Every finding on record at Brookdale Westlake Village

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and interview, the facility failed to ensure Resident #54's medications were administered as ordered, when the resident was administered another resident, (Resident #55's) fentanyl (opioid) patch. This finding affected one (Resident #54) of six residents reviewed for medication administration. The facility census was 53.Findings include: Review of Resident #55's medical record revealed the resident was admitted on [DATE], private pay hospice on 07/18/26 and discharged on 07/20/26 with diagnoses including secondary malignant neoplasm of the liver and intrahepatic bile duct, malignant neoplasm of the lateral wall of the bladder and adult failure to thrive.Review of Resident #55's physician orders revealed an order dated 07/10/26 (discontinued 07/10/26) for fentanyl patch 72-hour 25 micrograms/hour (mcg/hr) apply one transdermal patch in the morning every three days for pain; an order dated 07/12/26 (discontinued 07/12/26) for fentanyl patch 72-hour 25 mcg/hr apply one transdermal patch in the morning every three days for pain; and an order 07/15/26 (discontinued 07/19/26) for fentanyl patch apply one transdermal patch every 72 hours for pain and remove per schedule.Review of Resident #55's MARs and TARs from 07/10/26 to 07/20/26 revealed the fentanyl opioid pain patch on 07/10/26 was ordered at 1:32 P.M., administered at 3:04 P.M. and removed at 3:05 P.M. The MAR stated the order was discontinued. The MAR also documented the fentanyl opioid pain patch was applied at 9:00 A.M. on 07/12/26, 07/15/26 and 07/18/26. Review of the MARs and TARs confirmed the resident's fentanyl pain patch was applied as ordered.Review of Resident #55's Controlled Substance Record dated 07/10/26 for fentanyl 25 mcg/hr patch revealed a total of five patches. The form indicated on 07/11/26 at 9:04 P.M. LPN #812 signed off on the narcotic flow record as administered. Handwritten beside the nurse's name was signed off on the narcotic sheet as administered but no in the MAR.Review of Resident #54's medical record revealed the resident was admitted on [DATE] and discharged on 07/12/26 with diagnoses including acute respiratory failure with hypoxia, muscle weakness, and alcoholic cirrhosis of the liver with ascites.Review of Resident #54's 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #54's physician orders revealed an order dated 07/09/26 (discontinued 07/12/26) for lidocaine (local anesthetics) transdermal patch 4% (percent) apply to back topically one time a day for pain for three days. Apply the patch on in the morning and off at night. Add two patches to the affected area and remove per schedule.Review of Resident #54's progress note dated 07/11/26 at 9:03 P.M. authored by Licensed Practical Nurse (LPN) #812 revealed the lidocaine external patch 4% was applied to the back topically one time a day for pain for three days.Review of Resident #54's medication administration records (MARs) and treatment administration records (TARs) dated 07/11/26 at 9:00 A.M. revealed LPN #812 documented the lidocaine patch was applied.Review of the Interact SBAR (Situation-Background-Assessment-Recommendation) form dated 07/12/26 at 9:00 A.M. created by LPN Clinical Services Manager #813 revealed the Certified Nurse Practitioner (CNP) was notified of an opioid given in error.Review of Resident #54's progress note dated 07/12/26 at 6:00 P.M. authored by LPN Clinical Services Manager #813 revealed the nurse was made aware the CNP requested to send the resident to the emergency department (ED) by the family request.Review of Resident #54's progress note dated 07/12/26 at 7:58 P.M. authored by LPN Clinical Services Manager #813 revealed the resident was sent to the ED. The resident was admitted and did not return to the facility.Review of Resident #54's Hospital Medicine History and Physical Exam (H&P) form dated 07/12/26 revealed during the resident's stay, she was administered a fentanyl (opioid) patch instead of a nicotine patch. The resident was brought back to the emergency department for the same and further evaluation. The ED evaluation revealed the resident was reportedly stable without major acute findings.Interview on 08/14/26 at 7:50 A.M. with CNP #811 revealed Resident #54 was sent to the hospital because the resident's family requested the transfer. CNP #811 denied any changes in the resident's condition due to the medication error.Interviews on 08/14/26 at 8:30 A.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #54 was administered a fentanyl opioid patch in error by a brand new nurse. The Administrator and DON confirmed the new nurse was removed from the schedule and education provided.Interview on 08/14/26 at 11:16 A.M. with LPN #812 confirmed she accidentally administered Resident #55's fentanyl patch to Resident #54. LPN #812 denied Resident #54 had any type of change in condition during the 7:00 P.M. to 7:00 A.M. shift.Review of the Pharmacy policy revised 09/15/24 revealed second nurse should witness and document the removal and destruction of the old fentanyl pain patch and document on the MAR when possible.Review of the undated facility Transdermal Patch Placement Verification form and attached instructions revealed the form needed to be completed both shifts and when applying or removing a fentanyl patch. If the facility had an admission with a fentanyl patch, please ensure both forms were in the narcotic binder with the narcotic count sheet. When removing and disposing of the fentanyl patch, a second nurse must be present and utilize the Medsafe in the second floor medication room to waste the patch.This deficiency was corrected on 07/14/26 when the facility implemented the following corrective actions:On 07/11/26 at 9:04 P.M. LPN #812 administered Resident #55's fentanyl 25 mcg/hr patch to Resident #54 instead of a lidocaine patch 4%.On 07/12/26 at 9:00 A.M. Registered Nurse (RN) #810 found Resident #55's the fentanyl patch (opioid) 25 mcg on the resident and determined the patch was administered in error and the patch was removed. The resident was assessed.On 07/12/26 at 11:33 A.M., RN #810 notified Resident #54's family who were at the bedside of the narcotic error.On 07/12/26 at 7:58 P.M., LPN Clinical Services Manager #813 sent Resident #54 to the ED for evaluation.On 07/12/26 awhole house audit was completed by the DON/designee to ensure narcotic medications were administered as ordered. No findings were identified.On 07/13/26, LPN #812 was placed back in retraining for accurate medication administration with LPN #807 which was completed 08/04/26. All Omnicare online training was completed as well as return demonstration on medication administration.On 07/13/26, RN Assistant Director of Nursing (ADON) #814 completed medication administration education for all nursing staff.On 07/13/26, the Administrator and DON developed a new policy for two nursing staff to observe all narcotic patches on the residents during the shift-to-shift report. The Administrator confirmed two nurses were always required to observe narcotic pain patch removal, but now two nurses verified pain patches during every narcotic count and during administration as well as removal.On 08/04/26, the Administrator and the DON completed a Corrective Action form (writeup) for LPN #812. The form revealed on 07/12/26 the facility learned of a medication error on 07/11/26 by administering the wrong medication to the wrong resident.On 07/13/26 a Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Administrator, DON, RN Infection Preventionist #815, RN ADON #814, LPN Clinical Services Manager #813 and Regional RN #816 related to the floor nurse providing the wrong medication to a resident.RN ADON #814, LPN Clinical Services Manager #813, RN Infection Preventionist #815, and the DON would be completing Audits completed day shift and night shift, twice a shift, three times a week for one month then random audits thereafter.LPN #812 started back on floor 08/14/26 on the 7:00 P.M. to 7:00 A.M. shift.Observation of medication administration revealed 26 medications were administered with no errors. Further observation revealed two staff checked placement of Resident #12's pain patch.This deficiency represents non-compliance investigated under Complaint Number #3095401.

