/22 and 10/03/22. Review of the facility policy titled, Abuse, revised 01/31/20, stated residents have a right to be free of abuse, neglect, exploitation, and misappropriation of property. The policy continued to state the facility's procedure for prevention included providing a safe environment for residents. This deficiency represents non-compliance investigated under Complaint Number OH00138638.

Based on observations, resident and staff interview, review of the facility infection control log and review of the owner's manual for the chemical dishwasher, the facility failed to ensure dietary staff with skin conditions kept their arms properly covered and failed to ensure the chemical dishwashing machine maintained the appropriate level of chemicals for effective sanitation. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: 1. Observation on 07/05/22 at 8:51 A.M. of the kitchen found Dietary Staff (DS) #412 wearing a short sleeve black shirt. DS #412's arms were exposed and observed having flakey, white, scale like skin on both his right and left forearms. DS #412's right forearm was observed to have cracks with scabs and dried red areas between his elbow and his wrist as well as on the back of his right hand. DS #412 was observed preparing batter for pancakes and cooking pancakes on the stove. Interview on 07/05/22 at 9:33 A.M. with Resident #22 revealed the food was very good but the cook had some white stuff on his arms that wasn't good. Resident #22 did not elaborate as to what he meant by the cooks arms weren't good. Observation on 07/05/22 at 11:15 A.M. of the kitchen found DS #412 continued to work in the kitchen preparing food with white flakey skin on both arms and with cracked areas with dried blood on right forearm between his elbow and his wrist as well as the back of his right hand. DS #412 was observed preparing purees for the lunch meal. Interview on 07/05/22 at 11:34 A.M. with DS #412 revealed he had psoriasis and normally wore sleeves which covered his arms while he was working in the kitchen. DS #412 verified he was not wearing his sleeves, his psoriasis was cracked, and his arms were not covered while he was preparing food. 2. Observation on 07/05/22 at 8:48 A.M. of the kitchen found DS #408 running dishes through the dishwasher. Coinciding interview with DS #408 revealed the dishwasher was a chemical machine with sodium hypochlorite as the sanitizer and she did not have test strips to test if the chemicals were reaching proper levels. DS #408 stated it had been some time since they had test strips and she had no way of knowing the sanitation levels of the machine. Interview on 07/05/22 at 11:19 A.M. with DS #408 revealed DS #412 was able to find some test strips. Observation of the use of the test strips revealed the sanitation level was at 10 parts per million (PPM) and machine was supposed to run at 50 PPM. DS #408 verified the dishwasher was not reaching the proper level of sanitation for the sodium hypochlorite sanitizer. DS #408 reported they were supposed to be testing the chemical level every shift to make sure it was at the proper levels but they had not had test strips for some time so they were not completing testing and they were not keeping a log. Observation and interview on 07/05/22 at 11:21 A.M. with DS #412 found he ran the chemical level test again, found the sanitation level to be around 25 PPM, and verified the dishwasher was not reaching appropriate levels for sanitation. DS #412 reported it was not known how long the dishwasher had not been reaching the appropriate levels for sanitation as they had not had test strips available and a log was not being kept. DS #412 reported now they were aware of the issue they would put a repair order in and would use the three sink system to wash dishes until it was repaired. The facility confirmed all 49 residents residing in the facility receive their meals from the kitchen. Review of the Infection Control Log from 11/01/21 through 07/05/22 revealed there have been no food borne illnesses at the facility. Review of the Owners Manual for the American Dish Service Upright Dishwasher dated May 2008 revealed the chemical sanitizer used in the dishwasher was sodium hypochlorite and in the final rise should be 50 PPM to 100 PPM.

