Every finding on record at Autumnwood Care Center

Based on observation, staff interview and facility policy review, the facility failed to ensure commons areas on the secured memory care unit were maintained to provide a homelike environment. This affected all 14 residents (#13, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) on the memory care unit. The facility census was 89.Findings Include:Observation on 07/27/26 at 4:12 P.M. on the secured unit revealed two common areas where residents watched television or interacted. One was painted a dark green/blue and the paint was missing, exposing white wall, around most of the perimeter of the room approximately at the height where the backs of chairs would rub. Interview on 07/29/26 at 10:35 A.M. with the Administrator, and concurrent observation of the dark painted common room on the memory care unit, confirmed there were several areas of missing paint with scratches and gouges in the wall. The Administrator stated he was not aware the room looked like that and immediately entered a work order for it to be addressed. The Administrator stated the paint could be matched to cover the white areas.Follow-up interview on 07/29/26 at 10:40 A.M. with the Administrator revealed the common room was just repainted approximately six months previously and the removed paint and gouges were new. The Administrator further confirmed the doorframe into the common areas was scratched and the paint was removed.Observation on 07/29/26 at 11:35 A.M. and concurrent interview with Licensed Practical Nurse (LPN) #206 confirmed several areas on the common room with the dark paint were missing paint and had gouges. These resulted in several areas of stark white wall, with ragged paint edges, around the perimeter of the room. On the wall with an opening into the other common room, to the left of the opening approximately two and one half feet up from the ground was an area 20 inches wide and nine inches high void of paint with ragged edges along the paint line. Further to the left was an area approximately 20 inches width and 13 inches high with a cluster of several smaller spots where the paint was removed and there were scratches and gouges in the wall. To the right of the opening was an area approximately 12 inches wide by six inches high with all the paint missing and ragged edges along the paint line. Continued observation and interview of the wall with an opening to the main hallway revealed an area to the right of the opening measuring approximately nine inches wide and six inches tall where all the dark paint was removed, exposing a white area. Further, on the wall opposite the doorway to the main hallway was an area approximately 11 inches wide and 10 inches high with several smaller areas of scratches and gouges exposing white under the paint. LPN #206 confirmed the doorframe into the common room from the main hallway had scratches and paint removed revealing multiple colored layers of paint. LPN #206 stated Resident #30 liked to scratch at the paint and at the doorframes. Review of the policy, 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 included (but were not limited to): clean and orderly environment, (and) inviting colors and decor. This deficiency represents non-compliance investigated under Master Complaint Number 3118867 and Complaint Number 3107217.

Based on record review, staff interview, review of the facility's investigation, and facility policy review, the facility failed to ensure a thorough investigation was completed when a resident was injured during a transfer using a mechanical lift. This affected one (#17) of three residents reviewed for transfers via mechanical lift. The facility census was 89. Findings include:Review of the medical record for Resident #17 revealed an admission date of 08/12/25 with diagnoses of hypoxemia, congestive heart failure, and muscle weakness. Review of the quarterly Minimum Data Set assessment, dated 04/26/26, revealed Resident #17 had impaired cognition and was dependent on staff for chair to bed transfers. Review of Resident #17's care plan, initiated 09/04/25, with revisions, revealed she had activities of daily life self-care and mobility performance deficits related to advanced age with progressive difficulties caring for self, swallowing, and weight loss. Interventions for transfers included: the resident may require total, two staff assist to transfer with Hoyer lift; do not place the lift pad inside her brief. Review of a nursing progress note dated 06/02/26 at 9:23 P.M. revealed Resident #17 had a skin tear to her left upper wrist measuring length of 3 (no unit of measurment identified), no width and no depth. The wound was in-house acquired. Pain level was zero. Further review revealed the area was cleaned with saline, six steri-strips were applied, antibiotic ointment was applied, it was covered with an oil emulsion non-adhering dressing and covered with gauze wrap. Review of the facility's investigation into Resident #17's skin tear as a result from the transfer from a mechanical lift on 06/02/26 revealed a statement from the Director of Nursing (DON) documenting Resident reported she caught her left wrist during a Hoyer transfer and had a small skin tear measured 3 cm (centimeters) by 0.5 cm skin tear. Resident was able to independently move arms and denied wrong doing of staff. Reminded resident to keep arms close to self during transfer to avoid bruises or skin tears in the future. Treatment implemented as ordered. Family and Medical Director notified. Further review of the facility's investigation revealed a witness statement, dated 06/02/26 untimed, typed by Licensed Practical Nurse (LPN) #201 for Certified Nursing Assistant (CNA) #102 stating, writer was informed by STNA (State Tested Nursing Assistant) Resident was being transferred by another STNA and that she heard Resident saying ouch ouch due to Resident's hand being caught in Hoyer lift. Review of an interdisciplinary team progress note, dated 06/03/26 at 1:44 P.M., written by Assistant Director of Nursing #505, revealed the team discussed the skin tear to arm that occurred during transfer with Hoyer (mechanical) lift. Writer spoke with resident regarding Geri-sleeves being placed to arms to help prevent further skin tears and she was agreeable to try them. Placed on resident by writer. Interview on 07/27/26 at 12:35 P.M. with Resident #17 revealed she felt some staff were more rough than others when using the mechanical lift, but Resident #17 could not be specific or provide examples to explain what she meant. Resident #17 could not recall how many staff were present when using the mechanical lift. Interview on 07/28/26 at approximately 3:15 P.M. with the DON revealed CNA #102 and CNA #103 were the two staff who transferred Resident #17 via mechanical lift on 06/02/26, at the time of the incident resulting in Resident #17's skin tear. The DON confirmed two staff should be present when using a mechanical lift. Interview on 07/29/26 at 1:32 P.M. with CNA #102 and concurrent review of the witness statement dated 06/02/26, revealed CNA #102 stated she was not in the room during the mechanical lift transfer of Resident #17 on 06/02/26 resulting in the skin tear. CNA #102 further denied the statement written by LPN #201. Telephone interview on 07/29/26 at 1:46 P.M. with CNA #103 revealed she could not recall if she was present during Resident #17's transfer on 06/02/26 resulting in her skin tear. Telephone interview on 07/29/26 at 2:04 P.M. with LPN #201 revealed she had just started her shift on 06/02/26 at approximately 2:00 P.M. (second shift) when Resident #17's family came to LPN #201 at the medication cart requesting an adhesive bandage. LPN #201 said Resident #17's family stated they had previously requested one but had not yet received one. LPN #201 went to examine Resident #17 and saw the skin tear was too large for an adhesive bandage. LPN #201 stated the Nurse Practitioner was there and assessed the area also and confirmed the treatment orders of steri-strips were appropriate. LPN #201 stated she stopped a first shift CNA as she was leaving the facility at the end of first shift and asked her what she knew about the skin tear and typed the statement regarding Resident #17 saying ouch. LPN #201 stated she could not recall the CNA's name. Interview on 07/29/26 at 2:35 P.M. with the DON revealed she spoke with LPN #201 over the phone and had LPN #201 describe the CNA she interviewed for the witness statement. The DON determined the statement was made by CNA #103, not by CNA #102. Further interview with the DON, with review of the witness statement, indicated CNA #103 made the statement Resident #17 was being transferred by another CNA. The DON further stated she had attempted to contact CNA #103 and had not received a return call. Additionally, the DON stated the only other CNA assigned to the hall on first shift on 06/02/26 was CNA #102. The Surveyor informed the DON of an interview with CNA #102 wherein CNA #102 denied being in the room during the transfer. The DON confirmed she could not determine who was present during Resident #17's transfer via mechanical lift on 06/02/26 resulting in a skin tear. Additional review of the facility's investigation, and concurrent interview with the DON on 07/29/26 at 3:40 P.M., revealed LPN #201 was approached by Resident #17's family requesting a Band-Aid (adhesive bandage), and the family stated there was a small area bleeding. LPN #201 noted a 3 cm by 0.5 cm skin tear to left upper wrist. LPN #201 was informed by family and resident that it happened during transfer on a Hoyer lift. Continued interview at that time with the DON confirmed the facility did not complete any additional investigation into the cause of Resident #17's skin tear during a transfer via mechanical lift, including determining which staff were present during the transfer, and what factors contributed to the skin tear. Review of the policy, Accident and Incidents - Investigating and Reporting, revised July 2017, revealed the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Further, the policy revealed: the following data, as applicable, shall be included on the Report of Incident/Accident form: The date and time the accident or incident took place; the nature of the injury/illness; the circumstances surrounding the accident or incident; where the accident or incident took place; the name(s) of witnesses and their accounts of the accident or incident; . other pertinent data as necessary or required.This was an incidental finding identified during the Complaint Survey completed 07/29/26.

Based on observation, staff interview, and record review, the facility failed to ensure diet orders, including limited fluids, were provided per physician orders. This affected one (#12) of three residents reviewed for specialized diet orders. The facility census was 89. Findings Include:Review of the medical record for Resident #12 revealed an admission date of 07/16/26 with diagnoses of congestive heart failure, fracture of thoracic vertebra, and chronic obstructive pulmonary disease. Review of the nursing admission Assessment, initiated 07/16/26 and completed 07/18/26, revealed Resident #12 was alert and oriented to person, place and time and was ambulatory.Review of a nursing progress note, dated 07/19/26, revealed the physician was notified of family concerns and requests. Orders added for fluid restriction daily of 1800, daily weights and {changing the diet from} NAS (no added salt) to carb controlled diet.Review of Resident #12's diet order, dated 07/21/26, revealed he received a CCHO (consistent carbohydrate)/No Salt Packet diet, regular texture, regular (fluid) consistency, 1800 fluid restriction per 24 hours, 360 per meal 720 milliliters (ml) nursing.Observation during noon meal service in the dining room on 07/28/26 at 11:43 A.M. revealed Resident #12 sitting at a table with a glass of iced tea. Follow-up observation at 11:51 A.M. revealed Resident #12 had an empty glass and also a glass of chocolate milk. Follow-up observation at approximately 12:10 P.M. revealed two empty glasses in front of Resident #12. Interview on 07/28/26 at 12:20 P.M. with Dietary Manager #301 and Registered Dietitian (RD) #303 confirmed Resident #12's meal ticket, provided by the kitchen, did not reflect the physician ordered fluid restriction. RD #303 stated she believed the fluid restriction was a family preference.Interview on 07/28/26 at 12:25 P.M. with Dietary Aide (DA) #101 confirmed she served Resident #12 a glass of iced tea and a glass of chocolate milk. DA #101 stated she was unaware Resident #12 was on a fluid restriction. DA #101 was able to identify the glasses she provided Resident #12 were 240 ml each.Interview and observation on 07/28/26 at 1:10 P.M. with RD #303 and the drinking glasses provided to Resident #12 verified each glass was 240 ml.Review of Resident #12's meal ticket for 07/28/26 revealed he should receive a CCHO/NS (no salt) diet, no salt packets. Regular texture, regular fluid consistency.This deficiency represents non-compliance investigated under Complaint Number 3107217.

Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors and further failed to ensure medications were administered as ordered. This resulted in Actual physical harm and emotional distress for one (#10) resident on 04/19/26 at 10:17 A.M. when Resident #10 verbalized being distraught about not receiving her anti-anxiety medication (Ativan) because the facility had run out and she had not received the evening dose (to be administered between 3:00 P.M. and 6:00 P.M.) on 04/18/26 and the early dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/19/26, and she was observed to be shaking, tearful and in emotional distress requiring staff intervention. Additionally, a second resident (#19) did not receive her physician prescribed anticonvulsant medication (Phenobarbital) for the evening doses on 04/17/26 and 04/18/26 (to be administered between 3:00 P.M. and 6:00 P.M.), and the morning dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/18/26 as they were not available, placing the resident at potential risk for more than minimal harm. This affected two (#10 and #19) of three residents reviewed for medication administration. The facility census was 88. Findings include:1) Review of Resident #10's medical record revealed an admission date of 11/20/25 with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions.Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 02/09/26 revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #10's cognition was intact. Resident #10 did not have any communication issues and was coded as not having displayed any behaviors during the 14 days of the assessment period. Resident #10 received scheduled antianxiety and antidepressant medications. Review of Resident #10's care plans revealed the resident had an active care plan in place for being at risk for complications related to an anxiety disorder. The care plan was initiated upon admission and was most recently revised on 02/23/26. The goal was for the resident to be free from discomfort or adverse reactions related to anti-anxiety therapy, interventions included to administer medications as ordered and to monitor for side effects and effectiveness every shift.Review of Resident #10's physician's orders revealed the resident had an order to receive Ativan (used to treat anxiety disorders and related symptoms by calming the nervous system, reducing physical symptoms [racing heart, muscle tension], and decreasing panic attacks) 0.5 milligrams (mg) by mouth twice a day for anxiety and agitation. Review of the Medication Administration Record (MAR) from 04/18/26 through 04/19/26 revealed the evening dose (to be administered between 3:00 P.M. and 6:00 P.M.) on 04/18/26 and the early dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/19/26 were not administered. The MAR contained a documented reason for omission as other, see progress note for each missed administration. Review of the progress note dated 04/18/26 at 5:28 P.M. revealed Resident #10's Ativan was not administered as it was unavailable and on order.Review of the progress note dated 04/19/26 at 4:13 A.M. revealed Resident #10's Ativan was not administered as it was unavailable due to waiting on pharmacy to deliver.During an interview on 04/19/26 at 10:17 A.M. with Resident #10 revealed the resident has anxiety and depression and the facility had run out of her Ativan. Continued observation from 10:17 A.M. until 10:40 A.M. revealed Resident #10 was visibly upset as the resident was shaking and tearful. Licensed Practical Nurse (LPN) #300 responded to Resident #10, assessed the resident, called the physician, set up a telehealth visit for the resident to meet with the provider, and received an order to obtain a dose of Ativan from the facility's back up medication stock. Interview on 04/19/26 at 10:45 A.M. with LPN #300 verified Resident #10 had not received her physician ordered doses of Ativan the evening of 04/18/26 or in the morning of 04/19/26. Further interview with LPN #300 verified Resident #10 was shaking, tearful, and visibly upset and required staff intervention.Interview on 04/19/26 at 11:48 A.M. with the Director of Nursing (DON) verified the facility had nine tablets of Ativan available in the facility's back up stock of medications in the medication dispensing machine. The DON stated staff just needed to obtain an order from the physician and a code from the pharmacy to obtain the medication from the machine.Interview on 04/20/26 at 12:30 P.M. with Nurse Practitioner (NP) #301 revealed missing two doses of Ativan can cause disruption in treatment and increase the resident's anxiety.2) Review of Resident #19's medical record revealed an admission date of 09/23/24 with diagnoses including convulsions, anemia, stage four chronic kidney disease, major depressive disorder, syncope and collapse, tremor, cerebral infarction, and seizures.Review of the most recent quarterly MDS assessment, dated 02/08/26, revealed a BIMS score of 15, indicating Resident #19's cognition was intact. Resident #19 did not have any communication issues, had not displayed any behaviors during the 14 days of the assessment period, and was receiving scheduled anticonvulsant medications. Review of Resident #19's care plans revealed the resident had an active care plan in place for being at risk for being on sedative/hypnotic therapy related to convulsions/seizure disorder. The care plan was initiated upon the residents' admission and most recently revised on 02/08/26. The goal was for the resident to be free from discomfort or adverse side effects of hypnotic use with interventions that included to administer sedative/hypnotic medications as ordered by physician and to monitor and document side effects and effectiveness every shift. Review of Resident #19's physician's orders revealed the resident had an order to receive Phenobarbital (a medication that slows the activity of your brain and nervous system and is used to treat or prevent seizures) 32.4 mg by mouth every morning for seizures and 129.6 mg in the evening for convulsions. Review of the MAR from 04/17/26 through 04/19/26 revealed the evening doses on 04/17/26 and 04/18/26 (to be administered between 3:00 P.M. and 6:00 P.M.), and the morning dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/18/26 were not administered. The MAR contained a documented reason for omission as other, see progress note for each missed administration. Review of the progress note dated 04/17/26 at 5:21 P.M. revealed Resident #19's Phenobarbital was not administered as only one tablet of the two tablet dose was available to administer. Review of the progress note dated 04/18/26 at 12:43 P.M. reveled Resident #19's Phenobarbital was not administered as it was not available. Review of the progress note dated 04/18/26 at 4:12 P.M. revealed Resident #19's Phenobarbital was not administered as it was unavailable and on order.Interview on 04/19/26 at 10:27 A.M. with Resident #19 revealed she had not received her physician ordered doses of Phenobarbital since the morning dose on 04/17/26. Interview on 04/19/26 at 10:45 A.M. with LPN #300 verified Resident #19 did not receive the physician ordered dose of Phenobarbital on the evening of 04/17/26. Additionally, LPN #300 verified Resident #19 did not receive either of the physician ordered doses of Phenobarbital on 04/18/26.Interview on 04/19/26 at 11:48 A.M. with the DON verified the facility had four tablets of Phenobarbital available in the facilities over ride medication dispensing cabinet. Review of the facility policy titled General Guidelines for Medication Administration, most recently revised August 2020, revealed medications are to be administered as prescribed. The facility has sufficient staff and a medication distribution system to ensure safe administration of mediations without unnecessary interruptions.Review of the facility policy titled, Controlled Substance, most recently revised August 2020, revealed all controlled medications are requested when a minimum of a five-day supply remains, or in accordance with facility policy, to allow for time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary.Review of the facility policy titled, Administering Medications, most recently revised April 2019, revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.This deficiency represents non-compliance investigated under Master Complaint Number 2988837.

Based on observation, resident interview, and staff interview, the facility failed to ensure state survey results were available without having to request them. Furthermore, the facility failed to ensure notice of the availability of the state survey results were posted in prominent and accessible areas for the residents/public. This had the potential to affect all residents. The facility census was 88.Findings include:Interview on 04/21/26 at 8:38 A.M. with Resident's #15, #19, #25, and #70 revealed they were not aware where the state survey results could be found.Observation on 04/21/26 at 9:45 A.M. of the front lobby, nurses station between the 100 and 200 halls, both dining rooms, the nurse's station between the 300 and 600 halls, and all resident room hallways in the facility revealed no signage posted regarding the location of the state survey results.Interview on 04/21/26 at 9:50 A.M. with Receptionist #280 verified she was unaware of where the state survey results were located and was unaware of any signage posted in the facility regarding the location of the state survey results.Interview on 04/21/26 at 9:51 A.M. with Certified Nursing Assistant (CNA) #228 verified she was unaware of where the state survey results were located and was unaware of any signage posted in the facility regarding the location of the survey results.Interview on 04/21/26 at 9:53 A.M. with the Director of Nursing (DON) verified the state survey results were usually kept in either the hallway or the dining room, however the DON was unaware were the state survey results were located and the DON further verified she was unaware of any signage posted in the facility regarding the location of the state survey results.Interview on 04/21/26 at 9:55 A.M. with the Administrator verified the state survey results were not available in the facility without having to ask a staff member for the state survey results. Furthermore, the Administrator verified he was unaware of any signage posted in the facility regarding the location of the survey results.

