Every finding on record at Bridgetown Nursing and Rehabilitation Centre

Based on medical record review, review of hospital documentation, and staff interview, the facility failed to ensure admission medication orders were processed in a timely manner. This affected one (#80) of three residents reviewed for medication orders. The facility census was 43.Findings Include:Record review for Resident #80 revealed the resident was admitted to the facility on [DATE] and discharged on 06/12/26 with diagnoses including tracheostomy status, unspecified epilepsy, and unspecified convulsions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had impaired cognition and was assessed to be dependent on staff for all activities of daily living (ADLs). Review of Resident #80's hospital Discharge summary dated on 06/04/26 revealed the resident was to begin taking lacosamide, a medication to treat seizures, 10 milligrams per milliliter (mg/mL) with instructions for 20 mL (200 mg total) in the morning and 20 mL (200 mg total) before bedtime. The resident was also to begin taking levetiracetam (Keppra), a medication to treat seizures, 1000 mg with instructions for two (2) tablets (2000 mg total) in the morning and 2 tablets (2000 mg total) before bedtime; and valproic acid (Depakene), a medication to treat seizures, 15 mL (750 mg total) three times a day. Review of Resident #80's hospital after visit summary dated 06/04/26 revealed lacosamide, Keppra, and Depakene were not listed on the resident's medication list. Review of a nursing progress note revealed Resident #80 was admitted to the facility on [DATE] at approximately 2:15 P.M. Review of Resident #80's physician orders upon admission to the facility revealed the resident was not ordered lacosamide, Keppra, or Depakene on 06/04/26. The resident was ordered lacosamide 10 mg/mL with instructions to give 20 mL via gastrostomy tube (g-tube) twice daily on 06/05/26 at 8:12 A.M. No orders were initiated for the resident to be administered Keppra or Depakene. Review of Resident #80's June 2026 medication administration record revealed no evidence of the resident receiving Keppra or Depakene. Review of a progress note dated 06/06/26 revealed the resident was sent to the hospital and a progress note written on 06/12/26 revealed the facility was notified on 06/11/26 that Resident #80 would not be returning to the facility.Interview on 07/01/26 at 10:49 A.M. with Nurse Practitioner (NP) #114 confirmed she was not aware of Resident #80's orders for Keppra or Depakene from the hospital on [DATE]. Interview on 07/01/26 at 11:04 A.M. with MDS Coordinator #113 confirmed the facility was aware of Resident #80's seizure diagnoses prior to admitting the resident.Interview on 07/01/26 at 12:28 P.M. with the Director of Nursing (DON) confirmed the facility was to admit Resident #80 and the facility was only presented with the after visit summary dated 06/04/26. The DON stated NP #113 verified the orders the facility had at the time and put them in place. The DON confirmed Resident #80 had additional paperwork with him that was discovered by Licensed Practical Nurse (LPN) #43. LPN #43 went through the additional paperwork and notified the oncoming nurse, LPN #27.Interview on 07/01/26 at 12:41 P.M. with LPN #27 confirmed LPN #43 notified her of Resident #80 needing an order for lacosamide due to the order not being added. LPN #27 stated she notified the NP on 06/05/26 of the need for an order for lacosamide for Resident #80, but did not notify the provider of the need for Resident #80 to be ordered Keppra or Depakene. Interview on 07/01/26 at 1:28 P.M. with the DON confirmed the facility staff should have notified NP #114 of the need for Resident #80 to have orders for Keppra and Depakene.This deficiency represents non-compliance investigated under Complaint Number 3048797.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff wore the proper personal protection equipment (PPE) while providing care to residents in enhanced barrier precautions (EBP). This affected one (Resident #17) of three residents reviewed for incontinence care. The facility census was 44 residents.Findings include: Review of the medical record for Resident #17 revealed an admission date of 03/11/25 with diagnoses including acute respiratory failure, depression, anxiety, history of infectious and parasitic diseases, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 12/16/25 revealed the resident had severe cognitive deficits, required substantial assistance with activities of daily living (ADLs), and was incontinent of bowel and bladder. Review of the physician's orders for Resident #17 revealed an order dated 03/12/25 for EBP related to gastrostomy tube and tracheostomy. Observation on 03/02/26 at 1:18 P.M. of incontinence care for Resident #17 per Certified Nursing Assistants (CNAs) #44 and #46) revealed neither aide was wearing a gown while providing care. Interviews on 03/02/26 at 1:18 P.M. CNAs #44 and #46 confirmed neither aide had worn a gown while providing care to Resident #17. The CNAs confirmed they should have each worn a gown while providing incontinent care to Resident #17, because the resident was on EBP. Review of the facility policy titled Enhanced Barrier Precautions dated 05/2024 revealed EBP referred to an infection control intervention designed to reduce the transmission of multi-resistant organisms that employed targeted gown and glove use during high contact resident care activities. High-contact resident care activities included: dressing, bathing, transferring, providing hygiene changing linens, changing briefs or assisting with toileting, device care or use including central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, midline catheters, wound care.

Based on observation, staff interview, pest control contract review, and policy review, the facility failed to have an effective pest control program for the kitchen. This had the potential to affect all residents at the facility. The facility census was 41. Findings include:Observation during the tour of the kitchen on 09/02/25 at 9:01 A.M., with the facility Administrator revealed the lights over the food preparation and steam table area had multiple unknown brown items that appeared to be bugs. The dry food storage area had a soiled floor with food crumbs and debris scattered under the metal shelf with spider webs and cobs webs in the corners of the metal shelf. An observation of dirt, debris, food crumbs, liquid stains, along with dead bugs and live spiders were identified in between and under the shelves of dry food.Interview on 09/02/25 at 9:01 A.M., with the Administrator, during the initial tour of the kitchen, confirmed the lights over the food preparation area and steam table area had multiple brown items and the brown items scattered throughout the kitchen fluorescent lights had legs attached to them. The dry food storage area had a soiled floor with food crumbs and debris scattered under the metal shelf with spider webs and cobs webs in the corners of the metal shelf. The in between the shelves and the walls dead bugs and live spiders were identified. Observation on 09/03/25 at 4:40 P.M., revealed the kitchen light over the food steam table had multiple brown bugs throughout the light cover over food steam table. Interview with the Kitchen Consultant (KC) #500 on 09/03/25 at 4:40 P.M. confirmed the unidentified brown bugs throughout the light cover over the food steam table. Review of the facility pest control contract agreement, dated 07/01/19, revealed the kitchen will be treated with each service visit monthly. Review of the undated policy titled, Pest Control, confirmed the facility will maintain an effective pest control program. Further review of the facility policy stated the facility maintains an on-going effective pest control program to ensure that the building is kept free of insects and rodents. Review of the untitled and undated policy for the kitchen stated the purpose of the policy was to establish sanitation standards that prevent foodborne illness, ensure compliance with Ohio food safety laws, and maintain a clean, safe environment for service operations. Further review of the policy confirmed the facility will report signs of infestation immediately (droppings, gnaw marks, insects). Seal entry points and maintain screens/doors in good repair. This deficiency represents the noncompliance identified during the complaint investigation of Complaint Number 1348503