Based on medical record review, resident and staff interview, medical record review, review of a facility investigation, review of self-reported incidents (SRI's), and review of a facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency. This affected one (#38) of one residents reviewed for abuse. The census was 49. Findings include: Review of Resident #38's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurring daily. Review of of nursing progress notes between 05/12/22 and 05/22/22 revealed no documentation of Resident #38 sustaining any falls, no self-harming behaviors, and no staff witnessing any incidents between peers or other staff members. Resident #38 was documented attempting to kick and throw items, kicking doors, spitting out medications, urinating on the floor, disrobing in the public, pacing, and targeting staff with physical agitation. Review of a nursing progress note dated 05/22/22 revealed a nurse aide informed a nurse that Resident #38 had a purple bruise on her left eye. The bruise was described as a thin band from the outer corner to the inner corner of the left eye. Resident #38 was not able to tell staff what happened and no other injuries were noted. Review of a shower sheet dated 05/23/22 revealed Resident #38 was identified with a bruise to the left eye and review of a nursing progress note dated 05/23/22 revealed Resident #38's left eye had a dark violet discoloration surrounding her left eye with pale blue color between the eye brow and eyelid crease, and a dark violet dot measuring approximately 0.3 centimeters across at the lateral edge of the eye brow. Review of a facility investigation revealed the facility obtained written statements from staff members on 05/22/22 and 05/23/22 with no staff members having knowledge of Resident #38 being involved in any incidents; however, staff members indicated Resident #38 was unsteady on her feet and running into walls on previous shifts, had shown increased aggression, lunging, hitting, kicking, biting, and spitting at staff but no definitive cause of Resident #38's bruise to her left eye was identified. The facility reviewed progress notes surrounding the finding of the bruise between 05/17/22 and 05/21/22 and found documentation of increased behaviors but no falls or incidents where Resident #38 injured her left eye. Review of SRI's between 06/17/21 and 06/30/22 revealed the facility did not submit any allegations of injuries of unknown origin during this time frame. Further review of the SRI's revealed the bruise to Resident #38's left eye was not submitted to the State Survey Agency with no SRI's submitted by the facility between 05/10/22 and 06/01/22. An interview was attempted with Resident #38 on 07/06/22 at 8:24 A.M., however, Resident #38 responded with very low, incoherent mumbled speech and was not able to answer any questions related to the bruise on her left eye discovered on 05/22/22. Interview on 07/07/22 at 1:11 P.M. with the Director of Nursing (DON) stated the facility investigated the bruise to Resident #38's left eye and did not discover any definitive causes. The DON stated written statements and progress notes were reviewed during the investigation and Resident #38 was documented to be experiencing a lot of behaviors and had a unsteady gait. The DON stated due to all of Resident #38's behaviors and unsteady gait she did not feel the bruise to her left eye was suspicious as her gait and behaviors would be likely causes of the bruise. The DON verified Resident #38 had no documented falls or an incidents around the time the bruise was discovered, and verified there was no SRI submitted since she felt the bruise was not suspicious. Review of the facility's undated abuse policy defined injury of unknown source as the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number or injuries observed at one particular point in time, or the incidence of injuries over time. Incidents and allegations of injuries of unknown source must be reported to the Administrator or designee and they will notify the Ohio Department of Health (ODH) of injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. The facility will submit an online self-reported incident form in accordance with ODH's then-current instructions.

Based on observation, medial record review, and resident and staff interview, the facility failed to develop a comprehensive care plan to include a resident's vagus nerve stimulator (VNS) used to treat seizures. This affected one (#29) of 15 residents reviewed for care plans. The facility census was 49. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #29 was cognitively intact, required supervision for ADL's, had a [CONDITION(S)] disorder. Review of the plan of care, initiated 10/26/20, revealed Resident #29 was at risk for adverse effects and/or side effects from anticonvulsant therapy and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #29's contained no documentation regarding the use of a VNS - implanted device used to treat seizures. Observation on 07/05/22 at 12:35 P.M. of Resident #29 revealed the Resident #29 was wearing a black, watch size object on the right collar of her shirt. Interview of Resident #29 at the time of the observation revealed the resident had [CONDITION(S)] and had a VNS to help control her seizures. Resident #29 verified the black, watch size object was the magnet used for the VNS. Resident #29 stated she had the VNS for a long time, was able to recognize auras prior to a [CONDITION(S)] and was able to use the magnet to activate the VNS when needed. Interview on 07/06/22 at 7:57 A.M. of Licenses Practical Nurse (LPN) #406 verified Resident #29 had a VNS and carried her own magnet to activate the VNS when needed. LPN #406 stated Resident #29 was very familiar with her seizures and auras and was able to swipe the magnet over the VNS generator to prevent a [CONDITION(S)]. Interview on 07/06/22 at 9:59 A.M. of the Director of Nursing (DON) verified Resident #29 had a VNS and it was not included in the resident's care plan. The DON stated Resident #29 admitted to the facility with the VNS and mostly managed it herself but stated it should definitely be care planned. Follow up interview on 07/06/22 at 1:14 P.M. of the DON revealed the facility did not have a policy related to care planning.