Based on interviews, observation and facility policy review, the facility failed to ensure food was served at appetizing temperatures. This had the potential to affect 57 of 58 residents in the facility as Resident #37 did not receive meals by mouth.Findings include:Review of Food Committee meeting notes from 01/20/26, 02/04/26 and 03/03/26 revealed residents had complaints about food temperatures for room tray deliveries. The meeting on 02/04/26 residents met with Associate Dietary Manager #311 to discuss adjusting the food route for tray deliveries. The meeting on 03/04/26 revealed dietary was working on a new route for room tray deliveries.Interview on 04/14/26 at 4:08 P.M. with Resident #50 revealed the food was seasoned good but was not always warm enough and the staff would not heat it up. Resident revealed she brought a microwave to heat her food up, but staff would not allow her to have it so she had to eat the food the way it was.Interview on 04/14/26 at 4:20 P.M. with Director of Dining Services (DDS) #318 revealed facility cooks all food in the main kitchen and brings food to satellite kitchens on the first and second floors. Food is placed on steam tables and served to residents eating in the dining room and then staff plates food for residents eating in their rooms and delivers trays to their rooms. DDS #318 revealed there were previous issues with food remaining warm during COVID when they were using Styrofoam plates, but they have insulated plates and plate covers that help with keeping the food warm.Observation on 04/15/26 at 11:21 A.M. of lunch tray line with DDS #318 revealed a food cart left main kitchen at 11:32 A.M. and arrived on the 2nd floor satellite kitchen at 11:37 A.M. Server #440 and Server #441 placed table pans into the steam table at 11:43 A.M. and checked temperatures. Facility had a program where the thermometer automatically puts food temperatures into the computer system. At 11:58 A.M. staff started plating food for residents eating in the 2nd floor dining room. At 12:22 P.M. Server #441 started plating food for residents eating in their rooms. Server #441 was plating almost all food, cooking substitutes and adding side items to trays. Server #440 did not add drinks to the trays until after the food was plated. The first cart of room trays for rooms 221-228 left the satellite kitchen at 12:37 P.M. room [ROOM NUMBER] tray was on cart for 15 minutes before leaving the kitchen. Lunch for the 2nd floor was finished being served at 12:58 P.M. DDS #318 confirmed the observations.Observation and interviews on 04/16/26 at 12:00 P.M. of the 2nd floor tray line revealed at 12:45 P.M. a test tray was plated by Server #317 and placed on the last cart of trays. The cart left the satellite kitchen at 12:50 P.M. with Dinning Services Coordinator #443 and trays for room [ROOM NUMBER] and 229 were delivered. Test tray was taken off cart at 12:51 P.M. by DDS #318 who took the following temperatures: Crumb baked sole at 147 degrees Fahrenheit (F), chicken tenders at 120 F, green beans at 109 F, braised lima beans at 119 F, fruit at 56 F, and cream of cauliflower soup at 131 F.Each food item was tested and revealed the crumb baked sole was warm, the cream of cauliflower soup, braised lima beans and chicken tenders were lukewarm. The green beans were not warm. DDS #318 was allergic to fish but did try the green beans and confirmed they were not warm. Interview with DDS #318 revealed staff will serve the room trays before the dining room to see if this helps with food temperatures.Review of facility policy titled Food and Beverage Temperature Control with a last revised date of 2/26 revealed food and beverage temperatures must be maintained during transport of food.This deficiency represents non-compliance investigated under Complaint Number 1400647.

Based on observation, interviews, record review and review of the facility policy, the facility failed to implement an infection control program that properly tracked infection to prevent transmission of scabies and failed to ensure infection control procedures were maintained at all times. This affected two residents (Resident #26 and #38) and had the potential to affect all 58 residents in the facility.Findings include:1.Record review for Resident #38 revealed an admission date of [DATE] with diagnosis including infection and inflammatory reaction due to internal left hip prosthesis, subsequent encounter and aftercare following joint replacement surgery. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident #38 had impairment on one side of the lower extremities, had medically complex conditions, had intravenous (IV) access and received IV medications. Review of the care plan dated [DATE] revealed Resident #38 required enhanced barrier precautions (EBP) related to a midline used for IV antibiotics. Interventions revealed staff to use personal protective equipment (PPE) (Hand hygiene, gloves and gown) when providing high contact care activities. Review of the physician orders revealed Resident #38 had an order dated [DATE] for Cefazolin Sodium intravenous solution reconstituted two grams IV every eight hours for prosthetic joint infection until [DATE]. Normal saline flush IV solution 0.9% use 10 milliliters (ml) IV every eight hours for line maintenance. Flush with 10 ml pre and post IV med administration. An additional order was written on [DATE] for EBP for midline every shift. Observation during medication administration on [DATE] at 2:01 P.M. revealed Licensed Practical Nurse (LPN) #402 flushed Resident #38's midline catheter with 10 ml of normal saline after cefazolin solution completed infusion. Observation revealed LPN #402 never donned an isolation gown during the procedure. Observation after completion with LPN #402 of the EBP sign on Resident #38's entrance doorway revealed everyone must wear gloves and a gown for the following high contact resident activities (which included) device care and use. LPN #402 reviewed the sign and confirmed she never donned an isolation gown while disconnecting the IV antibiotic and flushing Resident #38's IV line with saline solution. 2. Record review for Resident #26 revealed an admission date of [DATE] with diagnosis including myocardial infarction, muscle weakness, pressure ulcer of right buttocks stage three, and pressure ulcer left buttocks stage two. Review of the Modification of the admission MDS assessment dated [DATE] revealed Resident #26 was cognitively intact and was occasionally incontinent of urine. Resident #26 used a walker for mobility, required substantial/maximal assistants for toileting hygiene, partial/moderate assistants for upper and lower body dressing, personal hygiene, sitting to a standing position, and supervision or touching assistants to walk 10 feet once standing. Resident #26 had an unhealed pressure ulcer, was at risk for pressure ulcers and received pressure ulcer care. Review of the care plan dated [DATE] revealed Resident #26 had potential for pressure ulcer development related to a stage three pressure ulcer to the right buttocks and a stage two pressure ulcer to the left buttocks. Interventions included to provide incontinence care as needed. Review of the current physician orders for Resident #26 revealed an order dated [DATE] for treatment to the buttocks, cleanse with normal saline, pat dry, apply [NAME] to the wound bed and cover with foam every evening shift. An additional order dated [DATE] revealed Resident #26 was to have Enhanced Barrier Precautions – wounds every shift. Observation on [DATE] at 7:38 A.M. of Certified Nursing Assistant (CNA) #430 provide morning care for Resident #26 revealed Resident #26 required hands on care while in bed to sit up then stand. Resident #26 then ambulated to the bathroom with use of her walker and assistants from CNA #430. Once Resident #26 reached the toilet, CNA #430 removed Resident #26's soiled (urine) brief. Observation revealed Resident #26 had a dressing on both the right and left buttocks. Both dressings had the edges rolling up and were not fully intact. Observation revealed CNA #430 never donned an isolation gown during care. CNA #430 confirmed Resident #26 had wounds on her buttocks. CNA #430 continued with washing Resident #26's face, arms, legs, and buttock/peri area, dressed and groomed Resident #26, walked her back to her bedside chair in her room then made her bed. Observation on [DATE] at 8:02 A.M. with CNA #430 revealed a sign near the entrance door of Resident #26's room. The sign read EBP, wear gloves and gown for the following high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care and wound care. CNA #430 confirmed she did not donn an isolation gown while providing any of the morning care observed for Resident #26. Observation on [DATE] at 11:25 A.M. of LPN #366 provide wound care to Resident #26's right and left buttocks revealed CNA #430 was present to assist with positioning Resident #26. Both CNA #430 and LPN #366 donned an isolation gown and gloves prior to care. After completing wound care to the left side of the buttocks, LPN #366 removed her gloves, left her isolation gown on, used hand sanitizer and exited the room (with the isolation gown on) revealing she needed more treatment supplies. LPN #366 closed the door behind her. After approximately three to four minutes, LPN #366 opened the door and donned a new isolation gown. LPN #366 revealed she threw the previous gown in the treatment cart trash. LPN #366 then completed Resident #26's wound care. Resident #26 stated, This is the first time any staff wore a gown for anything. Observation revealed upon exiting the room with LPN #366, the soiled gown LPN #366 previously removed was partially hanging out of the trash can that was connected to the treatment cart. Interview on [DATE] at 9:19 A.M. with DON revealed isolation gowns were to be removed and disposed of in the trash can prior to exiting a resident room on EBP. Review of the facility policy titled, Enhanced Barrier Precautions Policy dated [DATE] revealed EBP should be used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organism (MDRO's) to residents. EBP are used in conjunction with standard precautions and expand to the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to associate hand and clothing. Examples of care activities include providing AM or PM care including oral care, dressing, bathing, grooming. Taking the resident to the toilet or providing peri care, doing dressing changes or providing bed mobility. 3. Review of facility infection control log from [DATE] to [DATE] revealed Resident #63 was diagnosed with Norwegian Scabies on [DATE] and treated with Ivermectin 5 tablets for 3 weeks. No other residents were listed on the control log for being treated with Norwegian scabies or scabies. Review of medical record for Resident #63 revealed the resident was admitted on [DATE] and expired on [DATE]. Resident diagnosis included traumatic subdural hemorrhage, traumatic subarachnoid hemorrhage, chronic diastolic heart failure, dementia, essential tremor, lymphedema, and essential hypertension. Review of the progress notes revealed resident had a rash on [DATE], dermatology was consulted and resident was ordered diclofenac cream and appeared to be improving. A Physician Progress Note dated [DATE] revealed rash was improving, resident was not scratching and had been prescribed Atarax 25 Milligrams (MG) every 6 hours as needed and Diclofenac cream. A Nursing Progress Note dated [DATE] revealed facility Medical Director #445 was notified that Resident #63 rash was unchanged and itchy. Resident was ordered Singular 10 mg daily. A Nursing Progress Note dated [DATE] revealed Medical Director #445 had seen resident regarding rash and ordered: labs, Itraconazole 100 mg for 10 days, Terbinafine cream to chest for 10 days and Clotrimazole Betamethasone cream for 10 days. A Nursing Progress Note dated [DATE] revealed Resident #63 had returned from dermatology appointment and was diagnosed with Norwegian scabies. Previous orders were discontinued, resident was prescribed Ivermectin 3 MG for 3 weeks and to be placed in contact isolation. Review of e-mail sent by DON #422 dated [DATE] at 9:00 P.M. revealed staff was notified of a confirmed case of scabies in the building. DON #422 requested assistance with showering residents after their treatment and wiping the cream off. In addition, Also, if any staff member that would like to take Ivermectin prophylactically then please reach out to either me or Administrator. We will provide those medications. The e-mail also included a link from the Centers for Disease Control titled Clinical Overview of Crusted scabies. Review of Resident #22 medical record revealed an admission date of [DATE] with diagnosis that included: other fracture of first lumbar vertebra, other fracture of second lumbar vertebra, history of falling, multiple fractures of ribs, muscle weakness, dysphagia, cirrhosis of liver and scabies. A Nursing Progress Note dated [DATE] revealed resident had complained about her back being itchy but no redness or rash noted. A Physician Progress Note dated [DATE] revealed Resident #22 had complaints of rash on her back but no rash was present on exam. A Nursing Progress Note dated [DATE] revealed resident had a rash all over and was ordered Prednisone 20 MG daily for 5 days, Hydrocortisone cream and Benadryl. A Comprehensive Nursing Note dated [DATE] revealed resident had returned from a dermatology appointment, was diagnosed with scabies and ordered Ivermectin, Triamcinolone 0.1 %, and Permethrin 5 %. Resident was placed in contact precautions. Review of Resident #54 medical chart revealed a Nurse Progress Note dated [DATE] stating resident had a redness to his legs that were hot to the touch. Resident was ordered Ivermectin Oral Tablet 3 MG on [DATE] for treatment of scabies. Review of facility infection control log from [DATE] to [DATE] revealed neither Resident #22 nor Resident #54 were listed on the infection control log for scabies. Interview on [DATE] at 9:20 A.M. with Social Worker #325 revealed there was a scabies outbreak, she thinks it was only on the 2nd floor and did not think any staff had scabies from the outbreak. Interview on [DATE] at 9:44 A.M. with the Administrator and DON #422 revealed the facility coordinated with local health department and their Medical Director #445. The original case was in [DATE] and the second case was in [DATE]. DON #422 revealed the scabies case in September was Resident #22. She said no staff had symptoms or signs of scabies and no staff was treated prophylactically. Interview on [DATE] at 11:18 A.M. with Disease Investigator (DI) #446 from the Cuyahoga County Board of Health (CCBH) revealed the facility notified them on [DATE] of six cases of suspected scabies and provided treatment dates for the other residents that were treated on [DATE]. DI #446 recommended the facility to treat residents on the unit and staff that provided patient care on multiple residents. In addition, recommended facility treat staff and residents on the infected unit and those who were in common areas. DI #446 revealed he would have liked the facility to be more aggressive with the prophylactic treatment but that CCBH cannot enforce this recommendation. He said one case of scabies does not need to be reported to the health department. Interview on [DATE] at 3:08 P.M. with Administrator and DON #422 revealed that the previous staff person who was