Based on observation, staff interview, record review, and policy review, the facility failed to ensure staff doffed personal protection equipment (PPE) appropriately, failed to perform hand hygiene after providing direct care, and failed to ensure there was a proper receptacle for disposing of PPE for residents in Enhanced Barrier Precautions. This affected one (#8) of 14 residents sampled for infection control. The census was 41.Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, recurrent major depressive disorder, and aphasia following cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severely impaired cognition, had physical behaviors, did not wander, and occasionally rejected care. Review of care plan dated 09/02/25 revealed Resident #8 required tube feeding. Interventions included elevating head of bed during and following feeds, checking residual volume and gastric contents, maintaining enhanced barrier precautions, and monitoring/reporting adverse effects and signs of infection. Observation on 09/03/25 at 3:27 P.M., revealed Certified Nurse Aides (CNA's) #129 and #145 donned PPE including gloves, isolation gowns, and faces masks to provide incontinence care and repositioning to Resident #8. After direct care was completed, CNA #145 doffed her gloves and washed her hands in the resident's bathroom. CNA #129 doffed her dirty gloves and carried them with tied bags of soiled lined and trash out of the resident's room. Both CNA #129 and #145 exited Resident #8's room wearing isolation gowns and facemasks, doffed theses items in the hallway, and carried the items in their hands down the hallway to the soiled utility room. There was no trash receptacle near the door designated for PPE disposal, and there was no accessible hand sanitizer located inside or directly outside of Resident #8's room. During concurrent interviews on 09/03/25 at 3:42 P.M. with CNA's #129 and #145 each confirmed they did not doff PPE prior to exiting Resident #8's room. Each stated they put PPE in the soiled utility down the hall and verified there was no special trash can in Resident #8's room to doff PPE before exiting. CNA #129 stated I wish there was a hand sanitizer dispenser nearby and gestured towards the wall by Resident #8's room door. Review of policy titled Enhanced Barrier Precautions, dated 2024, revealed regarding the implementation of Enhanced Barrier Precautions (EBP), the facility ensured access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) and positioned a trash can inside the resident room near the exit for discarding PPE after removal and prior to exit of the room.

Based on observation, record review, staff interview, and policy review, the facility failed to maintain a maintain, store, and prepare food in a sanitary manner. This had the potential to affect all residents at the facility, who received food from the kitchen. The facility identified five Residents (#08, #15, #30, #33, and #45) who do not receive food from the kitchen. The facility census was 41. Findings include: Observation on 09/02/25 at 9:01 A.M., with the facility Administrator during the initial tour of the kitchen revealed the lights over the food preparation and steam table areas had multiple unknown brown items with legs attached inside the light. The ceiling fans had black fuzzy substance and debris all over them hanging over the food preparation area. The facility coffee pot was identified on the food preparation table with an electric socket hanging out from the wall and dry wall was observed in a pile around the back side of the coffee pot on the counter. Observation of the wall as you walk into the kitchen had a large hole in the dry wall as you approach the counter with the coffee pot. The wall was soiled with food splatter. The floor was heavily soiled and all along the wall and under the counters were heavily soiled with a black substance and food crumbs. The facility refrigerator contained a large clear plastic gallon tub of what appeared to be about forty hot dogs in water with no cover, no date, no label. The facility refrigerator contained three small containers of coleslaw with no label or date and six red drinks with lids no label or dates. A large cookie sheet of what appeared to be brownies no label or date. Located in front of the walk-in refrigerator was a metal shelf full of pans and behind the shelf was crumbs, food build up, dirt, debris, black grime. The kitchen knives in a container that hung above the metal shelves in front of the fridge had large crumbs and dirt build up on top of the container. Interview on 09/02/25 at 09:01 A.M., with the Administrator, during the initial tour of the kitchen, confirmed the lights over the food preparation and steam table areas had multiple brown items with legs attached inside the light. The ceiling fans had black fuzzy substance and debris all over them hanging over the food preparation area. The facility coffee pot was identified on the food preparation table with an electric socket hanging out from the wall and dry wall was observed in a pile around the back side of the coffee pot on the counter. The Administrator confirmed the wall as you walk into the kitchen had a large hole in the dry wall as you approach the counter with the coffee pot. The wall was soiled with food splatter. The floor was heavily soiled and all along the wall and under the counters were heavily soiled with a black substance and food crumbs. The Administrator confirmed the facility refrigerator contained a large clear plastic gallon tub of what appeared to be about forty hot dogs in water with no cover, no date, no label. The Administrator also confirmed refrigerator contained three small containers of coleslaw with no label or date and six red drinks with lids no label or dates. She confirmed a large cookie sheet of what appeared to be brownies no label or date. The Administrator confirmed the metal shelf located in front of the walk -in refrigerator was full of pans and behind the shelf was crumbs, food build up, dirt, debris, black grime. The Administrator confirmed the kitchen knives and container that hung above the metal shelves in front of the fridge had large crumbs and dirt build up top of the container. The Administrator confirmed the floor along the stove and under the stove had a large amount of food crumbs, dirt, and debris under [NAME] and round the stove and food preparation area. The trash cans did not have lids on them. The Administrator confirmed no lid was available. The Administrator confirmed the hallway outside the dry food storage area had a soiled floor with food crumbs dirt and debris, the dry food area under the metal shelf had dead bugs, live spiders, dried food, soiled spills, dirt, debris, and crumbs all over along with crumbs and debris. The ice machine has a wall with dirt debris and flood splatter all over it. Observation on the initial tour of the kitchen continued on 09/02/25 at 10:28 A.M. with the Administrator in the dishwasher machine room. The light over the three compartment sink did not have a cover on it and exposed florescent light bulbs. Observed the ceiling paint was chipped and hanging down over the three compartment sink. Observed the dish machine was a high temperature machine and the was should reach 160 degrees Fahrenheit (F) and 180 F for the rinse. Observed the dishwasher was ran a total of three times and never reached a temperature above 165 for both a wash and rinse. The Administrator confirmed the facility failed to keep a dishwasher temperature log. Interview with the Administrator when the initial tour of the kitchen continued on 09/02/25 at 10:28 A.M. into the dishwasher machine room. The Administrator confirmed the light over the three compartment sink did not have a cover on it and exposed florescent light bulbs. The Administrator confirmed the ceiling paint was chipped and hanging down over the three-compartment sink. The Administrator confirmed the dish machine was a high temperature machine and the was should reach 160 degrees Fahrenheit (F) and 180 F for the rinse. The Administrator confirmed the dishwasher was ran a total of three times and never reached a temperature above 165 for both a wash and rinse. The Administrator confirmed the facility failed to keep a dishwasher temperature log. The Administrator stated the plan will be for the facility to utilize plastic ware and paper until the dishwasher is repaired. The Administrator confirmed the dishwasher had a pile of food crumbs dirt debris and food splatter all over the top of the dishwasher. The Administrator confirmed the floor around the dishwasher was heavily soiled with a black substance food crumbs and debris. Observation on the lunch time meal on 09/02/25 at 12:35 P.M. revealed Resident # 20 was served her lunchtime meal on regular plates and silverware even though the facility stated they would utilize paper products until the dishwasher was repaired. Interview on 09/02/25 at 12:35 A.M. with certified nurse aide (CNA) #147 confirmed the lunchtime meals was served on regular facility plates, hot plates, and silverware. Interview on 09/02/25 at 3:08 P.M., in a follow up interview with the Dietary Manager (DM) #499 confirmed the facility utilized the facility plates and silver for lunch meal and will utilize for dinner meal even though the facility dishwasher has not been repaired and is not reaching a temperature to properly sanitize the dishes. A request was made for the dishwasher temperature log for the past three months. There was no records provided.Observation on 09/02/25 at 4:22 P.M. with DM #499 revealed the dishwasher reached a wash temperature of 145 F (should reach a minimum of 160 F) and a rinse temperature of 175 F (should reach a minimum of 180). Interview at this time with DM #499 confirmed the facility failed to obtain and log dishwasher temperature logs for the past three months. Review of the undated and untitled policy for the kitchen stated the purpose of the policy was to establish sanitation standards that prevent foodborne illness, ensure compliance with Ohio food safety laws, and maintain a clean, safe environment for service operations. Further review of the policy confirmed dish machines must be monitored for final rinse temperature or sanitizer concentration. For labeling and dated the facility has foods held in the refrigerator for more than twenty-four hours must be clearly marked with the date they must be consumed or discarded within seven days of preparation counting preparation day as day one. Items from manufacturer should be re- dated when opened. Labels should not extend beyond the manufacture's use by date. The facility must maintain logs for inspections and audits.