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one resident (#40) of two residents reviewed for falls. The facility census was 49. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbance, muscle weakness, abnormalities of gait, [CONDITION(S)] disorder, pseudobulbar affect, and [CONDITION(S)]. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating Resident #40 was severely cognitively impaired. Resident #40 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #40 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Resident #40 had no falls since the last review. Review of Resident #40's care plan revised 04/12/21 revealed supports and interventions for risk for falls. Interventions for falls included anticipate Resident #40's needs, encourage use of call light, ensure Resident #40 was wearing appropriate footwear when ambulating or mobilizing in his wheelchair, evaluate for appropriate equipment and devices, and provide a safe environment. Review of Resident #40's Fall Risk assessment dated [DATE] revealed Resident #40 was at risk for falls. Review of Resident #40's State tested Nursing Assistant Tasks revealed a task for dressing which stated Resident #40 was able to complete lower body dressing with stand by assistance, briefs with minimal assistance and shoes with set up. Resident #40 ranged from supervision to extensive assistance with dressing over the last 20 days. Observation on 07/05/22 at 9:28 A.M. of Resident #40 found him standing and walking in front of his wheelchair using it as a walker. Resident #40 was wearing regular white socks with no shoes. Attempted interview with Resident #40 found he was not able to be interviewed. Interview on 07/05/22 at 9:30 A.M. with Licensed Practical Nurse (LPN) #445 verified Resident #40 was pushing his wheelchair as a walker and it was not safe. LPN #445 asked Resident #40 to sit down in his wheelchair and the resident complied. Observation on 07/05/22 at 9:42 A.M. found Resident #40 standing using his wheelchair as a walker. Resident #40 continued to have regular socks on without grips and no shoes. Resident #40 was pushing his wheelchair around the hallways past staff and no redirection or interventions were provided. Resident #40's tennis shoes were observed to be in his room at the foot of his bed, positioned side by side. Observation on 07/05/22 at 4:38 P.M. found Resident #40 seated in his wheelchair propelling himself with his feet. Resident #40 continued to wear only white regular socks with no shoes. Resident #40's shoes were found to be in the same position at the foot of his bed. Observation on 07/05/22 at 4:40 P.M. found Resident #40 standing and pushing his wheelchair like a walker. Resident #40 was not wearing shoes and had only regular white socks on without grips. Observation on 07/05/22 at 4:44 P.M. with the Director of Nursing (DON) found her redirecting Resident #40 to sit in his wheelchair and not push it. Resident #40 laughed and complied. Coinciding interview with the DON verified Resident #40 was not supposed to be standing and pushing his wheelchair and verified he was not wearing proper shoes or non-skid socks. The DON stated she would help him get proper footwear on. Interview on 07/06/22 with State tested Nursing Assistant (STNA) #416 revealed Resident #40 was able to put his shoes on, but required staff assistance with getting them positioned so he could put them on. Resident #40 was not able to safely reach them if they were on the floor. STNA #416 reported he was able to dress himself with specific directions and getting all of the item out and laid out for him. Review of the undated facility policy titled, Falls Policy and Procedures, revealed residents would be reviewed for fall risk and applicable interventions would be implemented in accordance with the assessment.

Based on record review, staff interview, and review of the facility policy, the facility failed to notify a resident representative of a fall. This affected one (Resident #09) of three residents reviewed for falls. The facility census was 42. Findings include: Review of the closed medical record for Resident #09 revealed an admitted [DATE] and a discharge date of [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. The resident's balance was not steady but could stabilize without staff assistance. At the time of the assessment, there had been no falls since admission. Review of Resident #09's medical record revealed on 05/09/21, the resident walked up to the nurses station with a steady gait and with clear and appropriate speech and reported she had fallen in her room. There was no documentation the resident representative was notified. Interview on 06/22/21 at 1:10 P.M. with the Director of Nursing verified Resident #09's representative was not notified of Resident #09's fall on 05/09/21. Review of the undated facility policy titled, Falls Policy and Procedure, verified when a fall occurs the physician and responsible party will be notified. This deficiency is an incidental finding discovered during the course of this complaint investigation.