filling out the infection control log was no longer at the facility. DON #422 revealed that when the report for infectious disease in their electronic medical record system, Point Click Care, was ran it did not pull dermatologicals. She said this was the reason that the other residents that were treated for scabies were not listed on the infection control log. Interview on [DATE] at 2:24 P.M. with Administrator and DON #422 revealed 16 residents were treated for scabies, including six residents that had active rashes. DON #422 said there at 16 rooms on A Hall on the second floor and 14 room on B Hall. The residents with rashes and Resident #62 were all on A Hall and they provided prophylaxis treatment to all residents on that hall. Residents that received treatment were: Resident #43, Resident #40, Resident #32, Resident #25, Resident #21, Resident #16, Resident #20, Resident #15, Resident #6, Resident #54 and Resident #24. Previous residents that received treatment were: Resident #64, Resident #65, Resident #66 and Resident #67. Interview on [DATE] at 3:40 P.M. with DON #422 confirmed that residents were not on log for scabies. DON #422 provided the infection control map for [DATE] that had Resident #22 room [ROOM NUMBER] highlighted in orange with scabies written on it. DON #422 revealed facility needed to do a better job of tracking infections. Interview on [DATE] at 10:58 A.M. with the Administer revealed the [DATE] scabies outbreak was communicated to staff by the facility directors. He did not have information confirming staff was informed of the scabies outbreak. He said contact tracing was done for 7-days from diagnosis, and he would try to find documentation. Interview on [DATE] at 12:18 P.M. with the Administrator revealed all emails regarding contact tracing and other communication regarding the scabies outbreak were automatically deleted from their system after six months. He provided screen shots from his text message conversation with Executive Director #447 regarding contact tracing not revealing where Resident #63 got scabies from. Administrator said previous LPN #448 had contacted families and he was not sure were this was documented. Resident #22 and Resident #63 medical record included notes that family was updated but no further documentation was available regarding other residents families and visitors being informed of the scabies outbreak. Interview on [DATE] at 1:46 P.M. with the DON #422 regarding Excel document titled Review of facility Infection Line Listing 2025 revealed she thinks the associates listed as receiving treatment were the staff members that received treatment in [DATE] scabies outbreak. DON #422 revealed due to emails deleting after six months she was not positive if this was from the [DATE] or [DATE] outbreak or if this was the most updated list. She said during one of the outbreaks no staff took the treatment. Interview on [DATE] at 2:29 P.M. with the Administrator revealed he spoke with the CCDH and they can provide the emails between facility and CCDH. Administrator confirmed the facilities records regarding the scabies outbreak was not saved correctly an emails, documents, in-services, treatments and other relevant information was either unable to be provided or provided in pieces. Some information provided, the facility was unable to confirm if they were from the [DATE] or [DATE] outbreak. Interview on [DATE] at 2:29 P.M. with DI #449 from the CCDH revealed the facility had been having skin issues since [DATE]. She said the facility took a while to provide the line list and that when they received the information it was not very detailed. DI #449 sent the Final Report dated [DATE] and the Line List provided by the facility. Review of the Final Report written by DI #449 revealed CCBH was notified by the facility on [DATE] of an outbreak of a dermatological condition. The facility reported six residents that were experiencing ongoing rashes. Further review revealed: The index case had a history of multiple skin issues dating back to [DATE], which were undiagnosed. The index case was medically diagnosed with crusted scabies and received prophylactic treatment. All other residents were prophylactically treated, and their skin conditions have not worsened since treatment. However, no other residents report a crusted rash. Resident #63 received a diagnosis of crusted scabies but all other cases did not received skin scarping test to confirm diagnosis. The section titled: Epidemiological Investigation Findings revealed the following information The onset date for the cluster of rash cases started approximately two weeks prior to reporting date, exact date unknown. The index case has been having dermatological problems since [DATE], and was initially treated for a fungal infection. All (100%) of cases and the remaining residents on the same wing/unit were treated prophylactically with permethrin cream, two doses a week apart. Demographic information on the cases were not provided by the reporting facility. The section titled: Recommendations for Controlling Disease and/or Preventing/Mitigating Exposure revealed the following: A staff member who has skin-to-skin contact with a resident that has scabies should receive prophylactic treatment, even if they are asymptomatic. Other residents within the community should receive prophylactic treatment, even if they are asymptomatic. Use of standard precautions that include good hygiene, use of personal protective equipment, and proper disposal of single use gloves. Continued surveillance of skin changes for 8 weeks after the last case is identified. Review of Excel document titled Scabies Line List provided by the facility to the CCDH not dated revealed facility provided initials, room number and date of treatment for six residents (Resident #63, Resident #16, Resident #25, Resident #65, Resident #6 and Resident #67. Resident #43, Resident #40, Resident #32, Resident #25, Resident #21, Resident #16, Resident #20, Resident #15, Resident #6, Resident #54 and Resident #24. Previous residents that received treatment were, Resident #64, Resident #65, Resident #66 and Resident #67. Resident #63 was documented as having date of onset date as [DATE]. No other residents that were treated prophylactically were listed on the line list. Facility provided the following documents regarding the scabies outbreak: Review of Clinical Services In-Service Form-Skilled Nursing dated [DATE] revealed facility conducted an in-service on scabies with staff that also included infection control and hand hygiene. Review of facility Infection Line Listing 2025 revealed Resident #22 tested positive on [DATE] and Date of Recovery was [DATE]. Completed Associates that were treated prophylactically included LPN #402, Restorative Specialist #370, Registered Nurse (RN) #390, CNA #375, RN #365 and previous LPN Unit Manager #448. Review of facility document titled, Contact Tracing for Infectious Diseases Resident or Associate (AL/MC/SNF) with a last revision date of 09/23 included: Identifying Information, Symptoms, Signs and Significant Conditions, Exposure History, Diagnosis, Treatment and General Notes/Comments. The form dated [DATE] had Resident #22 information. The form dated [DATE] had Resident #63 information. No other residents contract tracing forms were provided. Appendix C: Scabies Outbreak Management Checklist from the Ohio Department of Health-Infectious Disease Control Manual (ODH-IDCM) Scabies Section 6 with a revised date of 11/23: revealed the following: -Section titled: Investigation and Monitoring: Daily skin assessments documented on all at-risk persons in the care of the institution/facility. This box was not checked off as completed and residents were only