Based on record review, staff interview, and review of job description, the facility failed to ensure the Director of Nursing (DON) was ensuring the nursing services for residents were being provided. This directly affected seventeen residents (#1, #3, #11, #14, #17, #19, #20, #22, #26, #28, #29, #30, #32, #33, #36, #37, and #38) and had the potential to affect all residents. The facility census was 41.Findings include:Medical record review for seventeen residents (#1, #3, #11, #14, #17, #19, #20, #22, #26, #28, #29, #30, #32, #33, #36, #37, and #38) revealed their Minimum Data Set assessments were not submitted timely. Interview on 09/02/25 at 2:00 P.M., with the Administrator in Training (AIT) #102 verified he had previously been the Director of Nursing (DON) for the building but was now the AIT. He stated he still helped out the acting Director of Nursing (DON) with her duties, as she was still the Minimum Data Set (MDS) nurse and the Infection Control Preventionist (ICP). Interview on 09/04/2025 at 10:58 A.M., with the Director of Nursing (DON)/Minimum Data Set (MDS) Nurse #112 verified there were many Resident MDS assessments that were late due to staffing issues she had to address as DON. DON #112 verified she was doing MDS duties, training staff to ensure resident care was being performed properly, performing infection control monitoring and ICP duties, and was the acting Director of Nursing, which started officially on 07/01/25. DON #112 stated since the MDS assessments weren't complete, the facility didn't have to submit them until the assessments were complete, which meant many were started but not completed and over 120 days past due. DON #112 stated she could not do it all of the tasks assigned to her and had to prioritize was she did and when, she prioritized new admissions assessments over quarterlies and annuals, and other tasks over doing MDS assessments. DON #112 verified care plans were created from the MDS assessments.Review of the undated job description for the Director of Nursing (DON), revealed DON's duties and responsibilities included to implement and evaluate the overall operations of the Nursing Services Department while in accordance with federal, state, and local regulations.

Based on record review, staff interview, and review of job description, the facility failed to ensure there was sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This directly affected seventeen residents (#1, #3, #11, #14, #17, #19, #20, #22, #26, #28, #29, #30, #32, #33, #36, #37, and #38) and had the potential to affect all residents. The facility census was 41.Medical record review for seventeen residents (#1, #3, #11, #14, #17, #19, #20, #22, #26, #28, #29, #30, #32, #33, #36, #37, and #38) revealed their Minimum Data Set assessments were not submitted timely. Interview on 09/02/25 at 2:00 P.M., with the Administrator in Training (AIT) #102 verified he had previously been the Director of Nursing (DON) for the building but was now the AIT. He stated he still helped out the acting Director of Nursing (DON) with her duties, as she was still the Minimum Data Set (MDS) nurse and the Infection Control Preventionist (ICP). Interview on 09/04/2025 at 10:58 A.M., with the Director of Nursing (DON)/Minimum Data Set (MDS) Nurse #112 verified there were many Resident MDS assessments that were late due to staffing issues she had to address as DON. DON #112 verified she was doing MDS duties, training staff to ensure resident care was being performed properly, performing infection control monitoring and ICP duties, and was the acting Director of Nursing, which started officially on 07/01/25. DON #112 stated since the MDS assessments weren't complete, the facility didn't have to submit them until the assessments were complete, which meant many were started but not completed and over 120 days past due. DON #112 stated she could not do it all of the tasks assigned to her and had to prioritize was she did and when, she prioritized new admissions assessments over quarterlies and annuals, and other tasks over doing MDS assessments. DON #112 verified care plans were created from the MDS assessments.Review of the undated job description for the Director of Nursing (DON), revealed DON's duties and responsibilities included to implement and evaluate the overall operations of the Nursing Services Department while in accordance with federal, state, and local regulations.

Based on observation, resident interview, staff interview, and record review, the facility failed to provide meals that were attractive and appetizing. This affected three Residents (#03, #05, and #20,) however, it had the potential to affect all 36 residents who receive food at the facility. The facility identified five Residents (#08, #15, #30, #33, and #45) who do not receive food from the kitchen. The facility census was 41. Findings include:1. Medical record review for Resident #03 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus (DM), post-traumatic stress disorder (PTSD), chronic fatigue, gastro-esophageal reflux disease (GERD), and bipolar disorder.Review of Minimum Data Set Assessment (MDS) for Resident #03 dated 04/10/25 revealed he was cognitively intact. Resident #03 required set up assistance from staff with meals. Interview on 09/02/25 at 11:00 A.M., with Resident #03 revealed the food is always served cold and dose not taste good. 2. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, obesity, diabetes mellitus (DM), anxiety disorder, gastro-esophageal reflux disease (GERD), and schizoaffective disorder.Review of the MDS assessment dated [DATE] revealed she was cognitively intact. Resident #05 required set up assistance from staff for meals.Interview on 09/02/25 at 10:40 A.M., with Resident #05 revealed the food at the facility is always served cold and it does not always have a pleasant taste. 3. Medical record review for Resident #20 revealed she was admitted to the facility on [DATE]. Her diagnoses included, sepsis, intestinal obstruction, cellulitis, acute kidney failure, lymphedema, absence of left leg above ankle, urinary tract infection, anemia, supraventricular tachycardia, and major depressive disorder. Review of the most recent MDS assessment 04/18/25 revealed Resident #20 was cognitively intact. Resident #20 set up assistance from staff with eating. Interview on 09/02/25 at 12:25 P.M., with Resident #20 stated the food is terrible at the facility and the facility does not have what they list for alternatives on the menu.Observation on 09/02/25 at 12:35 P.M., revealed Certified Nurse Aide (CNA) #147 brought Resident #20 her lunch and uncovered the meal. Observed CNA #147 apologized to Resident #20 for the way her potato wedges looked. Resident #20 stated she was unsure what they were and CNA #147 stated she was not sure why they looked the way they did. 4. Observation of the test tray leaving the facility kitchen on 09/03/25 at 5:23 P.M. The test tray arrived on the second floor cart at 5:25 P.M. and all the trays were passed on the cart. Once all the trays were passed the test tray was obtained by Kitchen Consultant (KC) #500. KC #500 tested the temperature of the test tray. The coleslaw temperature was 65 degrees Fahrenheit (F), the macaroni and cheese was 115 degrees F, the pulled pork was at 124 degrees F, and the milk was 51 degrees F and the ice cream cup was at 19 degrees F. Interview KC #500 on 09/03/25 at 5:25 P.M., with Kitchen Consultant KC #500 stated the coleslaw tasted as if it was at a room temperature and the hot food did not taste hot. KC #500 stated the dinner tray was unappealing because it was not maintained at an appetizing temperature.