Based on observation, interview, review of manufacturer's instructions, policy review and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement infection control measures in regard to COVID-19. This had the potential to affect six (Residents #1, #7. #9, #16, #32 and #33) who were identified by the facility as never contracting COVID-19. The facility census was 46. Findings include: Upon arrival to the facility on [DATE] at 12:38 P.M. the door was locked. Registered Nurse (RN) #51 responded to the doorbell without a face shield on. After entrance to the facility, RN #51 opened a drawer on a cart by the door to obtain a face shield. RN #51 verified the facility required the use of both an N-95 mask and a face shield for everyone in the facility at all times. RN #51 verified she did not have a face shield on. After completing the visitor screening, RN #51 did not advise the use of hand sanitizer after screening. During initial tour of the facility on 12/15/20 at 12:42 P.M., three residents were seated together, all within six feet of each other, in the hall outside of room [ROOM NUMBER]. Six residents were in the front common area, and other residents were roaming in the hall. None of these residents were wearing masks and there was no social distancing. On 12/15/20 at 1:06 P.M. Resident #24 was observed roaming the hall with no mask on. He verified he didn't have on a mask and stated he was told residents don't have to wear masks. At 1:15 P.M. Resident #14 and Resident #30 were also in the hall without a mask. Both verified they did not have on masks and thought it was no longer required. Staff do not advise them to put their masks on. At 1:34 P.M. Resident #1 was in the hall with no mask on. He verified he wasn't wearing a mask and stated staff don't care if he wears a mask. During observation on 12/15/20 at 1:20 P.M., Activities Director (AD) #55 was in the common room with 15 residents. None of the residents were wearing masks or social distancing. Residents were sitting beside each other in chairs and at tables around the perimeter of the room. Interview with AD #55 at the time of the observation verified this was a common practice to have the residents gather in the common room for activities. Staff would set up the chairs around the room for the residents to sit in and there was no social distancing. AD #55 verified the residents were right beside each other and not six feet apart. AD #55 stated Residents were not required to wear masks and that none of the residents were wearing masks. She verified she did not advise the residents to wear masks or educate them on the need to wear mask. During observation on 12/15/20 at 2:44 P.M., Cook #57 and Dishwasher #59 were in the kitchen. Cook #55 had her face mask under her chin, not covering either her mouth or her nose. Dishwasher #59 had her mask only over her mouth and not covering her nose. Both verified their face masks were not covering both their mouth and nose. Cook #55 stated she thought it was okay to have their masks off while there was just the two of them working in the kitchen. During observation on 12/15/20 at 2:47 P.M., AD #55 had her N-95 face mask on with both straps at her neck. AD #55 verified she did not have one on the straps on the crown of her head per the manufacturer's instruction. At 2:48 P.M. State tested Nursing Assistant (STNA) #61 was in the dining room and had her mask under her chin, not covering her mouth or her nose. STNA #61 verified the mask was under her chin at the time of the observation. STNA #63, also present in the dining room, was wearing her N-95 facemask with both straps at the back of her neck. STNA #63 verified she did not have one of the straps on the crown of her head per manufacturer's instruction. At 2:52 P.M. STNA #65, also in the dining room, had her N-95 mask on with both straps at the back of her neck and the face mask was not covering her nose. STNA #65 verified both straps of her face mask were at the back of her neck. During observation on 12/15/20 at 2:54 P.M., RN #51, Licensed Practical Nurse (LPN) #67 and the Director of Nursing (DON) were together in the nursing station. All were wearing their masks with both straps at the neck. All verified they did not have one of the straps on the crown of their head per manufacturer's instruction. LPN #67 stated they had been educated in the proper way to wear their mask. During observation on 12/16/20 at 8:55 A.M., Environmental Supervisor (ES) #73 was in the hall near room [ROOM NUMBER] and had her N-95 mask on with both straps at her neck. During interview at the time of the observation, ES #73 stated she didn't know one of the straps had to be on the top of her head. At 9:00 A.M. STNA #75 was also in the hall near room [ROOM NUMBER] she had on an N-95 mask with both straps at her neck. STNA #75 verified both straps were at her neck and stated it hurts to wear the mask with one strap on top of her head that way. During interview on 12/16/20 at 9:04 A.M., RN #51 stated residents should be wearing masks. During interview on 12/16/20 at 9:22 A.M., LPN #67 verified residents are supposed to wear masks and the residents did wear masks prior to the facility COVID-19 outbreak in October and November 2020. After the outbreak, the facility was no longer requiring residents to wear masks. During observation on 12/16/20 at 9:37 A.M.,Occupational Therapist (OT) # 77 had her masks straps at her neck. She verified the N-95 mask was not on correctly and stated the one strap must have slid down. During interview on 12/16/20 at 9:40 A.M., the DON verified N-95 masks and face shields are to be worn by all staff and visitors at all times while they are in the building. Everyone was required to complete COVID screening and hand sanitizing before they enter the facility. The DON stated staff have been educated on