receiving weekly skin assessments. -Section titled: Treatment: Prophylactic treatment offered to contacts, including staff, family Appendix D: Sample Data Sheet: Data Collection Form for Scabies with a revised date of 11/2023 had no resident identifying information filled out. Exposure History section was filled out but included no date of onset of symptoms. Appendix E: Sample Staff Line List and Appendix F: Sample Patient Line List were blank and facility was unable to provide list when requested. Appendix H: Sample Provider Letter Related to Scabies Outbreaks for healthcare providers revealed the following information: Family members and other close contact should receive prophylactic scabies treatment at the same time the patient is treated. Permethrin 5% cream (Elimite) is now the recommended agent for treatment of scabies. Review of the Center's for Disease Control (CDC) guidelines titled Public Health Strategies for Crusted Scabies Outbreaks in Institutional Settings dated [DATE] revealed the surviellance includes maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings; persons with crusted scabies may not show the characteristic symptoms of scabies such as rash and itching (pruritus). Maintain ongoing surveillance for scabies among all patients/residents and staff to identify new or unsuccessfully treated cases of scabies. Control & Treatment includes maintain records with patient name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff, use epidemiologic data about the distribution of confirmed cases by building, room, floor, wing, occupation (for staff), dates of admission, and onset of scabies-like condition to determine: 1. levels of risk for patients/residents and staff; 2. extent of the outbreak (e.g., confined or widespread in the facility); and 3. temporal relationship among cases. Isolate patients with crusted scabies from other patients/residents who do not have crusted scabies; consider assigning a cohort of caretakers to care only for patients/residents with crusted scabies, maintain contact precautions until skin scrapings from a patient with crusted scabies are negative, identify and treat all patients/residents, staff, and visitors who may have been exposed to a patient/resident with crusted scabies or to clothing, bedding, furniture, or other items (fomites) used by a patient/resident with crusted scabies; strongly consider treatment even in equivocal circumstances because controlling an outbreak involving crusted scabies can be very difficult and risk associated with treatment is relatively low, offer treatment to household members (e.g., spouses, children, roommates) of staff who are undergoing scabies treatment, treat patients/residents, staff, and household members at the same time to prevent re-exposure and continued transmission. Review of facility policy titled, Procedure: Scabies with a revised date of [DATE] revealed the family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. Review of facility policy titled, Infection Prevention and Surveillance with a last revised date of 03/26 revealed the Nurse Leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and the transmission of disease and infection. This deficiency represents non-compliance investigated under Complaint Number 1400647 and Complaint Number 1400669.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #24 was provided with timely incontinence care. This affected one resident (Resident #24) of three residents reviewed for incontinence. The facility census was 58.Findings include:Record review for Resident #24 revealed an admission date of 02/08/25. Diagnosis included chronic kidney disease, muscle weakness, overactive bladder, anxiety disorder, and polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired. Resident #24 was always incontinent of bowel and bladder, required substantial/maximal assistants for bed mobility, dependent for chair/bed to chair transfer and had no ulcers, wounds or skin problems.Review of the care plan dated 03/19/26 revealed Resident #24 had bladder incontinence. Interventions included checking the resident as required for incontinence. Wash, rinse and dry perineum.Interview and observation on 04/20/26 at 9:05 A.M. revealed Resident #24 was awake, lying in bed. Resident #24's room smelled of stool. Resident #24 revealed she pooped a little and revealed the girl said she would be back in, in a little bit. Observation on 04/20/26 at 9:34 A.M. revealed Licensed Practical Nurse (LPN) #408 entered Resident #24's room and applied a powder under the bilateral breast then exited the room. LPN #408 revealed Resident #24 was alert and oriented to person, place, and time with moments of confusion.Observation on 04/20/26 at 10:00 A.M. with Certified Nursing Assistant (CNA)/Scheduler #301of incontinence care revealed Resident #24 had a large bowel movement that extended up into the peri area. The bed pad and sheet also was soiled with stool/urine. CNA #301 revealed she started the shift at 8:00 A.M. and someone else was covering until she arrived. She had not been in to see Resident #24 yet. Observation after removing the stool revealed Resident #24's crease in her right and left thigh was red and open on the crease lines. The buttocks was deep red and excoriated covering the entire buttocks to the lower back. CNA #301 completed peri care and applied A&D ointment.Interview on 04/20/26 at 10:00 A.M. with CNA #431 revealed she started her shift at 6:30 A.M. and there was a call off, so it was her and one other CNA that was also agency staff. She did not realize and it was not on her schedule that she was supposed to cover Resident #24's room until another CNA arrived. CNA #431 revealed she did take Resident #24's breakfast tray in but she did not check or change her and revealed she did tell her someone would be with her. CNA #431 stated, I did not know her or that I was supposed to have her.Interview on 04/20/26 at 11:02 A.M. with Director of Nursing (DON) revealed residents should be checked on frequently for incontinence, no more than two hours, more frequently if needed. Each resident should always have an assigned aid, if a resident is lying in stool, they should be changed immediately. Review of the facility policy titled, Perineal Care revised September 2005 revealed the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.This deficiency represents non-compliance investigated under Complaint Number 2684091, 2907090 and 1400671.

Based on observation, interview, resident record review, and review of resident council minutes, the facility failed to ensure a sufficient supply of washcloths and towels available for morning care and as needed. This affected one resident (Resident #26) with the potential to affect all residents residing at the facility.Findings include:Record review for Resident #26 revealed an admission date of 03/19/26 with diagnosis including myocardial infarction, muscle weakness, pressure ulcer of right buttocks stage three, and pressure ulcer left buttocks stage two. Review of the Modification of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and was occasionally incontinent of urine. Resident #26 used a walker for mobility, required substantial/maximal assistants for toileting hygiene, partial/moderate assistants for upper and lower body dressing, and personal hygiene. Resident #26 had an unhealed pressure ulcer, was at risk for pressure ulcers and received pressure ulcer care. Review of the care plan dated 03/26/26 revealed Resident #26 had potential for pressure ulcer development related to a stage three pressure ulcer to the right buttocks and a stage two pressure ulcer to the left buttocks. Interventions included to provide incontinence care as needed.Review of the care plan