Based on record review, staff interview, and policy review, the facility failed to ensure resident assessments were completed in a timely manner. This affected seventeen (#1, #3, #11, #14, #17, #19, #20, #22, #26, #28, #29, #30, #32, #33, #36, #37, and #38) of seventeen residents reviewed for resident assessments. The facility census was 41.Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included unspecified vascular dementia, combined heart failure, chronic obstructive pulmonary disease, and hemiplegia and hemiparesis following cerebral infarction. Review of the medical record revealed Resident #1 had an annual minimum data set (MDS) assessment created on 06/12/25 that was In progress and had not been submitted. There was a note written in red letters which indicated the Assessment Reference Date (ARD) for the fourth quarter date 06/13/25 was 69 days overdue and the ARD for 07/03/25 was 49 days overdue. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with a diagnosis of epilepsy. Review of the quarterly MDS revealed dated 07/09/25 was still In Progress. There was a note written in red letters which indicated the ARD for the second quarter dated 07/11/25 was 41 days overdue. 3. Review of the medical record revealed Resident #11 had an admission date 05/31/24, with diagnoses including Chronic respiratory failure with hypoxia and dependence on respirator status. Review of the Annual MDS dated [DATE], Discharge Return Anticipated dated 08/19/25, and Entry dated 08/23/25 showed as In Progress. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included unspecified Parkinsonism, anxiety disorder, unspecified dementia, type II diabetes, and obesity. Review of the annual MDS assessment created on 06/18/25, that was in progress and was not submitted. 5. Review of the medical record revealed Resident #17 had an admission date of 03/12/25, with diagnoses including sepsis and bacteremia. Review of the quarterly MDS revealed a review date of 06/19/25 was marked In Progress. There was a note written in red letters which indicated the ARD for the first quarter dated 06/19/25 was 63 days overdue. 6. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included unspecified malignant neoplasm of the mouth, unspecified malignant neoplasm of the tongue, unspecified anxiety disorder, type II diabetes, major depressive disorder, and epilepsy. Review of the annual assessment dated [DATE] was in Progress and was not completed or submitted. There was a note written in red letters which indicated the ARD for the fourth quarter on 07/10/25 was 42 days overdue. 7. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb, malignant neoplasm of unspecified breast, unspecified heart failure, major depressive disorder, chronic obstructive pulmonary disease, and morbid obesity. Review of the quarterly assessment dated [DATE] was in progress and was not submitted. There was a note written in red letters which indicated the ARD for quarter one dated 07/10/2025 that was 42 days overdue. 8. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included recurrent major depressive disorder, Parkinson's disease, unspecified dementia, unspecified anxiety disorder, and type II diabetes. Review of the quarterly MDS assessment created on 08/02/25 was in progress and was not submitted. There was a note in red letters which indicated the ARD for third quarter dated 08/02/25 was 19 days overdue. 9. Review of the medical record revealed Resident #26 had an admission date of 05/17/23, with diagnoses including pulmonary edema and epilepsy. Review of the quarterly MDS with review dated 08/01/25 and was still In Progress. There was a note written in red letters which indicated the ARD for the for the first quarter dated 08/02/25 was 19 days overdue. 10. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, unspecified anxiety disorder, visual hallucinations, unspecified intellectual disabilities, localization-related symptomatic epilepsy, and unspecified paralytic syndrome. Review of the quarterly MDS assessment dated [DATE] was in progress and was not completed or submitted. There was a note written in red letters which indicated the ARD for the third quarter dated 07/05/25 was 47 days overdue. 11. Review of the medical record revealed Resident #29 had an admission date of 05/30/19, with diagnoses including chronic obstructive pulmonary disease and vascular dementia. Review of the quarterly MDS review dated 08/01/25 was still In Progress. There was a note written in red letters which indicated the ARD for the first quarter dated 08/02/25 was 19 days overdue. 12. Review of the medical record revealed Resident #30 had and admission date of 07/22/24 with diagnoses including sepsis and non-ST elevation (NSTEMI) myocardial infarction. Review of the annual MDS review was In Progress. There was a note written in red letters which indicated the ARD for the fourth quarter dated 08/01/25 was 20 days overdue. 13. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, diastolic heart failure, and chronic kidney disease stage III. Review of the quarterly MDS assessment was created on 07/18/25, was still in progress and had not been submitted. There was a note written in red letters which indicated the ARD for the first quarter on 07/23/25 was 29 days overdue. 14. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, cerebral palsy, dependence on a ventilator, interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, type II diabetes, and morbid obesity. Review of the annual MDS assessment created 06/16/25 and was in progress and was incomplete. Additionally, Resident #33 had an MDS for Discharge Return Anticipated dated 07/17/25 that was in progress and was not submitted. There was a note written in red letters which indicated the ARD for the third quarter was 47 days overdue. 15. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, severe depressive-type bipolar disease, major depressive disorder, and prediabetes. Review of the quarterly assessment dated [DATE] that was in progress and was not submitted. There was a note written in red letters which indicated the ARD for the first quarter dated 06/26/25 that was 56 days overdue. 16. Review of the medical record revealed Resident #37 was admitted on [DATE]. Diagnoses included type II diabetes, chronic obstructive pulmonary disease, unspecified bipolar disorder, unspecified anxiety disorder, and unspecified heart failure. Review of the quarter MDS created 07/14/25 was in progress and was not completed or submitted. There was a note written in red letters which indicated the ARD for the first quarter dated 07/15/25 was 37 days overdue. 17. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included unspecified bipolar disorder, unspecified major depressive disorder, type II diabetes, unspecified anxiety disorder, and stage IV chronic kidney disease with dependence on renal dialysis. Review of the quarterly MDS dated [DATE] that was in progress and was not submitted. There was a note written in red letters which indicated the ARD for the second quarter dated 06/28/25 was 54 days overdue. Interview on 09/04/25 at 10:58 A.M., with Registered Nurse (RN) #112 confirmed there were multiple MDS assessments that were late due to staffing issues as she was doing MDS, training staff, doing infection control, and acting Director of Nursing - starting officially on 07/01/25. Some of the MDS were completed on paper and not in the electronic record. RN #112 stated she couldn't do it all and had to prioritize what she did and when. She prioritized new admissions over quarterlies and annuals. Review of the undated policy titled Electronic Transmission of the MDS revealed all MDS assessments were completed and electronically encoded into the facility's MDS information system and transmitted to the CMS Internet Quality Improvement and Evaluation System (IQIES) in accordance with OBRA regulations governing the transmission of MSD data.

Based on record review, resident interviews, staff interviews, and policy review, the facility failed to ensure residents were provided care conferences and revise care plans as needed. This affected two (#05 and #44) of fourteen residents sampled for care plans. The census was 41.Findings include: 1. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, obesity, diabetes mellitus (DM), anxiety disorder, gastro-esophageal reflux disease (GERD), and schizoaffective disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed she was cognitively intact. Resident #05 was dependent on staff for medication administration, she required set up assistance from staff for meals, oral hygiene, toilet use, dressing and personal hygiene. Review of the progress for Resident #05 dated 05/29/25 revealed Resident #05 reported she rolled out of bed the previous Saturday (05/24/25). Resident #05 reported to the nurse she slipped when she attempted to stand. No immediate intervention was listed in the progress notes. Review of Resident the Fall Care Plan for Resident #05 dated 04/18/24 revealed Resident #05 was at risk for falls related to her above the knee amputation (aka), medication regimen, and comorbidities. Her interventions included, follow fall protocol and therapy as ordered physical and occupational. No other information was provided. Interview on 09/03/25 at 10:59 A.M., with the Director of Nursing revealed the facility completed an Interdisciplinary Team (IDT) team risk review on 05/30/25 and the facility determined that Resident #05's intervention from her fall would be non skid socks. The DON confirmed the facility failed to update Resident #05's care plan with fall intervention. 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, recurrent major depressive disorder, unspecified parkinsonism, and unspecified bipolar disorder. Review of the most recent MDS assessment dated [DATE] revealed Resident #44 had severely impaired cognition, had physical, verbal, and self-directed behaviors, did not wander, and occasionally rejected care. Review of the medical record revealed no documentation regarding quarterly care conferences. Interview on 09/02/25 at 9:46 A.M. , with Resident #44 stated she did not have regular care conferences and staff did not ask her what her care goals were. Interview on 09/03/25 at 1:35 P.M., with Social Services #108 verified she had no notes for care conferences with Resident #44 and/or family. SS #108 stated she had care conferences every time it was indicated on the MDS and spoke with the resident about concerns but did not document care conferences. Review of the undated policy titled Care Plans, Comprehensive Person-Centered, revealed the resident was informed of his/her right to participate in treatment planning and was given advance notice of care planning conferences. If participation was determined not to be practicable, an explanation was documented in the resident's medical record.