Based on observation, record review, staff interview, review of the Resident Assessment Instrument (RAI), review of the National Institute of Health website, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected three residents (#12, #52, and #76) and had the potential to affect six residents (#12, #14, #30, #47, #52, #76) the facility identified as being invasive ventilator dependent. The facility census was 88.Findings include:1. Review of Resident #12's medical record revealed an admission date of 10/16/12. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and dependence on respirator.Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required an invasive mechanical ventilator (Section O, question F1 of the assessment).Review of Resident #12's most recent care plan revealed the resident had altered respiratory status, difficulty breathing related to COPD, obstructive sleep apnea, and diffuse contractures limiting his mobility. The resident wore ventilator/average volume assured pressure support (AVAPS) per orders and was at risk for complications.Review of Resident #12's medical record revealed a physician order dated 04/16/26 for a ventilator/AVAPS AE (auto-titration mode of noninvasive ventilation) VT 425 machine with a maximum of 30 pressure support with an expiratory positive airway pressure (EPAP) of 6/ 15 and a respiratory rate between 10/15 respirations per minute with automatic speed and rise. May titrate settings for patient comfort/tolerance. Every shift for ventilator dependence, daily use required.Observation on 04/20/26 at 1:15 P.M. revealed Resident #12 was sitting in his room free of a tracheostomy or a respiratory ventilator. An AVAP machine was at bedside with a face mask attached.2. Review of Resident #52's medical record revealed an admission date of 01/02/25. Diagnoses included chronic obstructive pulmonary disease, dependence on respirator ventilator status, and obstructive sleep apnea. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed the resident required an invasive mechanical ventilator. Review of Resident #52's medical record revealed a physician's order dated 04/09/26 for a ventilator/AVAPS AE VT - 350 P, maximum of 30 pressure support,10/6 EPAP, and a respiratory rate of 10. May titrate settings for patient comfort/tolerance. Further physician order dated 04/09/26 revealed Resident #52 utilized ventilator/AVAPS for at least one hour during shift. Every shift for ventilator dependence, daily use required. Observation on 04/20/26 at 10:20 A.M. revealed Resident #52 was ambulating per self in her room. She was free of a ventilator or tracheostomy. Interview with Resident #52 on 04/20/26 at 10:20 A.M. revealed the resident does not use a ventilator but does utilize a CPAP (continuous positive airway pressure) machine while sleeping. The CPAP was observed at bedside.3. Review of Resident #76's medical record revealed an admission date of 08/12/22. Diagnoses included chronic obstructive pulmonary disease, obstructive apnea, acute and chronic respiratory status, and acute and chronic respiratory failure with hypoxia.Review of Resident #76's most recent care plan revealed he was respirator/vent dependence. The resident had COPD, morbid obesity, and obstructive sleep apnea with altered respiratory status, difficulty breathing and dependence on AVAP device while sleeping. Review of Resident #76's quarterly MDS assessment dated [DATE] revealed the resident was coded for an invasive mechanical ventilator.Review of Resident #76's medical record revealed a physician's order dated 04/09/26 for a ventilator/AVAPS AE VT- 325 P Max- 25, pressure support, 5-15 EPAP and 5 to 10 respiratory rates. May titrate settings for patient comfort/tolerance. An additional order dated 04/09/26 was to utilize ventilator/AVAPS for ventilator for at least one hour during this shift. Every shift for ventilator dependence. Interview with Licensed Practical Nurse (LPN) #300 on 04/20/26 at 10:10 A.M. revealed Resident #76 failed to have an invasive ventilator but utilized a CPAP at night. Observation of Resident #76 on 04/20/26 at 10:13 A.M. revealed he was sitting in a wheelchair in the lounge napping. The resident was free of any mechanical ventilation.Interview with MDS Nurse #152 on 04/21/26 at 12:28 P.M. revealed the physician utilized AVAPs so they were coding them according to the Resident Assessment Instrument (RAI) definitions. MDS Nurse #152 stated closed loop systems should be coded as invasive ventilators. The education the MDS nurse received revealed AVAPS continually monitored the resident and adjusts the volume as needed based off the predefined settings ordered due to the resident not being able to support their own respirations.Interview with the Ohio Department of Health Resident Assessment Instrument (RAI) and Outcome and Assessment Information Set (OASIS) Education Coordinator on 03/31/26 revealed the average volume-assured pressure support (AVAPS) is a non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation. AVAPS is most closely aligned with BiPAP and should be coded at O0110G2, BiPAP when used during the look-back period.A National Institute of Health StatPearls available at https://www.ncbi.nlm.nih.gov/books/NBK560600/ has an article titled Average Volume-Assured Pressure Support, that states different modalities of non-invasive ventilation exist, with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) being the most commonly used modes.Review of the RAI manual coding instructions for Invasive Mechanical ventilator (ventilator or respirator) revealed: code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents' receiving ventilation via an endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been weaned off of a respirator or ventilator in the last 14 days or is currently being weaned off a respirator or ventilator, should also be coded here. Do not code this item when the ventilator or respirator is used only as a substitute for BiPAP or CPAP.Review of the facility policy titled Resident Assessments undated revealed a comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were properly stored and labeled in accordance with professional standards. This had the potential to affected all facility residents. The facility census was 88.Findings include:1. Observation 04/19/26 at 8:22 A.M. of the medication storage cart for the 300-hall revealed an opened 24-ounce bottle of chocolate syrup approximately two-thirds empty, an opened 16-ounce bottle of Geri-Tussin (a liquid cough medicine), lot number F25103, approximately one-half empty, with a manufacturer's expiration date of 05/27, and an opened 16-ounce bottle of Milk of Magnesia, lot number DMR0388, approximately one-half empty, with a manufacturer's expiration date of 05/27 all without an open dates. Additionally, in the medication cart there was one three milliliter (mL) Lantus (a long acting insulin) pen, lot number 6F0555A, labeled for Resident #37, approximately one-half empty, with a manufacturer's expiration date of 09/30/28, the pen was labeled as opened on 03/14/26. Concurrent interview at the time of the observation with Licensed Practical Nurse (LPN) #302 revealed per facility policy, all medications should be labeled with an open date. LPN #302 verified the chocolate syrup, the Geri-Tussin, and the Milk of Magnesia where not labeled for when they were opened. LPN #302 also revealed that insulin pens are only good for 28 days after opening if they are stored at room temperature. LPN #302 verified the Lantus insulin pen for Resident #37 was dated as being opened on 03/14/26. 2. Observation on 04/20/26 at 1:11 P.M. of the 100-hall medication cart revealed a 1000 tablet bottle of 325 milligram (mg) tablets of acetaminophen (a medication used to treat pain and reduce pain), lot number 101Y06, was opened and approximately two-thirds full with a manufacturer's expiration date of 02/27, and a 17.9 ounce bottle of clear lax, (osmotic laxative used to treat occasional constipation by drawing water into the colon to soften stool and increase bowel movement frequency), lot number 5JR0420, approximately one-half full, with a manufacturers expiration date of 06/28 opened and undated. Concurrent interview with LPN #185 verified the acetaminophen and the bottle of clear lax were opened and undated. LPN #185 revealed, per facility policy, all medications are be labeled with the date which they are opened. 3. Observation of the medication storage room revealed a one bottle of tuberculin purified protein derivative, lot number 95156, approximately one-half full, with a manufacturer's expiration date of 09/27, not labeled with an open date. Interview with LPN #185 at the time of the observation verified the tuberculin bottle was not labeled with an open date and further verified per facility, all multi-dose bottles of testing solution are to be labeled with the date for which they are opened. Review of the manufacturers package insert for tuberculin purified protein derivative, revealed a vial of tuberculin purified protein derivative which has been entered and in use for 30 days should be discarded. Review of the Lantus manufacturers package insert stated the Lantus pen is to be discarded after being stored 28 days at room temperature. Review of the facility policy titled, Medications with Shortened Expiration Dates, dated June 2024, revealed once opened, Lantus Pen, expire 28 days after first use or removal from refrigerator, whichever comes first. Review of the facility policy titled Medication Labels, dated September 2018, revealed medications are labeled in accordance with facility requirements. Review of the facility policy titled, Vials and Ampules of Injectable Medications, dated September 2024, vials and ampules of injectable medications are used in accordance with manufacturers recommendations or the provider pharmacy's directions for storage, use, and disposal. Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are important to record on multi-dose vials. At a minimum, the date opened must be recorded. Triggered expiration dates may be found in the manufacturer's package insert, on the package provided, or on a reference chart by the pharmacy, or by contacting the pharmacist. Medication in multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP <797> guidelines recommend discarding multi-dose vials 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose and affixed to the vial. Review of the facility policy titled Administering Medications, most recently revised April 2019, revealed medications are administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, staff interview, resident interview, review of the test tray, and policy review, the facility failed to provide palatable food. This had the potential to affect 87 residents who receive food from the kitchen. The facility identified one resident (#1) who received nothing by mouth. The facility census was 88. Findings include:Observation on 04/19/26 at 12:13 P.M. revealed a test tray to be prepared in the kitchen. The test tray included ravioli in a red sauce, green beans, a breadstick, and Jello poke cake per the menu. At 12:14 P.M. the test tray was placed on the Memory Care meal cart. At 12:16 P.M. the Memory Care meal cart left the kitchen. At 12:18 P.M. the meal cart arrived at the Memory Care unit. At 12:19 P.M. two Certified Nursing Assistants (CNAs) began to pass the meal trays to the Memory Care unit residents. At 12:25 P.M. the final tray on the meal tray cart was passed.Observation on 04/19/26 at 12:30 P.M. of the test tray revealed a colorful and appetizing appearance however the ravioli was cold and lacked flavor, the green beans were cold, and unseasoned. Neither the ravioli or the green beans were palatable. The breadstick and Jello poke cake were flavorful.Interview after the sample of the test tray on 04/19/26 at 12:32 P.M. with Licensed Practical Nurse (LPN) #302 verified the ravioli and green beans were not palatable.Interview on 04/21/26 at 4:17 P.M. with Resident #30 verified the ravioli and green beans served on 04/19/26 were unpalatable. Furthermore, Resident #30 stated when she received her meal, the ravioli and green beans were cold.Review of the facility policy with a last revision date of October 2017 titled Food and Nutrition Services revealed food and nutrition staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe an appetizing temperature.

Based on observation, staff interview, and policy review, the facility failed to ensure residents on the Memory Care unit preferences regarding meals were identified and honored. This affected 15 residents (#9, #11, #16, #18, #33, #35, #48, #55, #56, #58, #60, #61, #76, #81, and #83) who resided on the Memory Care unit and received food from the kitchen. The census was 88.Findings include:Observation on 04/19/26 at 11:30 A.M. of meal service and meal tray preparation for the meal trays for the 100, 200, 300 and 400 halls revealed each resident's meal ticket contained the resident's name, diet order, allergies, preferences, dislikes and the alternate food items selected for the meal.Continued observation on 04/19/26 at 12:02 P.M. of meal service and meal tray preparation for the Memory Care unit revealed the Memory Care unit resident meal tray tickets contained the resident's name, diet order, and allergies. The meal ticket did not outline resident preferences, dislikes or alternate food items.Interview on 04/19/26 at 12:04 P.M. with Dietary Manager #181 verified the residents on the Memory Care unit meals tickets did not contain preferences or disliked food items as the residents are not asked because they are unable determine what they want each meal. Dietary Manager #181 stated the residents on the Memory Care unit receive the meal as posted. Dietary Manager #131 verified all other residents in the facility, not on the Memory Care unit, are able to determine what they want at each meal, and the staff mark the meal ticket accordingly. Interview on 04/19/26 at 4:03 P.M. with Certified Nursing Assistant (CNA) #240 verified the residents on the Memory Care unit do not preferences or dislikes posted on the meal tickets. CNA #240 stated Resident #56 and Resident #58 had certain food preferences, and those preferences are not honored. CNA #240 stated she has told the kitchen staff about the residents' preferences and they continue to only send the posted meal.Review of the facility policy revised July 2017 titled Resident Food Preferences, stated individual food preferences will be assessed by the Dietician or nursing staff upon admission (within 72 hours) and communicated to the interdisciplinary team. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Additionally, the Food Services Department will offer food choices for each scheduled meal, as well as access to nourishing snacks throughout the day and night.Review of the facility policy last revised on October 2017 titled Food and Nutrition Services, revealed each resident is provided with a nourishing, palatable, well-balanced diet taking into consideration the preferences of each resident. Furthermore, reasonable efforts will be made to accommodate resident choices and preferences.

Based on resident interview, staff interview, and policy review, the facility failed to ensure snacks were available and offered to residents. This had the potential to affect 87 residents who were able to receive snacks. The facility identified one resident (#1) as receiving nothing by mouth. The facility census was 88.Findings include:Interview with Resident #31 on 04/19/26 at 9:25 A.M. revealed the resident felt meals were served too close together. Resident #31 stated dinner was served at 4:00 P.M. and no snacks were offered or served in the evening, which left her hungry by breakfast. Interview on 04/21/26 at 8:38 A.M. with Residents #15, #19, #25, and #70 during the Resident Council meeting revealed Resident #15 and Resident #70 had never been offered snacks by the staff. Resident #25 stated if he wanted a snack, he had to ask for it, and the staff would go and get the snack. Resident #19 stated the staff did not offer them evening snacks.Interview on 04/21/26 at 10:01 A.M. with Certified Nursing Assistant (CNA) #278 verified the CNAs were responsible for the snacks being passed. CNA #278 stated the dietary staff were supposed to re-stock the coffee bar with snacks every day but that does not always happen. CNA #278 stated there is coffee bar between the 300 and 400 halls and another one between the 100 and 200 halls is snacks are available. Observation of the coffee bar between the 300 and 400 halls with CNA #278 was empty and contained no snacks.Interview on 04/21/26 at 10:05 A.M. with CNA #277 verified the CNAs are responsible for passing the snacks. CNA #277 stated the CNA's do not ask residents if they want snacks, but provide a snack is one is requested. Observation of the coffee bar between the 100 and 200 halls was empty and contained no snacks. Interview on 04/19/26 at 4:03 P.M. with CNA #240 verified the facility rarely stocks the Memory Care unit with snacks. CNA #240 stated they cannot provide snacks to the residents of the Memory Care unit because they are usually not available. Review of the facility policy last revised July 2017 titled Frequency of Meals, revealed nourishing snacks will be available for residents who need or desire food between meals and evening snacks will be offered routinely to all residents. The facility will choose what snacks are served at bedtime, however, the Dietician and Food Services Manager will solicit input from the residents and/or the Resident Council. Review of the facility policy revised July 2017 titled Resident Food Preferences, stated the Food Services Department will offer food choices for each scheduled meal, as well as access to nourishing snacks throughout the day and night.