the proper use of personal protective equipment (PPE) including the proper wearing of the N-95 mask, frequent hand sanitizing and the need for everyone to sanitize their hands before entering the building and that an N-95 mask and a face shield are required at all times while in the building. Residents should be encouraged to wear a face masks by the facility staff. Social distancing of residents was expected. The DON stated every resident in the facility had COVID-19 with the exception of Residents #1, #7. #9, #16, #32 and #33. During observation on 12/16/20 at 9:48 A.M., the Administrator was observed in his office with the DON. The Administrator was wearing an N-95 mask with his whiskers sticking out. The Administrator verified he had a full beard and the beard prevented the N-95 from creating a good seal around the mouth and nose. On 12/16/20 at 10:40 A.M. Cook #79 was observed in the hall with no mask and no face shield. Cook #79 verified she was not wearing a mask or shield and verified she knows she is supposed to wear both. During observation on 12/16/20 at 2:27 P.M., Maintenance Director (MD) #71 was wearing an N-95 mask with whiskers. MD #71 verified he had a beard and had whiskers sticking out of his mask. During observation and interview on 12/17/20 at 9:30 A.M., Resident #37 was not wearing a mask in the hall and stated recently no one was wearing a mask and no one had advised her to wear it in a month. At 9:34 A.M. Resident #22 was in the common room with no mask. She verified she did not have a mask on. No one told her to put on a mask. At 9:37 A.M., Resident #3, also present in the common room with no mask, said he had a mask but he lost it. Resident #32 verified no staff told him to wear a mask today. At 9:43 A.M. Resident #6 was not wearing a mask and said he already had the COVID and he does not wear a mask. Resident #6 stated the staff used to encourage him to wear a mask but that was a long time ago and no one told him to wear the mask today. Staff were present in the common room during this observation and at no time did they educate or advise residents to wear a mask. During interview on 12/17/20 at 9:45 A.M., AD #55, who was present with the residents, verified she did not advise anyone to put on a mask. There were three other residents, #39, #38 and #21, also in the common room without masks on. Review of the manufacturer's instruction for the 3M N-95 Respirator stated the mask should be worn over the nose, mouth and chin with one strap on the crown of the head and one strap behind the neck. Review of the facility policy titled Infection Prevention and Control Program, copyright date 2020, revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. All staff are responsible for following all policies and procedures related to the program. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility policy titled Coronavirus Surveillance, revised on 05/12/20, revealed the facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. COVID-19 (short for coronavirus disease 2019) is a new respiratory disease caused by a novel (new) coronavirus that was first identified during an investigation into an outbreak in Wuhan, China. Because it is new, much is still to be learned about [MEDICAL CONDITION]. What is currently known is that it is spread person¿ to-person, mainly between people who are within 6 feet of one another through respiratory droplets produced when an infected person coughs or sneezes. It may also be spread through airborne transmission if a person with COVID-19 infects others who are more than 6 feet away, but this usually occurs within an enclosed space that has inadequate ventilation. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. Review of the CDC recommendations at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html updated 11/04/20 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed Healthcare Personnel (HCP) refers to all paid and unpaid persons serving in healthcare settings. Healthcare settings refers to places where healthcare is delivered. Source Control refers to the use of cloth masks or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 to identify those who could have COVID-19 so appropriate precautions can be implemented. Take steps to ensure that everyone adheres to source control measures (wearing a mask) and hand hygiene practices while in a healthcare facility. Limit and monitor points of entry to the facility. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection and that they are [MEDICATION NAME] source control. They should also be reminded to frequently perform hand hygiene. HCP should wear a facemask at all times while they are in the healthcare facility. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Review of the CDC recommendations at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html updated 11/20/20 revealed as demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP) in Long Term Healthcare Facilities. The facility should educate residents, HCP and visitors about COVID-19, current precautions being taken in the facility, and actions they should take to protect themselves. Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Implement aggressive social distancing measures (remaining at least 6 feet apart from others). Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Remind HCP to practice social distancing and wear a facemask (for source control) when in break rooms or common areas. Considerations when restrictions are being relaxed include allowing communal dining and group activities for residents without COVID-19, including those who have fully recovered while maintaining social distancing, source control measures, (wearing masks) and limiting the numbers of residents who participate. This deficiency substantiates Complaint Numbers OH 209 and OH 048.