Based on observation, staff interview, and policy review, the facility failed to provide a clean and sanitary homelike environment. This affected two (#01, #05) out of two residents reviewed for environment. The facility census was 41. Findings include: 1. Medical record review for Resident #01 revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (AFIB), sepsis, gastro-esophageal reflux disease (GERD), primary generalized arthritis, vascular dementia, anxiety, congestive heart failure (CHF), chronic obstructive pulmonary disease, asthma, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed he had impaired cognition. Resident #01 was dependent on staff for medication administration, toilet use, bathing, and personal hygiene. He required maximum assistance from staff with oral hygiene. He required supervision from staff regarding eating. Observation on 09/04/25 at 12:16 P.M., revealed Resident #01's room had a privacy curtain that had a large brown stain, the floor was soiled throughout the room, with food crumbs and debris were identified under the bed. Resident #01's bed frame appeared to be heavily soiled with a build up outside the mattress and on the bed rails. Resident #01 had heavily soiled bedside table. Observed food crumbs and debris under the bed and Resident #01's pillow had a heavily soiled pillowcase.Interview on 09/04/25 at 12:17 P.M., with Certified Nurse Aide (CNA) #147 confirmed the heavily stained privacy curtain in Resident #01's room. The curtain had a large unknown brown stain down the front of the curtain. CNA #147 pulled the curtain toward her and exposed several dried stains and splatters throughout the curtains. CNA #147 confirmed Resident #01 had a heavily soiled bed frame with dirt and debris built up throughout out the bed frame outside of the mattress near the bed rails. CNA #147 confirmed Resident #01's bedside table was heavily soiled with stains and debris. CNA #147 confirmed the floor in Resident #01's room had dirt and debris throughout the room and food crumbs identified under the headboard of the bed. CNA #147 confirmed Resident #147 had what appeared to be an unknown dried caked substance on his pillow. 2. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, obesity, diabetes mellitus (DM), anxiety disorder, gastro-esophageal reflux disease (GERD), and schizoaffective disorder.Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed she was cognitively intact. Resident #05 was dependent on staff for medication administration, she required set-up assistance from staff for meals, oral hygiene, toilet use, dressing and personal hygiene. Observation on 09/07/25 at 12:13 P.M., revealed Resident #05 had an unknown fuzzy black and brown substance on the floor under her bathroom sink; the bathroom floor was heavily soiled with black buildup. The wall in the bathroom is a long smudge of black over the top of the handrail. The floor alongside the bed of Resident #05 was chipped and the flooring was ragged and chipped in spots with what appeared to have had pervious fall strips in place that were removed. Interview on 09/07/25 at 12:15 P.M., with CNA #147 confirmed Resident #05 had an unknown fuzzy black and brown substance on the floor under her bathroom sink, the bathroom floor was heavily soiled with black buildup. The wall in the bathroom is a long smudge of black over the top of the handrail. CNA #147 confirmed the floor alongside the bed of Resident #05 was chipped and the flooring was ragged and chipped in spots with what appeared to have had pervious fall strips in place that were removed. Review of the undated policy titled Environmental Services indicated all resident rooms will be cleaned each day. Further review of the policy confirmed that one of the daily tasks for housekeepers is to clean each resident room and bathroom daily. This deficiency represents the noncompliance identified during the complaint investigation of Complaint Number 1348503.

Based on medical record review, staff interview, and policy review, the facility failed to provide a bed hold notification to a resident upon discharge to the hospital. This affected one (#20) out of two residents reviewed for discharge to the hospital. The facility census was 41. Finding include: Medical record review for Resident #20 revealed she was admitted to the facility on [DATE]. Her diagnoses included: sepsis, intestinal obstruction, cellulitis, acute kidney failure, lymphedema, absence of left leg above ankle, urinary tract infection, anemia, supraventricular tachycardia, and major depressive disorder. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 was dependent on staff for medication administration and toilet use. She required moderate assistance form staff with bathing, dressing, personal hygiene, and toilet use. Resident #20 required set up assistance from staff with eating and oral hygiene. Review of Resident of the progress notes for Resident #20 revealed she was discharged to the hospital on [DATE]. Resident #20 returned to the facility 04/30/25. The medical record contained no documentation of a bed hold notice being provided. Interview on 09/04/25 at 10:23 A.M., with the Administrator confirmed the facility does not provide residents with bed hold notifications upon discharge from the facility. The Administrator stated it was easier for the facility to provide each residents with a monthly note of their bed hold status. The Administrator confirmed if a resident were to admit or discharge from the facility throughout the month they would not receive notification of the bed hold until the end of the month. The Administrator confirmed there was no evidence of Resident #20 receiving bed hold information upon discharge. Review of the policy titled Nursing and Rehabilitation Bed-Hold Policy, dated 05/30/25 and signed by Resident #20 revealed Resident #20 had 19 bed hold days remaining for 2025. Further review of the policy revealed the Policy was a fill in the blank policy to be signed by the resident. The policy read as followed: I ____(resident name) _____receive Medicaid covered services and wish for a bed to be held for me. I understand that I have 30 days per year and I currently have __(number of days)____days remaining. A line was available for resident's signature.

Based on medical record review and staff interview, the facility failed to properly assess a resident's Pre admission Screening and Resident Review (PASARR) screen. The facility failed to identify a mental health diagnosis. This affected one (#03) out of four residents reviewed for PASARR screening. The facility census was 41. Findings include:Medical record review for Resident #03 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus (DM), post-traumatic stress disorder (PTSD), anxiety, chronic fatigue, gastro-esophageal reflux disease (GERD), and bipolar disorder. Review of Minimum Data Set Assessment (MDS) for Resident #03 dated 04/10/25 revealed he was cognitively intact. Resident #03 was dependent on staff for medication administration. Resident #03 required set up assistance from staff with meal set up, oral hygiene, and upper body dressing. Resident #03 required supervision from staff with personal hygiene, bathing, and toilet use. Review of Resident #03 Preadmission Screening and Resident Review Notice (PASARR) dated 12/27/24 revealed the facility failed to identify Resident #03's diagnoses of Post Traumatic Stress Disorder (PTSD) and anxiety disorder. Interview on 09/04/25 at 11:15 A.M., with Registered Nurse and Administrator in Training confirmed the facility failed to properly screen Resident #03 when the facility failed to complete an accurate PASARR screening and failed to properly identify the diagnoses of anxiety disorder and (PTSD).

Based on record review, resident interview, staff interviews, and policy review, the facility failed to ensure residents had complete and accurate comprehensive care plans. This affected three (#1, #3 and #44) of fourteen residents reviewed for care plans. The facility census was 41.Findings include: 1. Medical record review for Resident #01 revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (AFIB), sepsis, gastro-esophageal reflux disease (GERD), primary generalized arthritis, vascular dementia, anxiety, congestive heart failure (CHF), chronic obstructive pulmonary disease, asthma, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed he had impaired cognition. Resident #03 was dependent on staff for medication administration, toilet use, bathing, and personal hygiene. He required maximum assistance from staff with oral hygiene. He required supervision from staff with eating. Review of the care plans for Resident #01 revealed no care plan was in place for dementia or impaired cognition. Interview on 09/04/25 at 10:42 A.M., with the Director of Nursing (DON) confirmed the Resident #01 had a diagnosis of dementia. The DON confirmed the facility failed to develop and implement a plan for care for the Resident #01's dementia diagnosis. 2. Medical record review for Resident #03 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus (DM), post-traumatic stress disorder (PTSD), chronic fatigue, anxiety, gastro-esophageal reflux disease (GERD), and bipolar disorder. Review of the MDS dated [DATE] revealed he was cognitively intact. Resident #03 was dependent on staff for medication administration. Resident #03 required set up assistance from staff with meal set up, oral hygiene, and upper body dressing. Resident #03 required supervision from staff with personal hygiene, bathing, and toilet use. Review of the care plans for Resident #03 revealed no care plan related to the diagnosis of PTSD or anxiety. Interview on 09/04/25 at 10:42 A.M. , with the DON confirmed the facility failed to complete a care plan for Resident #03 related to his diagnoses of PTSD and anxiety. 3. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, recurrent major depressive disorder, unspecified parkinsonism, and unspecified bipolar disorder. Review of the most recent MDS assessment dated [DATE] revealed Resident #44 had severely impaired cognition, had physical, verbal, and self-directed behaviors, did not wander, and occasionally rejected care. Interview on 09/02/25 at 9:43 A.M., with Resident #44 indicated she was edentulous and had a full set of dentures. She stated she thought she needed a new set. Review of the care plans for Resident #44 dated 05/17/23 had no plan of care related to dental needs. Interview on 09/03/25 at 1:30 P.M., with Social Services (SS) #108 stated the facility used 360-care for dental services. They were last in the building in July. SS #108 stated Resident #44 was last seen by dental services on 04/06/25 for denture concerns. Interview on 09/03/25 at 2:54 P.M., Administrator-In-Training (AIT) #102 verified Resident #44's comprehensive care plan was incomplete and did not have any reference to dental needs. Review of the undated policy titled Care Plans, Comprehensive Person-Centered, revealed the comprehensive, person-centered care plans described services that were furnished to maintain a resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review and staff interview, the facility failed to ensure residents were wearing physician ordered splint devices. This affected one (#16) of one residents reviewed for range of motion. The facility census was 41.Findings include:Review of Resident #16's medical record revealed an admission date of 06/07/24, with diagnoses including peripheral vascular disease and supraventricular tachycardia. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment and occasionally refused care. Review of physician orders dated 05/25/25 for a left resting hand splint to be applied in A.M. and check skin integrity every shift. Review of care plan dated 06/05/25 for the left wrist splint, to check skin every shift upon don and doff for signs and symptoms of skin break down. Review of care plan revealed no indication of refusal of care. Observation on 09/02/25 at 9:30 A.M. revealed Resident #16 did not have left hand splint. Observation on 09/02/25 at 11:00 A.M. revealed Resident #16 did not have left hand splint. Observation on 09/02/25 3:01 P.M. revealed Resident #16 did not have left hand splint. Observation on 09/03/25 at 10:43 A.M. revealed Resident #16 did not have left hand splint. Interview on 09/03/25 at 11:00 A.M. , with the Administrator in Training (AIT) #102 and Licensed Practical Nurse (LPN) #121 verified Resident #16 did not have her splint on. LPN #121 stated the night shift put the splint on her left hand, but Resident #16 frequently removed it. LPN #121 verified staff did not document when Resident #16 removed her splint or when it was reapplied.