Based on observation, staff interview, and policy review, the facility failed to ensure food that was open was properly stored. Furthermore, the facility failed to ensure eggs that were served undercooked were pasteurized. This had the potential to affect all 87 residents who received food from the kitchen, the facility identified one resident (#1) as receiving nothing by mouth. The facility census was 88. Findings include:Observation on 04/19/26 at 8:19 A.M. of reach in freezer #1 revealed sausage links, zucchini, two bags of biscuits, hash browns, Tator tots, chicken wings, and garlic bread all to be opened and undated.Interview on 04/19/26 at 8:22 A.M. with Dietary Manager (DM) #181 verified the sausage links, zucchini, two bags of biscuits, hash browns, Tator tots, chicken wings, and garlic bread were open in reach in freezer #1 and were undated.Observation with concurrent interview with DM #181 on 04/19/26 at 8:24 A.M. verified in the walk in refrigerator the eggs used in the facility were not pasteurized. Further observation with concurrent interview with DM #181of the walk in freezer revealed chicken patties and waffles were opened and undated.Interview on 04/19/26 at 11:37 A.M. with Dietary Aide (DA) #230 revealed residents were able to request how they wanted their eggs cooked including over-easy eggs.Observation on 04/22/26 at 7:06 A.M. of reach in freezer #1 revealed a bag of lima beans and a bag of onions were opened and undated.Interview on 04/22/26 at 7:07 A.M. with DM #181 verified the bag of lima beans and the bag of onions were opened and undated.Interview on 04/22/26 at 8:11 A.M. with DA #173 verified she was preparing three over-easy eggs for Resident #36. Concurrent observation revealed the facility served the three over-easy eggs to Resident #36.Review of the facility policy with a last revision date of July 2014 titled Preventing Foodborne Illness - Food Handling, revealed the facility recognizes critical factors implicated in foodborne illnesses and the primary focus focuses on preventative measures to minimize the risk to residents. All employees who handle, prepare or serve food will be trained in the policies of safe food handling. Any potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.

Based on observation, staff interview, review of the exterminator reports, and policy review, the facility failed to ensure effective pest control. This had the potential to affect 15 residents (#9, #11, #16, #18, #33, #35, #48, #55, #56, #58, #60, #61, #76, #81, and #83) residing on the Memory Care unit. The census was 88.Findings include:Observation on 04/21/26 at 10:11 A.M. of the Memory Care snack cabinet revealed mouse droppings to be on the shelves and at the bottom of the cabinet. Furthermore, a loaf of bread contained in the cabinet had a hole in the bag that appeared to be chewed through and some of the loaf of bread appeared to have small bite marks.Interview on 04/21/26 at 10:21 A.M. with Licensed Practical Nurse (LPN) #307 verified there were approximately 42 mouse droppings in the Memory Care snack cabinet. LPN #307 was unsure how long the mouse dropping had been in the cabinet and was not aware of when the last time the snacks from the cabinet were given to the residents.Review of the exterminator report dated 03/11/26 revealed the facility had treated for rats/mice in public areas, common areas and the south nurse's stations as it was documented that mice were sighted in the 600 hall and the south nurse's station. Review of the exterminator report dated 04/21/26 revealed the facility had general pest control treatment completed in the kitchen, dining room, public/common areas, laundry, therapy room, dishwashing area, dry goods storage, vending machina area, and near exit doors. The comments section read Performed routine service to all marked areas. Spoke with the Executive Director regarding the mouse situation at the south nurse's station near the 600 hallway and the Executive Director states that the issue has been resolved. Further review of the exterminator reports dated 03/11/26 and 04/21/26 revealed no evidence of the Memory Care unit having mice or being treated for mice. Review of the facility policy with a last revision date of May 2008 titled Pest Control revealed the facility shall maintain an effective pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and review of facility policy the facility failed to ensure a resident who was determined unable to self-administer medications did not self-administer nebulizer treatments. This affected one (#04) of one resident reviewed for medication self-administration. The facility census was 88. Findings include:Review of Resident #04's medical record revealed an admission date of 09/09/25. Diagnoses included acute renal failure, chronic obstructive pulmonary disease, and schizophrenia.Review of Resident #04's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive function was intact and that the resident required set up or clean up assistance for eating.Review of Resident #04's most recent care plan revealed the resident suffered from schizophrenia which affected the thought process. Medications were to be administered as ordered.Review of Resident #04's physician order for Ipratropium - Albuterol solution 0.5-2.5 milligrams (mg) per three milligrams solution stated three mgs was to be inhaled orally via nebulizer every six hours as needed for wheezing and shortness of breath and inhale orally via nebulizer two times a day for cough and congestion.Review of Resident #04's physician's order dated 04/16/26 stated to check lung sounds, pulse rate and oxygen saturation levels before and after the nebulizer treatment and for the staff to document the amount of minutes for set up and cleanup of equipment.Observation on 04/19/26 at 9:59 A.M. revealed Resident #04 had a one dose vial of Ipratropium - Albuterol solution and was placing it in the nebulizer without nursing supervision.Review of Resident #04's medical record revealed no evidence of an order for Resident #04 to self-administer medication.Review of Resident #04's medication self-administration assessment revealed Resident #04 was not able to self-administer medication.Interview with Licensed Practical Nurse #302 on 04/19/26 at 10:05 A.M. revealed Resident #04 was particular regarding the nebulizer treatment, so nursing would provide the aerosol treatment dose and allowed the resident to administer the treatment. The nurse verified Resident #04 failed to have an order to self-administer medication.Review of the facility policy titled Administration Procedure for All Medications revised 08/20 revealed medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications.

Based on record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure timely physician notification of medication unavailability for two residents (#10 and #19) of three residents reviewed for physician notification. The facility census was 88.Findings include:1. Review Resident #10's medical record revealed an admission date of 11/20/25, diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions.Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 02/09/26 revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #10's cognition was intact. Resident #10 did not have any communication issues and was coded as not having displayed any behaviors during the 14 days of the assessment period. Resident #10 received scheduled antianxiety and antidepressant medications. Review of Resident #10's care plans revealed the resident had an active care plan in place for being at risk for complications related to an anxiety disorder. The care plan was initiated upon admission and was most recently revised on 02/23/26. The goal was for the resident to be free from discomfort or adverse reactions related to anti-anxiety therapy, interventions included to administer medications as ordered and to monitor for side effects and effectiveness every shift.Review of Resident #10's physician's orders revealed the resident had an order to receive Ativan 0.5 milligrams (mg) by mouth twice a day for anxiety and agitation. Review of the Medication Administration Record (MAR) from 04/18/26 through 04/19/26 revealed the evening dose (to be administered between 3:00 P.M. and 6:00 P.M.) on 04/18/26 and the early dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/19/26 were not administered. The MAR contained a documented reason for omission as other, see progress note for each missed administration. Review of the progress note dated 04/18/26 at 5:28 P.M. revealed Resident #10's Ativan was not administered as it was unavailable and on order.Review of the progress note dated 04/19/26 at 4:13 A.M. revealed Resident #10's Ativan was not administered as it was unavailable due to waiting on pharmacy to deliver.Interview on 04/19/26 at 10:17 A.M. with Resident #10 revealed the resident has anxiety and depression and the facility had ran out of her Ativan. Interview on 04/19/26 at 10:45 A.M. with Licensed Practical Nurse (LPN) #300 verified Resident #10 had not received her physician ordered doses of Ativan the evening of 04/18/26 or in the morning of 04/19/26. Interview on 04/20/26 at 12:30 P.M. with Nurse Practitioner (NP) #301 revealed missing two doses of Ativan can cause disruption in treatment and increase the resident's anxiety. NP #301confirmed the facility did not notify him of the missed Ativan doses for Resident #10.2. Review of Resident #19's medical record revealed an admission date of 09/23/24, diagnoses included convulsions, anemia, stage four chronic kidney disease, major depressive disorder, syncope and collapse, tremor, cerebral infarction, and seizures.Review of the most recent quarterly MDS assessment, dated 02/08/26, revealed a BIMS score of 15, indicating Resident #19's cognition was intact. Resident #10 did not have any communication issues, had not displayed any behaviors during the 14 days of the assessment period, and was receiving scheduled anticonvulsant medications. Review of Resident #19's care plans revealed the resident had an active care plan in place for being at risk for being on sedative/hypnotic therapy related to convulsions/seizure disorder. The care plan was initiated upon the residents' admission and most recently revised on 02/08/26. The goal was for the resident to be free from discomfort or adverse side effects of hypnotic use with interventions that included to administer sedative/hypnotic medications as ordered by physician and to monitor and document side effects and effectiveness every shift. Review of Resident #19's physician's orders revealed the resident had an order to receive Phenobarbital (a medication that slows the activity of your brain and nervous system and is used to treat or prevent seizures) 32.4 mg by mouth every morning for seizures and 129.6 mg in the evening for convulsions. Review of the MAR from 04/17/26 through 04/19/26 revealed the evening doses on 04/17/26 and 04/18/26 (to be administered between 3:00 P.M. and 6:00 P.M.), and the morning dose (to be administered between 5:00 A.M. and 10:00 A.M.) on 04/18/26 were not administered. The MAR contained a documented reason for omission as other, see progress note for each missed administration. Review of the progress note dated 04/17/26 at 5:21 P.M. revealed Resident #19's Phenobarbital was not administered as only one tablet of the two tablet dose was available to administer. Review of the progress note dated 04/18/26 at 12:43 P.M. reveled Resident #19's Phenobarbital was not administered as it was not available. Review of the progress note dated 04/18/26 at 4:12 P.M. revealed Resident #19's Phenobarbital was not administered as it was unavailable and on order.Interview on 04/19/26 at 10:27 A.M. with Resident #19 revealed she had not received her physician ordered doses of Phenobarbital since the morning dose on 04/17/26. Interview on 04/19/26 at 10:45 A.M. with LPN #300 verified Resident #19 did not receive the physician ordered dose of Phenobarbital on the evening of 04/17/26. Additionally, LPN #300 verified Resident #19 did not receive either of the physician ordered doses of Phenobarbital on 04/18/26.Interview on 04/20/26 at 12:30 P.M. with NP #301 confirmed the facility did not notify him of the missed doses.Review of the facility policy titled Change in a Resident's Condition or Status, most recently revised May 2024, indicated the facility is to promptly notify the physician of changes in condition, including inability to administer medications as ordered.This deficiency represents non-compliance investigated under Master Complaint Number 2988837.