dated 03/19/26 revealed Resident #26 had an activity of daily living (ADL) self-care performance deficit related to muscle weakness. Interventions included to provide the resident with short simple instructions such as hold your washcloth in your hand. Put soap on your washcloth, wash your face, etc.Observation on 04/16/26 at 7:38 A.M. of Certified Nursing Assistant (CNA) #430 provide morning care for Resident #26 revealed Resident #26 ambulated to the bathroom with use of her walker and assistants from CNA #430. Observation revealed CNA #430 used a disposable wipe to wash Resident #26's face. CNA #430 revealed there were no clean washcloths or towels to wash her residents or dry them so she has to use the disposable wipes intended for incontinence care to wash their entire body. CNA #430 revealed this happens several days a week and sometimes they don't get any washcloths or towels until after she leaves at 2:00 P.M.; Resident #26 made a grumbling sound and revealed she would at least like a washcloth for her face. Observation revealed CNA #430 continued washing Resident #26's entire body with disposable wipes. Observation on 04/16/26 at 8:02 A.M. with CNA #430 of both the linen closets on the first floor, A and B hall revealed there were no washcloths or towels available for use. CNA #430 confirmed those were the only storage areas used for wash cloth and towel storage on the first floor.Observation on 04/16/26 at 8:08 A.M. with CNA #415 of both the linen closets on the second floor, A and B hall revealed there were no washcloths or towels available for use. CNA #415 confirmed those were the only storage areas used for wash cloth and towel storage on the second floor and revealed, We don't have washcloths or towels, laundry came and picked up the soiled linen, they will wash them then bring them back. CNA #415 revealed the staff had disposable wipes to clean residents' bottoms when they were incontinent, but the residents would have to wait until laundry washed the washcloths and towels to get the rest of their body washed up for the day.Observation on 04/16/26 at 8:30 A.M. with Director of Housekeeping #331 revealed the laundry personnel transported the laundry in a large bin from each soiled utility room in the skilled nursing facility to the laundry area located through the assisted living section of the facility. Director of Housekeeping #331 confirmed the skilled nursing facility had two resident floors and two closets on each floor where the washcloths and towels were stored for residents' use. The laundry personnel worked a total of eight hours a day, their shift began somewhere between 7:00 and 8:00 A.M.; When they arrived, they washed the tablecloths and napkins first. Director of Housekeeping #331 confirmed the staff had no clean towels or wash cloths this morning for any residents residing in the skilled nursing facility and revealed she ordered linens monthly and the staff threw most of them away. Director of Housekeeping #331 confirmed the lack of washcloths and towels was an ongoing problem, staff expressed to her two to three times a week that they had no towels or washcloths available to wash residents. Director of Housekeeping #331 confirmed she did not have any backup supply in stock either, she was waiting on the next shipment.Interview on 04/16/26 at 8:54 A.M. with Registered Nurse (RN) #390 confirmed there were days there were no washcloths or towels in the mornings. RN #390 stated, Residents just can't wash up except wipes for their bottoms, they said staff were throwing them away, I never seen that.Interview on 04/16/26 at 9:00 A.M. with Resident #43 revealed there are times there are no washcloths or towels to wash up in the mornings and stated, Lots of times I like to wash up and can't, it makes me feel awful.Interview on 04/16/26 at 9:30 A.M. with Administrator confirmed he was aware of residents not having enough washcloths and towels available for resident use daily. Administrator confirmed it was an ongoing issue especially when agency staff worked, they put them in the trash or hoard them in some residents rooms.Interview on 04/16/26 at 12:07 A.M. with Resident #51 revealed, There are mornings I can't wash because there are no washcloths or towels, I have had to use paper towels, it's terrible.Review of the Resident Council Meeting minutes dated 01/20/26 at 1:30 P.M. revealed the list of old business unresolved included towels for showers. Under the Summary of Issues was documented not enough towels and toilet paper in residents' bathrooms and for showers. Review of the section titled, Review of Prior Council Meeting revealed they met with Administrator about towel issue.

Based on record review and interview, the facility failed to ensure medications to treat diabetes were administered as ordered by the physician. This affected one (#35) of one resident reviewed for medication errors. The facility census was 58. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders for Resident #35 revealed she had an order for Novolog FlexPen 100 unit/milliliter, inject 10 units with meals for diabetes mellitus dated 09/05/24 and Insulin Detemir 100 units/milliliter, inject 55 units at bedtime for diabetes mellitus dated 09/06/24. Review of the nursing progress note dated 09/20/24 at 11:30 P.M. revealed Resident #35 was sent to the hospital. On 09/21/24 at 1:39 A.M. Resident #35 was administered her bedtime insulin and she had asked how many units of insulin she was being given. The nurse stated 55 units and administered the insulin. Resident #35 stated she gave her the wrong insulin after it had already been administered. The nurse checked the cart and realized she was out of her long-acting insulin (Insulin Detemir). Her blood sugar was obtained, and it was 125 (normal blood sugar range is 60-100). The physician was updated and completed a virtual visit with the resident who requested to be sent to the hospital for observation. On 09/21/24 at 6:00 A.M., Resident #35 returned to the facility with no new orders from the hospital. Review of the witness interview/statement form dated 09/21/24 revealed Licensed Practical Nurse (LPN) #397 went to administer Resident #35 her bedtime insulin at 9:20 P.M. Resident #35 asked her how many units of insulin she was being administered and LPN #397 stated it was 55 units, she administered the insulin and then the resident started screaming that she had given her too much insulin. LPN #397 stated she went to the cart and noticed the resident had been out of her nighttime insulin (Insulin Detemir). LPN #397 then took her blood sugar which was 125 and updated the physician. The statement said a virtual visit with the physician was held and the resident requested to be sent to the hospital. Interview on 09/30/24 at 3:47 P.M. with Resident #35 revealed LPN #397 had administered her the wrong insulin and dose on 09/20/24. She stated she went to the emergency room so that they could monitor her blood sugar. Interview on 10/02/24 at 10:39 A.M. with LPN #305 verified the medication error on 09/20/24 for Resident #35. She stated LPN #397 was an agency nurse who gave the wrong insulin to Resident #35. She stated she was supposed to get long-acting insulin (Detemir Insulin) and instead the nurse administered short-acting insulin (Novolog). LPN #305 stated the facility placed a do not return to the facility on agency nurse LPN #397. LPN #305 was unable to provide LPN #397's contact information. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated 12/01/07, revealed staff should verify each time prior to a medication being administered that it was the correct medication and correct dose. This deficiency represents non-compliance investigated under Complaint Number OH00157849.