Based on review of personnel files and staff interview, the facility failed to complete a performance review of Certified Nurse Aides (CNA) or annually. This had the potential to affect all 41 residents in the facility. The census was 41. Findings include: Review of personnel files revealed CNA #131 was hired on 09/08/08 and had no annual performance evaluation. Review of personnel files revealed CNA #136 was hired on 08/09/19 and had no annual performance evaluation. Interview with Administrator on 09/04/25 at 9:28 A.M. confirmed that no CNA evaluations were incomplete.

Based on record review, staff interview, and review of facility policy, the facility failed to notify the resident's representative of a significant change in the resident's care and treatment. This affected one (Resident #34) of three residents reviewed for notification of change in condition. The census was 42. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE] with presence of prosthetic heart valve, cerebral infarction with left sided hemiplegia and hemiparesis, vascular dementia, atrial fibrillation, and obesity. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #34 had moderate cognitive impairment and was always incontinent of bowel and bladder. The resident required supervision with eating, maximal assistance with oral hygiene and was dependent for toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders for Resident #34 revealed that on 06/17/24, Nurse Practitioner (NP) #1001 discontinued the order for Warfarin Sodium oral tablet 4 Milligrams (mg), give one tablet by mouth in the morning for clot prevention and on 06/13/24, ordered Eliquis oral tablet 5 mg. (Apixaban), give one tablet by mouth two times a day related to paroxysmal atrial fibrillation, coagulation defect, unspecified. Review of the care plan for Resident #34 revealed the facility is to notify the legal representative of new orders or changes in status (nursing or social services). Review of the progress notes for Resident #34 revealed no documentation that the facility notified the resident's representative of the change from Coumadin to Eliquis on 06/13/24. Interview on 08/29/24 at 1:10 P.M. with Licensed Practical Nurse (LPN) #403 revealed the physician changed the anti-coagulant for Resident #34 from Coumadin to Eliquis on 06/13/24 due to inconsistencies with the consulting laboratory's ability to obtain blood draws and provide PT-INR results needed for the physician to monitor the Coumadin dosing. Interview on 08/29/24 at 3:54 P.M. with Resident #34's family revealed the representative was not notified of the medication change from Coumadin to Eliquis until around 07/11/24. Interview on 08/29/24 at 5:10 P.M. with the Administrator and LPN #403 confirmed the facility failed to notify the legal representative for Resident #34 of the medication change on 06/13/24 from Coumadin to Eliquis. Review of the facility policy titled, Notification of Changes, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include a need to alter treatment and this may include a new treatment.

Based on record review, observation, and staff interview, the facility failed to complete comprehensive care plans on residents. This affected two (#14 and #15) residents of the four residents reviewed for care plans. The facility census was 39. Findings include: 1) Review of medical record for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of the care plan for Resident #14 revealed there was no care plan related to the resident's skin integrity and the Stage II pressure injury. Observation of wound care for Resident #14 on 04/15/24 11:34 A.M. provided by Wound Care Physician #53, revealed the resident had a stage two pressure ulcer on the right buttock that was being debrided. Interview with Wound Care Doctor #53 at the same time, verified the resident had a stage two pressure ulcer on her right buttock. Interview with Minimum Data Set (MDS) Coordinator #51 on 04/16/24 at 11:15 A.M. verified there were care plans that addressed Resident #14's skin integrity or the presence of a pressure ulcer. MDS #51 reported the care plan should address the resident's skin concerns. 2) Review of medical record for Resident #15 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, depression, pain, chronic kidney disease, anxiety, and history of skin cancer. Review of care plan for Resident #15, revealed there was no care plan related to the resident's skin integrity. Review of a physician's order dated 03/24/24 for Resident #15 revealed the resident was ordered to have moisture barrier cream applied to coccyx/peri area after each incontinent episode. Interview with MDS Coordinator #51 on 04/16/24 at 11:15 A.M. verified there were care plans that addressed Resident #15's skin integrity. MDS #51 reported the care plan should address the resident's skin integrity and being at risk for skin integrity concerns.

Based on record review, observation, staff interview, review of online resources from the Centers for Disease Control (CDC) and review of facility policy, the facility failed to follow infection control procedures during dressing changes. This affected one (#14) resident of the three residents reviewed for wound care. The facility census was 39. Findings include: Record review for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including but not limited to breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition. Observation of would care/dressing change for Resident #14 on 04/15/24 11:34 A.M. with Licensed Practical Nurse (LPN) #54 and State tested Nursing Assistant (STNA) #55 revealed LPN #54 removed a soiled incontinence brief and replaced it with a clean one. LPN #54 then cleansed the open wound on Resident #14's right buttock with saline and gauze. LPN #54 then placed a new wound dressing without completing any hand hygiene and changing her gloves. Interview with LPN #54 on 04/15/24 at approximately 11:40 A.M. verified that she never completed any hand hygiene and changed her gloves when going from a dirty wound area to a clean dressing on the resident's wounds. Review of online resources from CDC (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed healthcare personnel should complete hand hygiene before moving from a work area of a soiled body part to a clean body site on the same patient and healthcare personnel were to perform hand hygiene in accordance with the CDC recommendations. Review of the Infection Prevention and Control Program (dated 10/01/23) revealed hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. This deficiency represents non-compliance investigated under Complaint Number OH00152359.

Based on observation, interview and record review, the facility failed to notify residents in advance of menu changes. This had the potential to affect 37 residents who received food from the kitchen. The facility census was 38. Findings include: During observation on 05/16/22 at 12:10 P.M., the menu posted in the kitchen listed the lunch meal as baked veal cutlet, creamy dill sauce, bow tie pasta, roasted brussels sprouts, wheat dinner roll or bread, and blushing pears. Concurrent observation of the tray line revealed residents were served a cheeseburger, french fries, and fruit. During interview on 05/16/22 at 12:15 P.M., Dietary Manager (DM) #40 stated the residents do not like veal, so she normally serves them country fried steak, which she was not able to get, so she served burgers today. When questioned, DM #40 stated the residents had not been notified of the menu change prior to the meal and further stated the menus posted on the resident units were not current. DM #40 stated some residents call the kitchen each day to find out what they are getting and she lets them know at that time. During observation on 05/16/22 at 12:25 P.M., the four week menu cycle was posted on bulletin boards. During interview at this time, DM #40 stated the posted menus were from the fall/winter menu cycle and the spring/summer menus started in April. She has not had a chance to post the current menus. During interview on 05/17/22 at 11:48 A.M., Registered Dietitian (RD) #300 stated DM #40 let her know she accidentally ordered food for the menu for week 4 instead of the current week 2, so the food being served would follow the menu for week 4 for the rest of the week. RD #300 stated she became aware of the residents' dislike of veal and had changed the veal to country-fried steak.