Based on observation, staff interview, medical record review, and facility policy review revealed the facility failed to ensure dependent residents received proper grooming. This affected two (#56, #85) of four residents reviewed for assistance of daily living (ADL) care. The facility identified all residents residing in the facility as being dependent for ADL care. The facility census was 88.Findings include:Review of Resident #56's medical record revealed an admission date of 01/08/25. Diagnoses included Alzheimer's disease, dementia, suicidal ideations, anxiety, and amaurosis fugax (vision loss).Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a low cognitive function and required partial to moderate assistance regarding personal hygiene and showering.Review of Resident #56's most recent care plan revealed the resident suffered from an activity of daily living (ADL) self-care and mobility performance deficit related to severe cognitive impairment, impaired standing balance, decreased safety awareness, and limited activity tolerance and endurance. Interventions included for moderate assistance of one staff member for personal hygiene, grooming and hygiene tasks.Review of Resident #56's progress notes dated 03/01/26 through 04/21/26 revealed no mention of the resident refusing care.Observation of Resident #56 on 04/19/26 at 10:25 A.M revealed the resident had long nasal hair protruding outside of the resident's nostrils approximately one third of an inch.Attempted interview with Resident #56 was unsuccessful due to low cognition. Interview on 04/19/26 at 10:52 A.M. with Licensed Practical Nurse (LPN) #303 confirmed Resident #56 was in need to have nose hair trimmed. LPN #303 stated that she noticed the nasal hairs that morning and was looking into it as the hair from the resident's nose should have been trimmed on shower days.2. Review of Resident #85's medical record revealed an admission date of 01/01/26. Diagnoses included acute respiratory failure and pulmonary embolism. Review of Resident #85's MDS revealed the resident required substantial/maximum assistance for bathing and required moderate assistance for personal hygiene. Review of Resident #85's most recent care plan revealed the resident had a self-care deficit related to acute illness. The resident required staff assistance for grooming and personal hygiene.Observation on 04/20/26 at 7:10 A.M. revealed Resident #85's finger nails were long and extending approximately 1/2 an inch from his fingertips. Concurrent interview with Resident #85 revealed he does not like having long nails and that staff fail to trim his nails and that he normally had to wait for his sister to visit to receive nail care. Interview with Certified Nursing Assistant (CNA) #265 on 04/22/26 at 9:15 A.M. confirmed Resident #85's finger nails were long and in need of trimming. CAN #265 stated the resident was on Hospice care but added staff are to complete nail care on shower days. Interview with the Director of Nursing (DON) on 04/22/26 at 2:20 P.M. verified facility staff were required to complete resident ADL care even if they were also cared for by hospice staff. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting undated revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on medical record review, resident and staff interview, and policy review, the facility failed to provide bed hold notice to residents being sent to the hospital. This affected one (#6) of three residents reviewed for bed hold notices. The facility census was 80.Findings include:Review of medical record for Resident #6 revealed an admission date of 04/18/25. Diagnoses included chronic kidney disease stage III, low back pain, and malignant neoplasm of parotid gland. Review of the census line revealed Resident #6 was private pay.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact.Review of the nursing note dated 07/03/25 at 3:01 P.M. revealed Resident #6 was found on the floor of her bathroom lying on her side in front of the toilet. The resident was screaming out in pain during the transfer. The Certified Nurse Practitioner (CNP) was notified and a new order received to send the resident to the emergency room (ER) for evaluation.The nursing note dated 07/04/25 at 1:40 A.M. revealed Resident #6 returned to the facility from the ER with no new orders. There was no documentation of Resident #6 receiving a bed hold notice when Resident #6 was sent to the ER on [DATE].Review of bed hold notice provided by the facility revealed Resident #6 went out to the hospital on [DATE] and noted the resident was private pay. The notice stated I am requesting to hold a bed starting 07/03/25 to 07/04/25 and acknowledge that I agree to pay the full private pay per diem rate of $325 for that bed. The bed hold notice was signed by Resident #6 on 07/07/25.Interview on 07/08/25 at 1:26 P.M. with Social Worker (SW) #523 revealed she did not get the bed hold agreement signed until 07/07/25 due to the fact that the resident went to the hospital while she was off work. SW #523 stated she just came back on 07/07/25 and followed up with Resident #6 regarding her transfer to the hospital.Interview on 07/08/25 at 2:48 P.M. with Resident #6 stated the facility did not tell her about her bed being held before she went to the hospital. Resident #6 stated she was shocked when they came in yesterday (07/07/25) and had her sign a paper and owed money. Resident #6 denied giving her verbal consent to hold her bed when she left for the hospital. Resident #6 stated that if she did, she did not know what it was.Review of the policy titled Bed-Holds and Returns revised May 2025 revealed prior to a transfer, information will be given to the residents and the resident representatives that explains the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy as indicated by the state plan (Medicaid residents), and the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents).This deficiency represents non-compliance investigated under Complaint Number OH00167190 (1388262).

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a medication order was complete and accurate and further failed to ensure the medication order was transcribed correctly to make certain Resident #10 was administered the correct medication. Actual Harm occurred when an incomplete verbal order for a critically low potassium level (2.7 milliequivalents per liter [mEq/L] with normal potassium blood serum measuring between 3.5 and 5.5 mEq/L) was transcribed and medication administered inaccurately, resulting in Resident #10 receiving a medication to remove potassium from the blood rather than a medication to replace potassium (low potassium could result in cardiac arrhythmia, numbness, tingling, muscle weakness, spasms, and or muscle damage). Resident #10 required hospital treatment, additional laboratory testing and the replacement of potassium with 40 milliequivalents (mEq) administered orally and 10 mEq intravenously. This affected one (#10) of three residents reviewed for medication errors. The facility census was 81. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, congestive heart failure, and cardiomyopathy. Review of Resident #10's significant change Minimum Data Set (MDS) dated [DATE] revealed a low cognitive function. Resident #10 required a set up for eating. Review of Resident #10's most recent care plan revealed a cardiac diagnosis which required monitoring and medications for congestive heart failure and coronary artery disease. Review of Resident #10's medical record revealed Assistant Director of Nursing (ADON) #200 received a text message (verbal order) from Certified Nurse Practitioner (CNP) #500 on 12/26/24 at 1:16 P.M. stating Resident #10 had critical potassium results. The verbal order stated give 60 mEq now and 60 tomorrow morning and recheck potassium tomorrow a few hours after the morning medication. Review of the order placed by ADON #200 in the electronic medical record dated 12/26/24 at 3:11 P.M. revealed sodium polystyrene sulfonate suspension (Kayexalate) 15 grams per 60 milliliter (ml) was to be administered by mouth one time for hyperkalemia. Review of Resident #10's Medication Administration Record (MAR) dated 12/26/24 revealed Licensed Practical Nurse (LPN) #250 administered sodium polystyrene sulfonate suspension 60 ml by mouth at 4:31 P.M. Review of Resident #10's medical record dated 12/26/24 at 5:30 P.M. revealed CNP #500 was updated on a medication error and a new order was obtained to send Resident #10 to the emergency room for evaluation. Resident #10's family was updated on the transfer and Resident #10 was transported to the hospital by the facility van. Review of Resident #10's hospital record dated 12/26/24 revealed the resident was an [AGE] year-old female who presented to the emergency department at 5:51 P.M. for evaluation of possible hypokalemia due to nursing home staff reporting that resident's potassium was low (2.7 mEq/L at 12:43 P.M. per nursing home laboratory test results) and resident was given 60 grams Kayexalate by mistake. Resident #10's potassium level in the emergency department was 2.8 mEq/L, Resident #10 was ordered to receive 40 mEq of potassium orally and 10 mEq intravenously. Resident #10 was discharged and returned to the facility at 11:59 P.M. on 12/26/24 with orders for follow up blood testing to be completed on 12/27/24. Diagnoses included hypokalemia (low potassium) and accidental ingestion of a substance. Review of Resident #10's repeat blood work on 12/27/24 revealed a potassium level of 3.2 mEq/L. Interview with ADON #200 on 01/15/25 at 1:29 P.M. revealed she received a text order from CNP #500 which read critical potassium on Resident #10. Give her 60 mEq right now and 60 tomorrow morning and recheck potassium tomorrow a few hours after the morning medication. ADON #200 revealed she realized her error about an hour after placing the electronic order when she reviewed her text messages and noted the order was not clear. ADON #200 verified she placed an inaccurate order in the electronic medical record for Resident #10. ADON #200 stated when she discovered the error she tried to stop the floor nurse from administering the medication, but was too late, the Kayexalate had already been administered. Interview with the Administrator on 01/16/25 at 3:24 P.M. revealed Resident #10 had low potassium levels and on 12/26/24 CNP #500 had ordered additional potassium to increase the residents potassium level. The Administrator stated ADON #200 misread the incomplete order which was texted to her phone and placed an order for Kayexalate into Resident #10's electronic medical record and once the error was identified Resident #10 was taken to the emergency department for evaluation and was required to receive a potassium infusion. Telephone interview with LPN #250 on 01/21/25 at 1:40 P.M. revealed ADON #200 informed her verbally that Resident #10's potassium was high, and the level needed to be decreased, and an order for Kayexalate had been entered. LPN #250 verified she administered the medication and within a couple of minutes of administering the medication the ADON informed LPN #250 the order was an error. LPN #250 revealed knowledge of Resident #10's history of hypokalemia and verified the resident took a potassium supplement twice daily but had come to the conclusion that her potassium levels must have increased. LPN #250 stated she failed to check the laboratory results herself. Interview with the Administrator on 01/21/25 at 3:10 P.M. revealed the facility failed to have a policy regarding clarification of CNP and physician orders when incomplete. Review of the Medical Director Agreement, signed on 06/18/24 revealed adequate and appropriate services will be provided to residents. Review of the undated facility policy titled Electronic Signatures and Electronic Orders, revealed the facility permits the use of electronic orders in accordance with recognized standards and laws. Review of the facility policy titled Documentation of New or Changed Physician Prescribed Orders, revised 07/01/24 stated a medication order should include the medication name, strength, dosage, time or frequency and route of administration. This deficiency represents non-compliance investigated under Complaint Number OH00161202.