Based on medical record review, facility investigative document review, staff interview, and facility policy review, the facility failed to report an allegation of staff-to-resident physical abuse in a timely manner to the state agency. This affected one resident (#38) of three residents reviewed for abuse. The facility census was 60. Findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, encounter for palliative care, hypertension, anemia, anxiety disorder, insomnia, cellulitis of lower left limb, bipolar disorder, history of falling, and hypokalemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had a severe cognitive impairment. Review of Resident #38's medical records revealed no allegations or support for an allegation of physical abuse. Review of facility investigation regarding Self-Reported Incident (SRI) number 239692, dated 09/29/23, revealed an allegation of physical abuse made by Dietary Staff #106, against State tested Nursing Aide (STNA) #107 towards Resident #38. The facility completed a thorough investigation and determined there was no support for this allegation; however, it was also determined during the investigation that Dietary Staff #106 saw the alleged incident on 09/05/23 and did not report it until 09/29/23. Interview with Administrator on 10/06/23 at 2:25 P.M. confirmed the report of physical abuse was not made until 09/29/23, when it should have been reported on 09/05/23. He stated when he interviewed Dietary Staff #106 as to why she didn't report it on 09/05/23, she didn't have an adequate reason. Review of facility Abuse, Neglect, and Exploitation policy, dated October 2022, revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Alleged violations involving abuse should be externally reported (state department of health) as soon as practical, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse. This deficiency was an incidental finding related to Master Complaint Number OH00146912.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, facility investigation review, and facility policy review, the facility failed to provide adequate supervision and equipment to ensure all residents remained inside the facility as required. This affected one resident (#61) of three residents reviewed for possible elopement. The census was 60. Findings Include: Resident #61 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, muscle weakness, difficulty walking, lack of coordination, mild cognitive impairment, metabolic encephalopathy, mild cognitive impairment, chronic kidney disease (stage III), atrial fibrillation, atherosclerotic heart disease, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had a severe cognitive impairment. Review of Resident #61 elopement assessment, dated 09/08/23, revealed he scored a zero on the safety assessment, but the facility still deemed him to be an elopement risk based on his cognitive abilities and wandering tendencies. So, at that time, a wanderguard (a bracelet worn by a resident to prevent elopement) was placed on him. Another elopement risk assessment was completed on 09/11/23, which indicated he was a score of two and a risk for elopement. Review of facility Self-Reported Incident (SRI) number 239106, dated 09/12/23, revealed Resident #61's wanderguard was not on his body; it was noticed by Registered Nurse (RN) #101. She did not report that he did not have a wanderguard on to anyone, but the facility staff maintained visual supervision on him. Between 11:15 A.M. and 11:30 A.M., RN #101 indicated to nursing management that she could not find Resident #61. Elopement and missing individual protocol were immediately implemented, which included looking for him off property. He was found approximately a five-minute walk from the facility on the sidewalk; he had left the facility campus. He was returned to the facility with no injuries or health declines, and a wanderguard was placed back on him. Interview with the Administrator on 10/06/23 at 10:40 A.M. and 1:42 P.M. confirmed Resident #61 left the facility campus and was not being supervised as he should. He found out during the investigation that RN #101 knew his wanderguard was not attached to him, she had been attempting to find the nursing supervisor to get another one, and he left the facility prior to her being able to get another one. Interview with RN #101 on 10/06/23 at 11:34 A.M. confirmed she was checking for Resident #61's wanderguard in the morning of 09/12/23 and could not find it. She ensured he was in a safe spot prior to going to look for the nursing supervisor, to get a new wanderguard. She confirmed she did not inform anyone else in the facility that his wanderguard was not on. She attempted multiple times to find the nursing supervisor without success. Each time she would go back to check on Resident #61, and she could not find him the last time. They checked for him around the whole facility and finally found him on the sidewalk near the road. He had no injuries or health declines. Review of facility Missing Resident policy, dated September 2023, revealed a missing resident requires immediate associate attention. To assist with the prompt location of a resident, the following procedures should be followed until the resident is found. The supervisor should verify whether or not the resident has signed out. Also, they need to obtain the last time the resident was seen, clothing they were wearing, cognitive and emotional status, height, weight, hair color, and adaptive equipment used, and any distinctive traits of the resident. The staff are to conduct a thorough interior search of the community, notify security personnel, conduct a thorough exterior search of the community, and contact the administrator and director of clinical services. Local law enforcement will also be notified if needed. When the resident is located, the facility will review them for injury or change in condition, complete and incident report, notify the health care provider, and notify the resident's legal representative if necessary. The incident was deemed to be past non-compliance on 09/13/23 due to the following items provided by the facility: 09/12/23, Resident #61 was fully assessed by facility nursing and deemed to be in good health; there were no injuries or health declines noted. A new wanderguard was placed on his body. 09/12/23, Director of Nursing (DON) provided education to all nursing staff, including State tested Nursing Aides (STNA) about the facility's elopement policy and the use of wanderguards for residents. RN #101 was also re-educated and counseled about the importance of communicating when a resident does not have a wanderguard on, and they are ordered to have one. 09/12/23, facility maintenance staff tested all wanderguard doors and devices; all were working appropriately. 09/12/23, facility nursing staff reviewed all resident medical records and assessments, deemed there were no other residents who used nor needed a wanderguard at that time. 09/12/23, extra wanderguards were moved from the storage room to the floor nurse medication carts for easier access. Starting 09/12/23, the facility-initiated elopement and missing individual drills once per shift, each day for one week (ending on 09/18/23.) Then, starting 09/19/23, the facility initiated the same drill twice a week, for two months. This was being completed as planned based on review of documents on 10/06/23. This deficiency represents non-compliance investigated under Complaint Number OH00146456.

Based on observation, record review and staff interview, the facility failed to provide evening activities at reasonable times for the residents. The facility census was 26. Findings include: Observation on 10/18/22 at 5:00 P.M. revealed residents were in the dining room eating dinner. Interview on 10/18/22 at 5:10 P.M. with Activity Assistant #303 stated that she does one on one activities with the residents from 5:00 P.M. through 7:00 P.M. Interview on 10/18/22 at 5:15 P.M. Registered Nurse (RN) #215 stated that residents eat dinner in the dining room every night and dinner starts at 5:00 P.M. Observation on 10/18/22 at 5:35 P.M. revealed there were no activities being held on second floor. Observation and interview on 10/18/22 at 5:38 P.M. State tested Nurse Aide (STNA) #200 revealed that she was assisting the residents with dinner. STNA #200 stated that residents take their time eating and finish their meal around 6:00 P.M. Observation and interview on 10/18/22 at 5:42 P.M. with STNA #201 revealed she was delivering trays to the residents eating in the room. STNA #201 stated that they pick up trays from room after 6:10 P.M. after cleaning the dining room and we don't rush residents eating. Observations and interviews on 10/18/22 at 5:45 P.M. with Dietary Manager #300 revealed that dinner was being served to residents from pantry and the residents are served until 6:00 P.M. Review of the activities calendar for August 2022, September 2022 and October 2022 revealed evening activities were scheduled at 5:00 P.M. on Tuesdays and Thursdays. Review of the Scheduled mealtimes revealed dinner was served at 5:00 P.M. Interview on 10/19/22 at 11:38 AM with Director of Resident Programs #301 revealed that she has overseen the skilled nursing facility (SNF) since the end of March. She verified and agreed that activities scheduled at 5:00 were not a good time because of dinner.

Based on record review, staff interview, observation, and review of facility policy, the facility failed to ensure staff screened for COVID-19 signs and symptoms prior to working. This had the potential to affect all 51 residents in the facility. Findings include: Review of Staff Schedule on 03/07/22 and screening log revealed Agency STNA #106 did not screen at the start of her shift. Interview on 03/07/22 at 7:48 A.M. with Agency State tested Nurse Aide (STNA) #106 revealed she did not know she was supposed to screen prior to the start of the shift. Agency STNA #106 stated her shift started at 6:00 A.M. Observation on 03/07/22 at 7:57 A.M. revealed STNA #106 was taking her temperature and answering the screening questions in the lobby. Interview on 03/07/22 at 1:00 P.M. with the Director of Nursing (DON) revealed the screening log and schedule verified Agency STNA #106 did not screen until after she was almost two hours into her shift. Review of the facility policy titled Skilled Nursing COVID-19 Testing Practice revealed upon arrival to work employees will take the temperature of associates and ask about the presence of COVID-19 symptoms; perform [CONDITION(S)] testing of associates who have signs or symptoms of COVID-19. Associates who have fever or symptoms should be excluded from work pending results of the test. This deficiency substantiates Complaint Number OH 480.