Based on medical record review, observation, staff and resident interview, review of hospital records, and review of a self-reported incident (SRI) the facility failed to provide adequate supervision to prevent accidents for one cognitively impaired resident (Resident #9) with known behaviors of wandering into other resident rooms uninvited. This affected one of three residents reviewed for wandering behaviors. This resulted in actual harm to Resident #9 when she wandered into Resident #51's room, and then sustained a right femur (hip) fracture when Resident #51 was attempting to remove Resident #9 from his room. The facility census was 60. Findings include: Resident #51 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 ((MDS) dated [DATE] assessment identified the resident as having good memory and recall, no delusions or hallucinations, occasional verbal behavioral symptoms towards other, and no physical behavioral symptoms towards others. Resident #51 was assessed as needing only supervision with setup help for bed mobility, transfer, and walking in his room. He did not walk in the corridor, but used a motorized wheel chair with supervision. Resident #9 was initially admitted to the facility in (MONTH) of (YEAR) and readmitted on [DATE] following a hospitalization for a right femur fracture. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] identified the resident as having hallucinations and delusions, poor short and long term memory problems, severely impaired cognitive skills for daily decision making, but able to recall the location of her room and staff names and faces. Further review of the MDS identified the resident as needing only supervision with limited assistance of one staff person for bed mobility and transferring. The resident was able to walk in her room with supervision and setup help only but required limited assistance of one staff person to walk in the corridor. The assessment also identified the resident as having wandering behaviors daily, which did not intrude on the privacy or activities of others. Resident #9 stood 58 inches tall and weighed 88 pounds. Review of Resident #9's nursing progress notes revealed licensed nursing staff documented the resident was wandering into other resident's rooms on the second floor of the facility during the night shift of duty (7:00 P.M. through 7:00 A.M.) on [DATE] at 1:25 A.M., [DATE] 2:26 A.M., [DATE] at 3:13 A.M., [DATE] at 1:21 A.M., and on [DATE] at 4:04 A.M. There was no documentation of the resident having behaviors of wandering into other residents' rooms during the day shift of duty (7:00 A.M. through 7:00 P.M.). Resident #9's most recent psychiatry follow-up dated [DATE] revealed the psychiatrist noted Resident #9 had good and bad days. The resident gets restless and wanders around, and she gets intrusive. The psychiatrist documented the resident had hallucinations and talked to people. The psychiatrist noted in the plan for Resident #9 that the resident had been restless, wanders, was intrusive, and gets moody. He added a medication for mood disorder at that time. Review of Resident #9's nursing progress notes for [DATE] revealed Registered Nurse (RN) #98 documented at 5:00 P.M. she heard a loud thump and a scream from Resident #51's room and went to investigate. She found Resident #9 on the floor of Resident #51's room and Resident #51 was attempting to get Resident #9 up. Resident #51 stated he shoved Resident #9 in an attempt to her her out of his room. Resident #9 was immediately assessed and no bleeding was noted. The charge nurse on duty came to assess Resident #9, and RN #98 notified the Director of Nursing (DON). Resident #9 was in severe pain and unable to move her right leg, she also had a hematoma on her right temporal lobe. Resident #9's physician, and emergency services were notified, and the resident was transported to a local hospital for evaluation. Review of Resident #9's hospital records dated [DATE] from the emergency department of the local hospital revealed on x-ray the resident sustained [REDACTED]. Review of Resident #9's comprehensive assessments, and plan of care revealed a care plan to address the resident's pacing, and her risk of falling. The plan of care did not identify, assess, or plan care for the problem behavior of wandering into other resident's rooms and the inherent risks of such behavior related to the safety of Resident #9, or the impact on the other residents' right to privacy. As a result of the incident between Resident #51 and Resident #9 the facility submitted an SRI on [DATE] of an incident involving potential resident to resident abuse. The investigation was completed by the Administrator. On investigation, the Administrator concluded abuse did not occur as Resident #51 did not intend to hurt Resident #9 as he stumbled when escorting her out of his room which resulted in Resident #51 pushing Resident #9 to the floor. An interview was conducted with the Administrator on [DATE] at 9:58 A.M. regarding the incident between Resident's #51 and #9 on [DATE]. He reported he was not present at the time of the incident but was notified by the DON within minutes of the incident, and of Resident #9 being sent to the hospital for evaluation. The Administrator assisted the DON in submitting the SRI on [DATE], and continued the investigation on [DATE]. He reported just after the incident Resident #51 was put on 1:1 supervision, and was moved to the first floor of the facility on [DATE]. He indicated Resident #51 agreed to the room change. The Administrator reported Resident #51 was moved as precautionary measure as there was still one other resident who wandered and resided on the second floor. The other resident had since discharged to another facility. When queried about Resident #9's wandering behavior the Administrator communicated he had observed her walking around the second floor. He indicated she was confused but pleasant and conversational. He denied being aware of any complaints from other residents about Resident #9 going in and out of their rooms. When queried about the behavior of Resident #51 the Administrator communicated he interviewed the resident on [DATE] regarding the incident of [DATE] involving Resident #9. The Administrator stated Resident #51 communicated to him Resident #9 had come in his room and he asked her to leave but she ignored him. Resident #51 was in his motorized wheel chair at the time. Resident #51 told the Administrator he got up from his wheel chair and tried to escort the resident out of the room. Resident #51 said he stumbled while escorting Resident #9, and she fell to the floor. Resident #51 denied falling to the floor and said he walked back to his wheelchair. The Administrator shared Resident #9 may have been in Resident #51's room earlier that day. He reported Resident #51 stated he did not mean to hurt Resident #9, he just wanted her to leave his room. Resident #51 appeared remorseful to the Administrator. Resident #51 was educated that he was not to touch any other resident. He stated the resident was alert, and oriented, and aware of his actions. The Administrator shared Resident #51 had not had any physical behavioral symptoms towards other residents since his admission, and had no other incidents since the [DATE] incident Resident #9 was observed sitting up in her wheel chair near the second floor nursing station on [DATE] at 10:38 A.M. The resident was conversational, but confused and the conversation did not make sense. She was able to propel herself a limited amount in her wheel chair. Resident #9 did not appear to be in any pain, and did not show signs of any emotional distress at that time. She was thin and frail appearing. Resident #9 stated to the surveyor on departure give me a call when you get home. An interview was conducted with State tested Nurse Aide (STNA) #108 on [DATE] at 10:45 A.M. regarding Resident #9's wandering behaviors, and if she was known to enter other resident's rooms uninvited. STNA #108 reported she worked the first shift of duty (7:00 A.M. through 7:00 P.M.) and was familiar with Resident #9. STNA #108 stated Resident #9 would wander into other residents rooms maybe three days out of a week during the day shift and the nursing staff would redirect her. She shared the resident walked a lot and would walk in other residents' rooms, some of the resident's would yell at the resident to get out of their rooms. STNA #108 reported if she saw the resident start to enter another resident's room she would immediately redirect her, and if other resident's were yelling for the resident to get out of their rooms she would go to their room right away. She communicated if Resident #9 was up and walking staff knew to watch her because of her wandering. An interview was conducted with Resident #51 on [DATE] at 10:52 A.M. regarding the incident involving himself and Resident #9 on [DATE]. Resident #51 was located on the first floor of the facility in a private room, he was alert and oriented to himself, place, time, and situation. He explained Resident #9 would wander in and out of his room every day and at night. He stated at night she would move his stuff around. Resident #51 said if he told the nursing staff they would remove her from the room and give her a snack. He also indicated staff would let Resident #9 come in other residents room if nursing staff were also in the room. He stated he would use his call light to have the nurses come and get Resident #9, but he felt nursing staff got annoyed because of him using his call light a lot. Resident #51 stated on the day of the incident, [DATE], Resident #9 came into his former room on the second floor, sometime after lunch but before supper. He said she was standing right beside him and he asked her to leave. Resident #9 asked why, but eventually left on her own. He stated about 25 minutes later she was back in his former room on the second floor going through his former roommates things. Resident #51 stated he told Resident #9 to stay out of his roommate's stuff and that she had to go. He said he got up from his motorized wheel chair and took a hold of the back of her arm to guide her towards the door. He explained he was able to walk some in his room if he steadied himself on something or used a cane. Resident #51 communicated as he was walking Resident #9 to the door, he stumbled and this caused Resident #9 to stumble. He said to the best of his recollection he must have pushed her when he stumbled and he caused her to fall. He reported he was aware Resident #9 was injured when she fell . He stated he only meant to help her out of the room and he did not intend on hurting her. He stated he felt sorry that she got hurt. Resident #51 confirmed the Administrator talked with him about not touching other residents and if he had a problem to use the call light. He stated that was the first time he touched any resident who had wandered into his room. An interview was conducted with Licensed Practical Nurse (LPN) #92 on [DATE] at 11:18 A.M. regarding Resident #9's wandering behaviors and if she was known to enter other resident's rooms uninvited. LPN #92 reported she worked the first shift of duty (7:00 A.M. through 7:00 P.M.) and was familiar with Resident #9. LPN #92 confirmed Resident #9 did wander the halls on the second floor, and would sometimes stop at a doorway to talk to a resident. Sometimes Resident #9 would walk into another resident's room while trying to talk them. She reported the other residents would call nursing staff to have Resident #9 taken out of their room. LPN #92 stated Resident #9 was not aggressive towards anyone, and was not a threat to other residents. She explained nursing staff was aware of Resident #9's wandering behaviors and would pay special attention to her whereabouts when she was up and wandering. LPN #92 denied any residents on the second floor had complained to her about Resident #9 wandering into their rooms. An interview was conducted with STNA #119 on [DATE] at 11:28 A.M. regarding Resident #9's wandering behaviors, and if she was known to enter other resident's rooms uninvited. STNA #119 reported she routinely worked the first shift of duty (7:00 A.M. through 7:00 P.M.) on the second floor and was familiar with Resident #9. STNA #119 reported she was aware of the incident between Resident #51 and Resident #9 a few weeks ago. She stated that the day of the incident, [DATE], she heard Resident #51 yelling at Resident #9 to get out of his room and she helped remove Resident #9 from his room. STNA #119 shared sometime later she was in a resident's room, across the hall, providing personal care and she heard Resident #51 faintly saying get out, get out she then heard a loud noise. She stated she was in the middle of personal care and could not leave the resident she was with. STNA #119 reported as soon as she was finished caring for the other resident she went to Resident #51's room. She saw Resident #9 on the floor with Resident #51 nearby telling Resident #9 to get up. Resident #51 said he didn't push her he just shoved her. He said she wouldn't get out of his room, and he was guiding her out. She stated the nurses were assessing Resident #9 at that time. STNA #119 communicated Resident #9, would roam rooms with a former resident. She stated that nursing staff tried to keep an eye on Resident #9 if she was up wandering. If the aides got busy they would take her to the nursing station for visual supervision from the nurses until the aides were free to watch her. STNA #119 reported she had heard complaints from residents on the second floor about Resident #9 and a former resident who wandered into other residents rooms when they did not want them there. Interviews were conducted with alert and oriented Residents #14, #23, #24, and #33 on [DATE] between the hours of 10:27 A.M. through 12:27 A.M. regarding any incidents of other residents coming into their rooms uninvited. All four residents reported they had experienced incidents of residents coming into their rooms uninvited, and that they would tell them to leave or would use the call light to get nursing staff to remove the. Resident #23 and #24 identified Resident #9 by name as one of the resident's that would wander into their room. An interview was conducted with RN #98 on [DATE] at 12:33 P.M. regarding the lack of assessment and care planning for Resident #9's behaviors of wandering in and out of other residents rooms which put the residents at risk. She stated she had not received any reports from nurses or STNA's that Resident #9 was demonstrating those behaviors, and had not seen any documentation of this occurring. This is an incidental deficiency found during the course of the investigation of Control Number OH 489.