Based on observation, staff interview, and review of facility policy, the facility failed to maintain the kitchen in a safe and sanitary manner. This had the potential to affect 77 residents in the facility, Resident #52 received no food by mouth and thus received no food from the kitchen. The facility census was 78. Findings include: Observation on 12/09/24 at 8:35 A.M. of the kitchen found Dietary Staff (DS) #534 was running dishes through the dishwasher. Coinciding interview with DS #534 revealed she was not aware if the dishwasher was a high temperature or chemical machine. Review of the dishwasher found it was labeled as a high temperature machine with the final rinse temperature should be 180 degrees Fahrenheit (F). Observation of the temperature gauge as DS #534 ran the dishwasher found it reached 164 degrees F for the wash and the gauge did not move off the 100 degree mark for the rinse. Observation and coinciding interview on 12/09/24 at 8:37 A.M. with Dietary Director (DD) #601 found when the dishwasher was run again the rinse gauge continued to read 100 degrees and did not move. The dishwasher was run a third time along with an internal temperature gauge puck and DD #601 verified the highest temperature the dishwasher reached was 154 degrees F. DD #601 reported he was unaware of how long the dishwasher was not reaching the 180 degrees F for the rinse cycle and directed the staff to use the three sink system for sanitation after the dishes were ran through the dishwasher. Review of Dishwasher Temperature Record for the month of December 2024 revealed the dishwasher wash and rinse temperatures were taken with every meal. Of the 24 rinse temperatures documented there were 20 times the dishwasher did not reach 180 degrees on the rinse cycle. Observation on 12/09/24 at 8:49 A.M. of the dry storage area found a one gallon bottle of soy sauce open and approximately 1/3 used on the dry storage shelf. The bottle was labeled refrigerate after opening. Interview on 12/09/24 at 8:50 A.M. with DM #601 verified the soy sauce was being stored on the dry storage shelf and it should have been in the refrigerator. DM #601 disposed of the soy sauce. Further review of the dry storage area on 12/09/24 at 8:50 A.M. found a scooped contained in the bulk rice puff cereal. Interview on 12/09/24 at 8:51 A.M. with DM #601 verified there was a scoop contained in the bulk rice cereal and the scoop should have been stored outside of the container and not left in the container. Observation on 12/09/24 at 8:56 A.M. of the reach in freezer found an open box containing an open clear plastic bag of cheddar cheese omelets. Approximately five omelets were observed in the open box. Coinciding interview with DM #601 verified the box of omelets were left open and were not currently being use. Review of the facility policy titled, Food Receiving and Storage, revised October 2017 revealed refrigerated food must be stored below 41 degrees unless otherwise specified by law. All foods stored in the refrigerator or freezer would be covered, labeled and dated. Review of the facility policy titled, Dishwasher Machine Use, revised March 2010 revealed the facility's dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degree Fahrenheit (F) or less than 180 degrees F for all other machines. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and would record the results in the facility approved log. Inadequate temperatures would be reported to the supervisor and corrected immediately.

Based on observation, staff interview, review of the manufactures instructions for the dishwasher, review of dishwasher temperature logs, and review of facility policy, the facility failed to ensure the dishwashing machine was maintained in a safe operating condition. This had the potential to affect 77 residents in the facility, Resident #52 received no food by mouth and no food from the kitchen. The facility census was 78. Findings include: Observation on 12/09/24 at 8:35 A.M. of the kitchen found Dietary Staff (DS) #534 was running dishes through the dishwasher. Coinciding interview with DS #534 revealed she was not aware if the dishwasher was a high temperature or chemical machine. Review of the dishwasher found it was labeled as a high temperature machine with a final rinse temperature noted to be 180 degrees Fahrenheit (F). Observation of the temperature gauge as DS #534 ran the dishwasher found it reached 164 degrees F for the wash and the gauge did not move off the 100 degree mark for the rinse. Observation and coinciding interview on 12/09/24 at 8:37 A.M. with Dietary Director (DD) #601 found when the dishwasher was run again the rinse gauge continued to read 100 degrees and did not move. The dishwasher was run a third time along with an internal temperature gauge puck and DD #601 verified the highest temperature the dishwasher reached was 154 degrees F. DD #601 reported he was unaware of how long the dishwasher was not reaching the 180 degrees F for the rinse cycle and directed the staff to use the three sink system for sanitation after the dishes were ran through the dishwasher. Review of Dishwasher Temperature Record for the month of December 2024 revealed the dishwasher wash and rinse temperatures were taken with every meal. Of the 24 rinse temperatures documented there were 20 times the dishwasher did not reach 180 degrees on the rinse cycle. Interview on 12/10/24 at 9:44 A.M. with DM #601 revealed a couple months prior they had been having an issue with the temperature gauges on the dishwashing machine. They had been using the puck with every wash cycle to ensure the temperature of the water was reaching the required levels. If the dishwasher did not reach the proper levels the kitchen staff would put the dishes through the three sink system to ensure proper sanitation. DM #601 reported the gauges were repaired at the end of November and they stopped using the pucks. DM #601 reported he was not aware the dishwasher was still not working correctly until yesterday when the puck read 154 after the rinse cycle. DM #601 verified the three sink system was not utilized from 12/01/24 to 12/09/24. The temperature log was reviewed and DM #601 verified there were a number of times in December where the dishwasher did not reach proper temperatures for the rinse cycle. Interview on 12/10/24 at 10:28 A.M. with DM #601 revealed the dishwasher had been fixed by Regional Director of Maintenance #605. Coinciding observation found the dishwasher gauge read 164 degrees F for the wash cycle and 190 degrees F for the rinse cycle. Observation on 12/11/24 7:41 A.M. of the dishwasher for internal water temperatures using a thermometer puck with DM #601 found the rinse cycle read 186 degrees F on the gauge but 149 degrees F on the puck. DM #601 reported the dishwasher had not been in use yet this morning and typically took a couple times running to reach temperature. Additional temperatures were as follows: 12/11/24 at 7:42 AM the rinse gauge read 190 degrees F and the puck read 164 degrees F. 12/11/24 at 7:43 AM the rinse gauge read 190 degrees F and the puck read 166 degrees F. 12/11/24 at 7:45 AM the rinse gauge read 188 degrees F and the puck read 172 degrees F. Coinciding interview with DM #601 revealed they would be having a service professional come out again to fix the dishwasher. DM #601 verified the gauge was providing inaccurate readings of the dishwasher temperatures which indicated the dishwasher was reaching the appropriate rinse temperature of 180 degrees F or higher when in fact the actual internal water temperature was much lower. 12/11/24 at 7:47 A.M. the rinse gauge read 188 degrees F and the puck read 173 degrees F. 12/11/24 at 7:48 A.M. the rinse gauge read 198 degrees F and the puck read 176 degrees F. 12/11/24 at 7:50 A.M. the rinse gauge read 200 degrees F and the puck read 179.6 degrees F. 12/11/24 at 7:51 A.M. the rinse gauge read 200 degrees F and the puck read 179.6 degrees F. 12/11/24 at 7:52 A.M. the rinse gauge read 200 degrees F and the puck read 179.7 degrees F. On 12/11/24 at 7:53 A.M. a different thermometer puck was used to ensure the puck in use was accurate. The rinse gauge read 260 degrees F and the new puck read 172 degrees F. 12/11/24 at 7:54 A.M. the rinse gauge read 210 degrees F and the internal temperature on the puck read 176.9 degrees F. 12/11/24 at 7:56 A.M. the rinse gauge read 212 degrees F and the puck read 177.8 degrees F. 12/11/24 at 7:57 A.M. the rinse gauge read 210 degrees F and the puck read 179.9 degrees F. On 12/11/24 at 7:58 A.M. both pucks were ran through the dishwasher cycle along with two high temperature test strips which had indicators which turned black when an internal temperature of 180 degrees F was reached. The rinse gauge read 212 degree F, the two pucks read 179.9 degrees F and 177.2 degrees F, while the two test strip indicators remained white. Coinciding interview with DM #601 verified the dishwasher continued to not reach the proper temperatures and they would use the three sink system to ensure sanitation until the dishwasher was repaired. Interview on 12/12/24 at 1:22 P.M. with DM #601 revealed the dishwasher was still not getting up to temperature. DM #601 reported they had a service order in for the company to come out and repair it. The facility was waiting on the company to contact them back with a date of when they would be coming out to evaluate the machine and complete the repairs. In the mean time, DM #601 reported they would continue running the dishes through the dishwasher and then putting them through the three sink system. Review of the Manufactures Instructions for dishwasher utilized by the facility revealed the water temperature for the wash cycle was to be 160 degrees F and the rinse cycle was to be 180 degrees F. Review of the facility policy titled, Dishwasher Machine Use, revised March 2010 revealed the facility's dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degree Fahrenheit (F) or less than 180 degrees F for all other machines. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and would record the results in the facility approved log. Inadequate temperatures would be reported to the supervisor and corrected immediately.

Based on observation, resident interviews, staff interviews, and review of facility policy, the facility failed to ensure the dryers in the facility laundry room were cleaned appropriately. This had the potential to affect all residents in the facility. Additionally, the facility failed to ensure a well-maintained environment. This affected two residents (Resident #24 and Resident #68) of two residents reviewed for environment. The facility census was 78. Findings include: 1. Observation on 12/10/24 at 12:02 P.M. revealed the walk-in vent area behind the facility's three industrial dryers were covered in lint. An interview on 12/10/24 at 12:02 P.M. with Laundry #502 verified these findings. An interview on 12/10/24 at 12:02 P.M. with Laundry #502 revealed Maintenance Supervisor #535 cleans the lint once per year. 31638 2. Observation of Residents #24 and #68 room on 12/09/24 at 9:45 A.M. revealed above Resident #24's bed was a large brown stain on the ceiling. Interview with Residents #24 and #68 on 12/09/24 at 10:35 A.M. verified their ceiling had large brown stain. They stated the stain had been there for a long time. When asked if it bothered them they stated they looked at the spots and imagined the different shapes like clouds, but they wished the ceiling could be painted. Interview with Maintenance Supervisor #527 on 12/12/24 at 8:07 A.M. verified there was a large brown stain on the ceiling in Residents #24 and #68's room. He stated he planned to paint the ceiling. When asked if it was a leak he stated the stain was from a leak but it had been repaired sometime ago but was not able to remember the exact timeframe. Review of the facility policy titled, Maintenance Service, undated, revealed the maintenance department was responsible for providing routine scheduled maintenance service to all areas.