Based on observations, staff interviews, review of kitchen audit forms and review of facility policy, the facility failed to maintain safe and sanitary conditions in the kitchen above the food preparation area. This had the potential to affect 45 of 45 residents who received food from the kitchen. The facility census was 45. Findings include: Observation on 11/09/20 at 9:00 A.M., of the kitchen revealed large amounts of dust build up on the ceiling above the food preparation table. Dust build up was also observed hanging from the two florescent light fixtures running the length of the kitchen. In addition, a brown, fuzzy, substance was found on the ceiling above the food preparation and dishwashing areas. Interview on 11/09/20 at 9:07 A.M., with Dietary Staff (DS) #105 verified the build up of dust and the brown fuzzy substance on the ceiling above the food preparation and dishwashing area. DS #105 stated they have assigned cleaning tasks and DS #105 reported she was never assigned so she never dusted or cleaned the ceiling. DS #105 reported it would be the Dietary Manager's responsibility to make sure everything was cleaned how it was supposed to be cleaned. DS #105 reported it had been a while since there had been a manager in the kitchen. Interview on 11/09/20 at 9:10 A.M., with DS #104 verified the ceiling was dusty and dirty. DS #104 reported it was not her assigned job to clean the ceiling and she was not sure who was supposed to do it. DS #104 confirmed it needed to be cleaned. Interview on 11/10/20 at 2:47 P.M., with Dietary Technician (DT) #200 verified the last time she had been in the building to oversee the kitchen was in September. (DT) #200 reported she was supposed to check back in October 2020, but since COVID-19, she had not been back in the facility. DT #200 reported the dietary staff in the kitchen were trained and in-serviced annually and as needed. DT #200 reported DS #105 was working on her Safe Serve Training and they were all overseen by the dietician for dietary audits. DT #200 verified the dietician had not been in the facility either due to COVID-19. Review of the undated facility policy titled, Infection Control Overview, revealed infection control within the food and nutrition services department shall be maintained and monitored to promote food safety and prevent food borne illnesses. Cleaning was the removal of food, soil, and other types of debris from a surface. Review of the facility undated form titled, Food Safety and Sanitation Audit, revealed a qualified person was to be designated as Director of Food and Nutrition Services. Dietary staff were to have appropriate competencies and skill set in accordance with the facility's assessment. General sanitization included the ceiling was to clean and free from damaged tiles and holes. Review of the undated facility policy titled, Operation and Cleaning Procedures, revealed to promote safety and infection control all employees shall follow standard operating and cleaning procedures. The Dietary Manager shall be responsible for developing operating and cleaning procedures. This deficiency substantiates the allegations in Complaint Number OH 009.