Based on record review and staff interview, the facility did not provide appropriate supervision for one resident when transferring in the shower resulting in actual harm to the resident. The resident was lowered to the floor and sustained bilateral leg fractures. This affected one (#15) of eight sampled residents. All 58 residents have been identified to be at risk for a fall. Finding include: Record review of physician orders [REDACTED]. Review of the plan of care for alteration in safety and and awareness with potential for falls initiated 04/10/11 noted interventions that included assist with transfers as needed with a two person assist. Review of physician orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident required extensive assist of two people for bed mobility, transfers, toilet use, and bathing. Review of an incident report dated 09/30/11 at 8:00 A.M. documented the resident was in the shower room and being transferred at the time of the fall. The report indicated possible risk factors for the fall was the wet floor and wet hand rails. Interventions included to educate the State tested Nurse Aide (STNA) on safer ways to shower the resident. Review of a witness statement by STNA #8 dated 09/30/11 documented the resident was holding onto the shower rail in front of her while the STNA dried her bottom. The resident sat down on the shower chair. STNA #8 had the resident stand again as she pulled the resident's pants up. When the resident sat down, she sat on the edge of the shower chair and was going down. The STNA grabbed behind the resident and was holding her as the resident slowly went down to the floor. Nurses notes dated 10/01/11 at 12:30 P.M., documented the resident complained of bilateral hip pain. The physician was called and X-rays were obtained. X-rays dated 10/01/11 stated the resident had total bilateral hip replacements. The right hip replacement was "superior to the original site of the acetabulum. The device appears to be well seated to the lateral aspect of the pelvis". Nurses note dated 10/02/11, not timed, documented the resident had increased congestion, confusion and was seeing objects on the floor and was sent to the emergency room for an evaluation and admitted with pulmonary infiltrates, urinary tract infection, symptomatic anemia and delirium. X-rays were taken again at the hospital on [DATE] due to pain and swelling of the left knee. Results documented an oblique fracture involving the distal femoral metaphysis with one half shaft width medical displacement of the distal fragment with a [DIAGNOSES REDACTED]. Review of an orthopedic consultation dated 10/05/11 revealed the resident was seen for evaluation of left knee pain. According to the resident, "she was transferring from a shower chair to a wheelchair approximately three days ago when she slipped, causing injury to her left knee. She was brought to the emergency room shortly thereafter and admitted with acute delirium apparently related to an urinary tract infection. The x-rays revealed a displaced fracture of the left distal femur. The resident was not an operative candidate. She had a closed reduction and casting under monitored anesthesia care". On 10/07/11 the orthopedic physician noted post casting for bilateral femur fracture and continue non-weight bearing status for both lower extremities. Interview with the License Practical Nurse (LPN) #22 on 12/22/11 at 9:45 A.M. revealed the resident has had a plan of care since admission that indicates she requires a two person assist at all times. The resident's status for the amount of assistance required has not changed since then. Interview with the Director of Nursing on 12/22/11 at 10:00 A.M. confirmed the plan of care for falls indicated the resident needed the assistance of two staff for transfers. Interview with STNA #8 on 12/27/11 at 1:38 P.M. revealed she showered the resident and she was the only STNA assisting the resident. She stated the resident could not ambulate but could stand and assist with transfers. STNA #8 had the resident grab hold of the rail in the shower room and had her stand in order for her to dry the resident off. She had the resident sit back down and then had her stand again so she could pull the up the resident's pants. When she sat down again, the resident was on the shower chair on the edge and started to go down to the floor. She stated she didn't know if the resident was ever a two person assist but she is now since she returned from the hospital. Review of the current physician's orders [REDACTED]. This deficiency substantiates Complaint Number OH 770.