Based on medical record review, staff interview, physician interview, review of the hospital records, and policy review, the facility failed to ensure early identification of a change in the resident's condition. This resulted in Actual Harm when Resident #41, who was taking an anticoagulant medication, experienced a moderate amount of blood in the stool during a bowel movement. A thorough assessment and immediate notification to the physician was not completed. Subsequently, approximately 33 hours later the resident was hospitalized and received three units of packed red blood cells for a critical low hemoglobin level. This affected one (Resident #41) of one resident reviewed for anticoagulant therapy. The facility census was 73. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #41 was cognitively intact, required supervision for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident received seven days of an anticoagulant medication during the review period. Review of the progress note dated 09/12/22 at 2:25 A.M. revealed the resident had a moderate amount of blood in the toilet with traces of blood in the stool. Resident #41 denied any abdominal pain. A stool sample was obtained if needed to send out to the laboratory. The writer documented they would pass on in report to notify the doctor in the morning. No other assessment of the resident was documented. Review of the progress note dated 09/13/22 at 1:18 A.M. revealed Resident #41 had emesis times one of clear liquid after taking a drink of water. The resident denied abdominal pain or further nausea. There was no other assessment of the resident documented. Review of the progress note dated 09/14/22 at 3:28 P.M. revealed a late entry note was written for 09/13/22 at 9:30 A.M. which stated the night shift reported during morning Resident #41 had more blood in the stool. When Resident #41 woke up in the morning the resident was jaundice, confused, hallucinating, and had complaints of abdominal pain. The writer of the note referenced the physician was faxed the day before on the resident condition. The physician stated the facility may send resident to the emergency room if the condition worsens. The resident was noted to be assessed by the facility nurse and the physician office was called and informed of the resident's condition. Review of the progress note dated 09/13/22 at 2:59 P.M. revealed Resident #41 was admitted to the hospital with a gastrointestinal bleed. Review of Resident #41's September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the vital sign report revealed there was no documented blood pressure readings or pulses obtained after Resident #41 had reported blood with her bowel movement on 09/12/22. Review of the September 2022 treatment administration record (TAR) revealed the staff were monitoring the resident every shift for side effects of anticoagulant therapy including nausea, emesis, blood in the stool and were to document number of episodes a shift. All entries were coded as zero indicating no episodes of blood in stool, nausea, or emesis including entries on 09/12/22 and 09/13/22, when the nurse progress notes documented the resident had episodes of blood in the stool. Review of the fax communication between the facility and the physician on 09/12/22 at an undetermined time verified the physician was notified Resident #41 had an episode of moderate bleeding with a bowel movement and there was blood in the stool. The fax documentation had a reply from the physician questioning if the resident was on an anticoagulant, ordered a complete blood count (CBC), wanted to know the characteristics of the stool such as hard or if the resident had hemorrhoids. The fax documented to send the resident to the Emergency Department (ED) if the resident condition worsened or if there was worsening blood in the stool. There was no evidence in the medical record the facility completed the orders attached to the 09/12/22 faxed physician notification of completion of the laboratory test of a CBC, informing the physician if the resident had hard stools or hemorrhoids, and to verify if the resident was taking an anticoagulant. Review of the hospital gastroenterology consult note dated 09/16/22 revealed Resident #41 presented to the emergency department on 09/13/22 where she reported she had not felt well. Per reports Resident #41 had some black stool and a report of bright red blood earlier in the week. She was on [MEDICATION(S)], and her last dose was reported as 09/13/22. No additional information could be obtained from her due to her mental status. She presented to the ED with a hemoglobin of 4.7 grams per deciliter (g/dL) and received three units of packed red blood cells. (A critical low hemoglobin level is a value of less than 5.0 g/dL which can lead to heart failure and death. A normal hemoglobin level is 11.9 g/dL to 15.11 g/dL.). Review of the resident discharge summary from the hospital dated 09/16/22 revealed Resident #41 had orders for a CBC and Basic Metabolic Panel (BMP) on 09/19/22. There was no evidence in the medical record these laboratory tests were performed. Interview with Licensed Practical Nurse (LPN) #501 on 09/28/22 at 7:55 A.M., verified if a resident was on an anticoagulant and the resident had signs of active bleeding, she would not give the medication and would call the physician, and inform them of her findings and follow any orders the physician would provide. Interview with LPN #413 on 09/29/22 at 8:35 P.M., verified the residents on anticoagulants are monitored for abnormal bleeding and bruising. The LPN stated if a resident on an anticoagulant had bleeding, she would contact the physician and report the condition of the resident and would get instructions from the physician regarding any immediate orders such as holding the anticoagulant medication and on-going monitoring. Interview with the Director of Nursing (DON) on 09/28/22 at 2:39 P.M. verified the facility documented on 09/12/22 at 2:25 A.M. Resident #41 had a moderate amount of blood in the toilet and blood visible in the resident stool and left the physician notification for the day shift staff to complete. The DON verified with a moderate amount of blood visible she would expect the physician notification to occur right away and not wait until the next shift. Interview with Physician #700 on 09/28/22 at 4:43 P.M., verified he would not necessarily expect to be notified of blood in a resident's stool if the amount was small and the resident was known to have hemorrhoids, which he was not made aware in this case. The physician assumed the facility staff probably took Resident 41's vital signs and the vital signs were stable, and they decided to notify me in the morning. The physician verified Resident #41's hemoglobin was low when she was in the ED, and she received blood products to raise her hemoglobin. A follow-up interview with the DON on 09/29/22 at 11:56 A.M., verified the physician ordered Resident #41 to have a CBC when he was notified of the blood in Resident #41's stool on 09/12/22 and it was not completed. The DON verified the documentation of the resident having blood in the stool had not included vital signs for the resident, and the medical record had no other documented vital signs/assessment when the resident had experienced blood in the stool. Interview with the Administrator and the DON on 09/29/22 at 10:09 A.M., verified the CBC and BMP ordered for Resident #41 on 09/19/22 was not completed as ordered. A follow-up interview on 09/29/22 at 1:28 P.M., with the Administrator verified there was no documentation in Resident#41's medical record indicating the physician was notified the resident was on a blood thinner when the fax notification related to blood with a bowel movement requested to know additional information. The Administrator verified the medical record had no documentation the 09/12/22 CBC laboratory test being completed as ordered by the physician. Review of the policy titled Notification of Change, dated 2006 last revised in 12/2016 revealed when there is a need to alter treatment significantly immediate notification of the resident will occur. There will also be consultation with the resident's physician and the resident's representative if consistent his/her authority. Definition: Need to alter treatment significantly includes the following: a need to change a current treatment, discontinuing a current treatment or commencing a new treatment. Procedure: Immediate notification of the resident; consult with the resident's physician; notification of the resident representative is to be done in the following situations: - A significant change in the resident's physical, mental or psychosocial status including a deterioration in the health, mental, cognition, medication change, or psychosocial status in either life-threatening conditions, or clinical complications. - A need to alter treatment/plan of care significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form or treatment).