Based on staff and resident interview, review of staffing schedules, review of facility policy, and review of Centers for Medicare and Medicaid Services (CMS) memo regarding visitation, the facility failed to allow residents to have outdoor visitation, despite the facility having no positive cases of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 48 residents who resided at the facility. The facility census was 48. Findings include: Interview on 10/29/20 at 10:18 A.M. the Director of Nursing (DON) stated no outdoor visitation had taken place at the facility since the COVID-19 pandemic started. The DON confirmed skype and window visits were the only visits allowed since the pandemic started. The DON stated the reason the facility did not have outdoor visitation was due to policies and procedures being in place which restricted visitation. Interview on 10/29/20 at 3:47 P.M. State-tested Nurse Aide (STNA) #500 reported the facility had an adequate supply of Personal Protective Equipment (PPE). Interview on 10/29/20 at 3:57 P.M. Registered Nurse (RN) #505 reported the facility had an adequate supply of PPE. Interview on 11/02/20 at 10:26 A.M. Resident #1 verified no outdoor visitation with family had taken place since the COVID-19 pandemic. Interview on 11/02/20 at 2:17 P.M. with the DON reported the facility's ideal staffing schedule would be the following: two nurses and four to five aides for first shift; two nurses and four to five aides for second shift; and two nurses and two aides for third shift. The DON verified the facility was not under a staffing crisis prior to 10/18/20 (the start of positive COVID-19 cases in residents and staff within the facility). Interview on 11/02/20 at 4:24 P.M. the DON reported the facility's first positive COVID-19 case was 10/16/20. The DON was notified of the positive case during the evening of 10/17/20, which led to all staff and residents being tested on [DATE]. The DON confirmed multiple staff and residents had tested positive, leading the facility to have an outbreak of COVID-19. The DON confirmed the facility had no prior COVID-19 cases or outbreaks. The DON confirmed prior to 10/18/20, the facility had adequate staffing. Interview on 11/02/20 at 4:50 P.M. with Registered Nurse (RN) #510 confirmed no outdoor visitation had taken place and only window visits had been allowed since the COVID-19 pandemic started. RN #510 confirmed the facility had an adequate supply of PPE. Review of staffing schedules from 09/01/20 to 09/30/20 revealed the following: for first shift there were approximately two nurses and four to five aides scheduled; for second shift there were approximately two to three nurses and four to five aides scheduled; and for third shift there were approximately two nurses and two aides scheduled. Review of staffing schedules from 10/01/20 to 10/18/20 revealed the following: for first shift there were approximately two nurses and four to five aides scheduled; for second shift there were approximately two to three nurses and four to five aides scheduled; and for third shift there were approximately two nurses and two aides scheduled. Review of facility policy titled, Visitation, Infection Control, During Outbreaks Policy, dated March 2020 revealed the Administrator could restrict or ban visitation during an outbreak. Review of undated facility policy titled, Coronavirus Surveillance, revealed, visitors would be screened for signs or symptoms of respiratory infection. Review of CMS memo titled, QSO-20-39-NH dated 09/17/20 revealed in May 2020, CMS released nursing home reopening recommendations, which provided additional guidance on visitation for nursing homes as their states and local communities progress through the phases of reopening. In June 2020, CMS also released guidance that expanded on topics such as outdoor visits, [MEDICATION NAME] care situations, and communal activities. This deficiency substantiates Complaint Number OH 807.

Based on medical record review, policy review and staff interview, the facility failed to provide and administer physician ordered anticonvulsant medications. This resulted in actual harm when the resident began having multiple [MEDICAL CONDITION] activity, experiencing symptoms of body rigidity with convulsions and staff observations of resident's eyes rolling back in her head. This affected one (#19) of three residents reviewed for medication administration. This had the potential to affect 22 residents identified by the facility as receiving anticonvulsant medications. The facility census was 49. Findings include: Review of Resident #19's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a intact cognition. Further review of the MDS revealed the resident had [MEDICAL CONDITION] disorders or [MEDICAL CONDITION]. Review of Resident #19's medical record revealed a physician order dated 12/07/15 for [MEDICATION NAME] (anticonvulsant) two tablets 300 milligrams (mg) twice daily for [MEDICAL CONDITION] and [MEDICATION NAME] XL (anticonvulsant) 600 mg twice daily for [MEDICAL CONDITION]. An order dated 02/20/17, added Onfi (sedative) 