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of CMS website for county COVID-19 positivity rates, review of guidance from the Centers for Disease Control (CDC) and Prevention website related to; preparing for Coronavirus Disease 2019 (COVID-19), Infection Prevention and Control (IPC) recommendations, responding to COVID-19 for nursing homes and health care facilities, and counterfeit respirators, surveyor observations, medical record reviews, staff interviews, review of daily census sheets, county health department staff interview, review of the resident COVID-19 test results spreadsheet, review of facility policy regarding cleaning of an isolation room, review of facility policy regarding infection control for suspected or confirmed COVID-19 residents, and review of facility policy regarding transmission based precautions, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 including; properly cohorting positive residents, providing dedicated staff for COVID-19 positive residents, ensuring staff were wearing proper Personal Protective Equipment (PPE) while working on or entering the COVID-19 isolation unit, quarantine unit, or resident room, and not posting proper signage at the resident rooms identifying the necessary PPE to be worn upon entering a room. This resulted in Immediate Jeopardy when Resident #151, who had not tested positive for COVID-19, remained on the COVID-19 isolation memory care unit with twelve COVID-19 positive residents and subsequently became infected with COVID-19. Additionally, on 11/17/20, the facility stopped cohorting COVID-19 positive residents in a designated COVID-19 isolation area, which place an additional eleven residents (#119, #120, #122, #123, #124, #128, #129, #130, #131, #162, and #174) in Immediate Jeopardy who later tested positive for COVID-19 and placed an another eleven residents (#107, #110, #112, #113, #114, #115, #116, #121, #126, #140, and #144) in Immediate Jeopardy who had tested negative for COVID-19 when they were allowed to stay on the same hall with COVID-19 positive residents, without dedicated staff, with staff not utilizing proper PPE, and with staff not cleaning environmental surfaces from non-COVID-19 areas to areas with known COVID-19 infection, which placed them at risk for hospitalization , COVID-19 health complications, and/or death related to the facility's COVID-19 outbreak. The facility census was 72. On 11/24/20 at 1:01 P.M., the Administrator was notified Immediate Jeopardy began on 11/09/20 when the facility cohorted a non-positive COVID-19 resident (#151) on the same hall with COVID-19 residents and did not provide dedicated staffing to the non-positive COVID-19 resident. The Immediate Jeopardy continued on 11/17/20 when the facility stopped moving residents who tested positive for COVID-19 into a designated COVID-19 isolation unit, considering the whole facility under isolation. Eleven residents (#119, #120, #122, #123, #124, #128, #129, #130, #131, #162, and #174) became infected when they were cohorted on the same hall with positive COVID-19 residents without dedicated staff and without staff using proper PPE. Additionally, during observations on 11/23/20 and 11/24/20, staff were not wearing appropriate PPE in the isolation room of a COVID-19 positive resident, were observed pulling their mask under their mouth to talk to a resident while cleaning, were observed not to wear N95 masks in COVID-19 resident rooms, staff did not sanitize their hands when passing meal trays between resident rooms, staff adjusted the mask on a COVID-19 positive resident with non-gloved hands, and housekeeping cleaned rooms of residents on COVID-19 isolation, rooms of residents who were not infected with COVID-19, and common areas in no particular order. As of 11/25/20, the facility had a census of 72 residents. Of the 72 residents, 11 residents tested positive for COVID-19, 50 were identified as recovered, and 11 residents continue to test negative. The Immediate Jeopardy was removed on 11/25/20 at 11:30 P.M. when all staff were educated on the facility COVID-19 infection control policies and the facility implemented the following corrective actions: · On 11/23/20, the Director of Nursing (DON) educated Housekeeping #200 regarding wearing appropriate PPE and wearing PPE appropriately in resident rooms. · On 11/24/20 at 8:30 A.M., the Administrator spoke with the local health department regarding an appropriate cohorting plan. · On 11/24/20 at 7:00 P.M., the Administrator, DON, and Corporate COVID Team reviewed facility processes, policies, and procedures related to COVID-19, including: cleaning of an isolation room, transmission based procedures including proper signage, discontinuation of transmission based precautions, and resident care equipment. · On 11/24/20 at 8:00 P.M., the Administrator or designee began education to all staff in COVID-19 infection prevention and control policies including: cleaning of an isolation room, transmission based procedures including proper signage, discontinuation of transmission based precautions, and resident care equipment. This was completed on 11/25/20 at 11:30 P.M. · On 11/25/20 at 8:30 A.M., the DON reviewed the corrective action plan with the Medical Director. · On 11/25/20 at 12:00 P.M., the Administrator created and posted appropriate signage for the COVID-19 quarantine and isolation hallways. · On 11/25/20 at 4:00 P.M., the facility had completed resident room changes and all residents were appropriately cohorted. COVID-19 isolation units were created and the 600 Hall was turned into the COVID-19 quarantine unit. Dedicated staff were assigned to all halls in the facility. · On 11/26/20 at 3:00 P.M., the Corporate Clinical Director, the Corporate Clinical education Consultant/Infection Preventionist, and the Administrator in Training completed audits on infection control cohorting, signage, dedicated staff audit, donning and doffing PPE, and housekeeping. · The medical records for four current residents (#133, #136, #141, and #155) and one former resident (#180) were reviewed for COVID-19 monitoring, testing, and follow-up care after testing. No concerns were identified during the review of these records. Although the Immediate Jeopardy was removed on 11/25/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Review of the CMS COVID-19 Nursing Home data website (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg) of the most recent county positivity rates revealed the facility's county percent positivity in the prior fourteen days was 14.6% and coded the color red, indicating substantial community transmission. Review of the Resident Test with Results Date spreadsheet revealed on 11/01/20 the facility had five residents who had tested positive for COVID-19. Review of the Resident Test with Results Date spreadsheet revealed residents tested on [DATE] with results returned on 11/09/20. Review of the Daily Census with positive COVID-19 dates revealed Resident #151 was the only resident on the 400 Hall, memory care unit, who was not positive for COVID-19 on 11/09/20. The Daily Census revealed Resident #151 remained on the 400 Hall with the other positive residents. Fifteen other residents in the facility also tested positive for COVID-19. Interview on 11/23/20 at 11:44 A.M. with the DON revealed the results of resident COVID-19 testing on 11/06/20 revealed all but one resident (#151) in the memory care unit was positive for COVID-19. Four residents (#152, #156, #157, and #159) who had previously tested positive were moved back to the memory care unit from the COVID-19 isolation unit, along with the eight newly positive residents. Review of the medical record for Resident #151 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Resident Test with Result Date spreadsheet revealed four additional residents tested positive for COVID-19 on 11/16/20. Resident #151 was tested for COVID-19 on 11/13/20 and received positive results on 11/17/20. Twenty-four other residents in the facility also tested positive for COVID-19 on 11/17/20. Review of the Resident Test with Result Date spreadsheet revealed on 11/22/20, two additional residents (#120 and #162) tested positive for COVID-19. Review of the Daily Census sheet dated 11/23/20, with dates of resident positive COVID-19 results identified, revealed on the 100 Hall five residents (#105, #106, #108, #109, and #111) were COVID-19 positive and five residents (#107, #110, #112, #113, and #114) were not diagnosed with [REDACTED].#117, #118, #120, #125, #127) were COVID-19 positive and twelve residents (#115, #116, #119, #121, #122, #123, #124, #126, #128, #129, #130, and #131) were not diagnosed with [REDACTED].#132, #135, #136, #137, #138, #139, #141, and #145) were COVID-19 positive and two residents (#140 and #144) were not diagnosed with [REDACTED].#174 was not diagnosed with [REDACTED].#161, #162, #163, #164, #165, #168, #169, #170, #171, #173, #176, and #177) were COVID-19 positive. The 600 Hall housed no residents with thirteen empty rooms. Review of the Census by Room Number dated 11/23/20 and Resident Test with Results Date identified, Resident #136 received a positive COVID-19 result on 11/17/20 and shared a room with Resident #144 who was negative. Resident #165 tested positive for COVID-19 on 11/17/20 and shared a room with Resident #174, who received a positive COVID-19 result on 11/24/20. Observation on 11/23/20 between 8:55 A.M. to 9:30 A.M., revealed no isolation precaution signage in place on the rooms of residents who were in COVID-19 isolation or quarantine, leaving no way for staff to identify what type of PPE or what precautions were required to provide care for the residents in the room. No designated COVID-19 isolation unit was observed to be in use. Observation on 11/23/20 at 9:40 A.M. revealed State tested Nurse Aide (STNA) #201 transported COVID-19 positive Resident #136 into the resident ' s room. STNA #201 was wearing a mask and eye protection but no gown or gloves. STNA #201 remained in Resident #136 ' s room until the resident was transferred into bed. Observation on 11/23/20 at 9:48 A.M. revealed Housekeeping #200 enter the room of Resident #133 and Resident #141 without wearing eye protection, a gown, or gloves and wearing an ear loop mask. Housekeeping #200 was observed talking with Resident #133, pulling her mask down under her mouth while talking. Observation on 11/23/20 at 9:51 A.M. revealed Therapy Assistant #204 providing services to Resident #140. Therapy Assistant #204 was observed wearing a mask with ear loops. Interview on 11/23/20 at 11:40 A.M. with Therapy Assistant #204 verified wearing an ear loop mask while providing services to Resident #140. Interview on 11/23/20 at 9:52 A.M. with Housekeeping #200 verified the facility provided eye protection and pointed to a pair of goggles hanging from the housekeeping cart. Housekeeping #200 stated the goggles are always falling down while cleaning. Housekeeping #200 verified wearing a mask with ear loops and not wearing eye protection, a gown, or gloves while cleaning the room of a COVID-19 positive resident. Housekeeping #200 also verified pulling the ear loop mask down to talk in the resident ' s room. Observation on 11/23/20 at 9:59 A.M. in the shared room of Resident #136, who was COVID-19 positive, and Resident #144, who was COVID-19 negative, revealed both residents in their room. Resident #144 was sitting in the recliner closest to Resident #136 ' s space, the privacy curtain was not drawn, and neither resident was wearing a mask. Observation on 11/23/20 at 11:22 A.M. revealed STNA #205 at the beginning of the 500 Hall serving the lunch meal trays. STNA #205 was not wearing gloves and was wearing a gown with the back of the gown open and untied. STNA #205 provided the meal to COVID-19 positive Resident #171 and Resident #162 without hand sanitizing in between. STNA #205 next provided the lunch meal to Resident #173, who was COVID-19 positive, touching the resident ' s bed and table tray then returning to Resident #162 and #171 ' s room wearing the same gown and not sanitizing hands between rooms. STNA #205 provided drinks and straws, touching the drink container, for Resident #162 and #171. Interview on 11/23/20 at 11:36 A.M. with STNA #205 verified the back of the gown was not tied closed, the gown was not changed between resident rooms, the staff touched the bed and table tray in Resident #173 ' s room, and did not hand sanitize between interactions with residents. Interview on 11/23/20 at 11:44 A.M., the DON revealed after receiving the COVID-19 positive resident test results on 11/17/20 the facility no longer moved or cohorted residents based on COVID-19 status. The DON stated the facility placed all residents on droplet precautions. The DON verified COVID-19 negative residents were cohorted with positive COVID-19 residents. The DON stated they were not using dedicated staff for COVID-19 positive residents, but did try to ensure staff were scheduled consistently in the same resident hall. Observation on 11/23/20 at 1:28 P.M. revealed Activity Director #202 walking through the 200 Hall wearing a mask with ear loops. Activity Director #202 did not stop in any resident ' s room. Interview on 11/23/20 at 1:30 P.M. verified Activity Director #202 was wearing an ear loop mask provided by the facility. Observation on 11/23/20 at approximately 12:30 P.M. of the box of N95 masks with ear loops revealed a statement on the side of the box indicating the product was a non-medical device. Interview on 11/23/20 at 1:35 P.M., STNA #203 stated the same isolation precautions are used for all residents whether the residents are COVID-19 positive or not diagnosed with [REDACTED].#203 stated she only wears a gown and gloves when providing resident care for all residents. STNA #203 stated a gown and gloves are not required when going into a resident ' s room for another reason such as checking on them, delivering meal trays, or getting something off the floor. Interview on 11/24/20 at 9:22 A.M., Licensed Practical Nurse (LPN) #400 stated when all residents on the 400 Hall except Resident #151 were COVID-19 positive, there was no dedicated staffing. The staff provided care for all residents on the hall in no particular order. Observation on 11/24/20 at 9:40 A.M. revealed COVID-19 positive Resident #136 in the resident room doorway. LPN #405 placed and adjusted a facemask on Resident #136 while not wearing a gown or gloves. Interview on 11/24/20 at 9:46 A.M., LPN #405 verified placing a mask on Resident #136 and adjusting it on the resident ' s face without wearing a gown or gloves. LPN #405 did not know if Resident #136 was COVID-19 positive or not. Interview 11/24/20 on 10:07 A.M., STNA #206 revealed he/she was working the 100 Hall and will also assist with feeding residents on the 200 Hall during the lunch meal. STNA #206 revealed there was no particular order which residents are provided meal assistance, including COVID-19 positive residents and residents who have not been diagnosed with [REDACTED]. Observation on 11/24/20 at 10:10 A.M. revealed Housekeeping #250 exiting the 200 Hall and proceed to clean the staff/visitor restroom. Interview on 11/24/20 at 10:18 A.M. with Housekeeping #250 confirmed cleaning all 200 Hall resident rooms and then cleaning the common area including the staff/visitor restroom. Housekeeping #250 stated the 200 Hall resident rooms were not cleaned in any particular order. Housekeeping #250 revealed starting at one end of the hall and cleaning towards the other end, only alternating resident rooms if a resident is receiving care. Housekeeping #250 stated her cleaning order for the day was first cleaning the 200 Hall resident rooms, then the common area, and then the 100 Hall resident rooms. Interview on 11/25/20 at 11:43 A.M., the County Health Department Commissioner verified the local health department was not aware of the cohorting plan utilized by the facility. Review of the Resident Test with Result Date spreadsheet revealed on 11/24/20 seven additional residents (#119, #122, #124, #128, #129, #131, and #174) tested positive for COVID-19. Review of the Resident Test with Result Date spreadsheet revealed on 11/25/20 two additional residents (#123 and #130) tested positive for COVID-19. Eleven residents (#107, #110, #112, #113, #114, #115, #116, #121, #126, #140, and #144) continued to test negative for COVID-19 Observation on 11/30/20 at 10:54 A.M. revealed Registered Nurse (RN) #500 on the 300 Hall with no eye protection in use. Interview on 11/30/20 at 10:55 A.M. with RN #500 verified he/she was not wearing eye protection. Additional observation on 11/30/20 at 11:33 A.M. revealed RN #500 ' s facemask was positioned below the nose. When observed, RN #500 repositioned the facemask to cover the nose. RN #500 continued to not wear a face shield or goggles. Interview on 11/30/20 at 11:35 A.M., the Administrator verified RN #500 was not wearing a facemask appropriately and was not wearing eye protection. Observation on 11/30/20 at 11:52 A.M. revealed STNA #208 wearing a face mask with ear loops and was working on the 600 Hall, which was now a COVID-19 quarantine unit. The DON was present, asked STNA #205 to change the facemask immediately and discard the remaining facemasks with ear loops that were present on the unit. Interview on 11/30/20 at 11:53 A.M., STNA #208 verified the face mask had ear loops. Review of facility policy titled Environmental Services/Housekeeping Cleaning of an Isolation Room, dated April 2020, verified housekeeping staff will don proper PPE upon entering a resident ' s room requiring precautions and/or isolation. Droplet precautions include gloves, gown, and surgical mask or N95 mask if applicable. Review of the undated facility policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) verified in the event of a facility outbreak place residents in private rooms, cohort residents identified with same symptoms/COVID-19 confirmation, and only essential staff to enter rooms/wings. Only essential personnel to enter the room with appropriate PPE and respiratory protection including gloves, gown, appropriate respiratory protection, and eye protection. Hand hygiene includes using Alcohol Based Hand Sanitizer (ABHS) before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves. Review of facility policy titled Infection Prevention and Control Manual Transmission-Based Precautions, dated 2017, verified when single-resident rooms are in short supply, place residents together in the same room residents who are infected with the same pathogen and are suitable roommates. If it becomes necessary to place residents who require droplet precautions in a room with a resident who does not have the same infection, ensure the residents are physically separated from each other, draw privacy curtain between beds to minimize opportunities for close contact. Review of the CDC website COVID-19 guideline titled Responding to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Review of the CDC website COVID-19 guidelines titled Preparing for COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), dated 06/25/20, revealed the recommendations in this guideline supplement the guideline titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID19 Pandemic. These guidelines indicate under the heading Core Practices the facility should identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Review of the CDC website COVID-19 guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID19 Pandemic (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), dated 07/15/20, revealed under Section 2.: Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection, revealed as a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions, put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, put on clean, non-sterile gloves upon entry into the patient room or care area, and put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The guideline also indicates if worn properly, a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control). The guidance also revealed HCP (Healthcare Personnel) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with COVID-19 infection. The guidance further noted HCP should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the CDC website COVID-19 guidelines titled Counterfeit Respirators/Misrepresentation of National Institute of Safety and Health (NIOSH) Approval, https://www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html, dated 12/04/20, revealed NIOSH-approved respirators have an approval label on or within the packaging of the respirator (i.e. on the box itself and/or within the users ' instructions). A sign that the respirator may be counterfeit includes the filtering facepiece respirator has ear loops instead of headbands.