5 mg twice daily for [MEDICAL CONDITION]. On 03/31/17, a new order for [MEDICATION NAME] (anticonvulsant) 100 mg twice daily for [MEDICAL CONDITION]. Review of Resident #19's Care Plan dated 03/06/17, revealed the resident was at risk for injury caused by [MEDICAL CONDITION]. Interventions included to administer anticonvulsant medications per MD (medical doctor) order and notify the MD if [MEDICAL CONDITION] are suspected or observed. Review of Nurses Notes revealed on 04/25/17, Resident #19 was transferred to a hospital for planned [MEDICAL CONDITION] monitoring. The resident returned to the facility on [DATE] with new orders for a change in the dosing of Onfi. On 05/02/17, Onfi was changed to 5 mg every morning and increase 10 mg at bedtime for [MEDICAL CONDITION]. Review of Resident #19's May 2017, MAR indicated [REDACTED].M. and P.M. doses. [MEDICATION NAME] was not available on 05/25/17, 05/26/17, 05/27/17, 05/28/17, 05/29/17, 05/30/17 and 05/31/17 and not administered for the A.M. and P.M. Review of Resident #19's Nurses' Notes between February 2017 and 05/20/17 revealed the resident experienced [MEDICAL CONDITION] activity on 02/17/17, 02/19/17, 02/20/17, 03/18/17 and 04/01/17. Review of the Resident #19's Nurses Notes revealed on 05/28/17 at 9:58 A.M., the resident was observed having a [MEDICAL CONDITION] for approximately four to five minutes. She had her head down on the table and was shaking. There were no injuries. On 05/31/17 at 7:35 A.M., the resident was sitting up to chair, in dining room eating breakfast when began convulsing mildly with her eyes noted to be rolling back. The [MEDICAL CONDITION] activity lasted approximately 30 seconds without injuries. The resident was heard letting out a loud moan. The resident was taken back to her room and laid in bed. The resident's body went rigid and began convulsing and her eyes were noted to roll back. The [MEDICAL CONDITION] lasted approximately 30 seconds without injuries. On 05/31/17 at 11:00 A.M., the resident was sitting up in the day room when her body became rigid and mildly convulsing with her eyes noted to roll back. The [MEDICAL CONDITION] lasted approximately five minutes without injury. [MEDICATION NAME] was administered as ordered by physician due to increased anxiety due to [MEDICAL CONDITION]. On 05/31/17 at 11:44 A.M., the resident was sitting up in day room once again, when the resident's body became rigid and mildly convulsing. [MEDICAL CONDITION] activity last approximately 30 seconds without injury. On 05/31/17 at 12:15 P.M., the resident was sitting on her bed, working with rubber bands, when the resident's body became rigid and mildly convulsing and her eyes were noted to roll back. Audible snorting sounds were heard with some drooling noted. [MEDICAL CONDITION] activity lasted approximately two minutes. Further review of the medical record revealed on 05/26/17, the physician was notified of the resident not having the anticonvulsant medications. There is no documented evidence of the doctor further being notified on the other days of the resident still not having the anticonvulsant medications and having multiple [MEDICAL CONDITION] activity. Review of Resident #19's May and June 2017, MAR indicated [REDACTED]. Interview on 06/12/17 at 12:18 P.M. with Unit Manager #250 revealed on 04/25/17, Resident #19 was discharged to the hospital for planned [MEDICAL CONDITION] testing with knowledge that the resident would be returning. On discharge, Resident #19's medications were left in the medication cart due to her expected return. Once Resident #19 returned on 05/02/17, the medication doses were adjusted following new orders. The pharmacy was not notified of the resident's return. On 05/25/17, Resident #19's supply of [MEDICATION NAME] and Onfi were depleted. The pharmacy was alerted to the situation but was told since the resident had been discharged they required a new prescription from the physician. The physician was notified on 05/26/17, but took several days to complete the new prescription therefore Resident #19 was without the medication. Onfi was ultimately received on 05/31/17 and [MEDICATION NAME] on 06/01/17. Unit Manager #250 confirmed that Resident #19 had a [MEDICAL CONDITION] on 05/28/17 and on 05/31/17 had multiple [MEDICAL CONDITION]. Resident #19 was never sent out to hospital and resumed the medications on the day they were received from the pharmacy. Resident #19 has had no [MEDICAL CONDITION] since that time. Unit Manager #250 verified there was no documentation of additional notification with the physician about the need for new scripts or the resident having [MEDICAL CONDITION] activity. Review of the facility policy titled Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy dated 08/2014, revealed if not automatically refilled by the pharmacy, repeat medications (refills) are ordered as follows: reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider. Quantities of medications sent from the pharmacy may vary in accordance with payer status, insurance plan or law. This deficiency substantiates Complaint Number OH 572.