Based on observation, interview, and record review the facility failed to ensure appropriate hand washing was implemented during dining service and failed to appropriately handle food. This affected two residents (Residents #2 and #5) observed in the first floor dining room and had the potential to affect one of two residents (Residents #8 and #28) observed in the second floor dining room. The facility census was 44. Findings include: 1. Record review of Resident #2 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition and required extensive assistance of one staff with eating. The (MONTH) 2019 physician orders revealed an active order with a start date of 02/21/19 for staff to assist/feed at all meals. Resident #2's care plan initiated on 05/09/19 for Activities of Daily Living (ADL) intervention included this order. Record review of Resident #5 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed Resident #5 was alert and oriented and had intact cognition. Resident #5 required extensive assistance of one staff with eating. The care plan initiated on 08/06/19 for Activities of Daily Living (ADL) intervention included an intervention for staff to assist with meals and encourage Resident #5 to self feed as much as possible. On 11/13/19 at 12:12 P.M., Resident #2 was seated at the table with Resident #5 and State tested Nurse Aide (STNA) #240 was seated between them. Resident #2 was observed to sneeze into his hand. STNA #240 grabbed a tissue from a box on the table and assisted Resident #2 by cleaning his hand and shirt with the tissue. STNA #240 stayed seated and held the dirty tissue in her hand. Then STNA #240 was observed to pick up Resident #5's cup and plate with her contaminated hand and move it closer to the resident. Interview on 11/13/19 at 12:14 P.M. with STNA #240 verified the above observations and stated she should have thrown away the tissue and washed her hands. Review of the facility policy titled, Hand washing/Hand Hygiene, revised 09/2017, revealed use of an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following situations, which included after contact with blood or bodily fluids and before and after assisting a resident with meals. 2. Observation on 11/13/19 at 12:10 P.M. in the second-floor dining hall revealed, Dietary Aide, (DA) #277 was preparing an egg salad sandwich on a high divide adaptive plate. While cutting the sandwich in sections, DA #277 held the sandwich with her non-gloved left hand, while cutting the sandwich with her gloved right hand. This had the potential to affect Resident #8 or #28, both of which would have been served an egg salad sandwich using a high side adaptive divided plate. Interview with (DA) #277 on 11/13/19 at 2:10 P.M. confirmed that she was not wearing a glove on her left hand when holding the sandwich to cut in sections. (DA) #277 stated she was knowledgeable of infection control procedures during the interview.

Based on record review, facility self-reported incident review, interview, and review of facility policy for Misappropriation the facility failed to prevent misappropriation of money for two residents (Resident #31 and Resident #55). This effected two residents (Resident #31 and Resident #55) of three residents reviewed for misappropriation. The facility census was 53. Findings include: Resident #31 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) 3.0 revealed Resident #31 had intact cognition. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/17/19, Resident #55 was discharged from the facility to home and was not available for interview during the survey. Review of the MDS 3.0 dated 12/28/18 revealed Resident #55 had intact cognition. Review of a Self-Reported Incident (SRI) dated 10/09/18 revealed, on 10/06/18 at 6:30 P.M., Resident #31 reported to facility staff she was missing $47.00 in cash. Review of the investigation revealed on 10/06/18 upon returning to her room Resident #31 discovered her purse and billfold open when she specifically recalled them being closed when she left her room. The facility notified the police and initiated an investigation into the missing money. Review of the Administrator's statement revealed during an interview with the Administrator and a police officer, STNA #505 admitted that he stole the money from Resident #31. STNA #505 was immediately suspended and charges were filed by the police related to the theft. The allegation was substantiated by the facility and the police investigation was ongoing. Review of an SRI dated 10/22/18 revealed, on 10/21/18, during the course of an ongoing investigation of theft allegations (refer to the SRI dated 10/09/18) STNA #505 admitted to stealing money from an additional resident (Resident #55) while working at the facility. This incident of theft was reported to local law enforcement and criminal charges were filed. The allegation of misappropriation was substantiated by the facility. STNA #505 who had remained on suspension since 10/09/18 was terminated. Interview on 02/13/19 at 11:30 A.M. with the Administrator verified, on or about 10/06/18, STNA #505 stole money from two residents (Resident #31 and Resident #55) while working at their facility. The Administrator stated, on 10/06/18 around 6:30 P.M., Resident #31 reported to staff that she had left her room and, when she returned, she found her purse and billfold open. Resident #31 stated she was then unable to locate $47.00 in cash that she had in her billfold. The Administrator initiated an investigation and reported the theft to local police. The Administrator and a police officer interviewed several residents and staff, including STNA #505. When interviewed, STNA #505 admitted he stole $47.00 from Resident #31's purse because he had financial issues at home but, denied stealing money from any other residents. STNA #505 was immediately suspended pending further investigation. The Administrator stated on 10/21/18, he received additional information, from an enforcement agent who reportedly interviewed STNA #505 at his home. STNA #505 admitted he also stole money from Resident #55 while working at the facility. The Administrator then interviewed Resident #55 and the resident reported he was missing about $48.00 in cash from his room that he had not previously identified. The Administrator stated they substantiated the allegation of misappropriation and immediately terminated the employment of STNA #505 who had until then remained on suspension. On 02/14/19 at 8:00 A.M., Resident #31 declined to be interviewed concerning the missing money. Review of the facility abuse, neglect and exploitation policy revised 10/2018 revealed the facility's policy was to protect residents and ensure they were free from abuse, neglect, mistreatment, misappropriation of resident property with steps including to screen and train their staff; prevent, identify, investigate and report all allegations.

Based on observation and staff interview the facility failed to ensure foods were stored in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect 50 of 50 residents who received meals from the kitchen. The facility identified one resident, Resident #252 who received nothing by mouth (NPO). Findings include: During the initial kitchen tour with Dining Services Manager (DSM) #100 on 10/09/18 between 8:32 A.M. and 8:47 A.M. the following observations were made in the walk in freezer: An undated and unlabeled pan of food identified to be broccoli. An undated and unlabeled package of food identified to be cod filets in a plastic bag. An undated and unlabeled package of food identified to be french fries in a plastic bag. In addition, the he walk-in freezer was observed to have significant ice build up. Ice build up had begun on produce packages sitting in a cardboard box in the walk-in freezer. DSM #100 verified the above observations at the time of discovery. Review of the storage of perishable food policy, dated 05/01/10 revealed all pre-dished items must be covered, labeled and dated to prevent off flavors, drying, or cross-contamination while refrigerated.

Based on record review and interview the facility failed to ensure accurate and complete medical records were maintained for Resident #2 and Resident #44 related to change in condition. This affected two residents (Resident #2 and #44) of 51 residents residing in the facility. Findings include: 1. A review of Resident #44's medical record revealed the resident was sent to the hospital while receiving a [MEDICAL TREATMENT] treatment at an outside facility. Resident #44 was sent to the emergency room and admitted on [DATE] and 07/20/18 with a change in condition. However, there was no documentation contained in the resident's medical record regarding the reason for hospitalization , duration and/or family/physician notification of admission. An interview with the Director of Nursing (DON) on 10/10/18 at 9:00 A.M. verified there was no documentation created by facility staff regarding Resident #44's admissions on 06/20/18 and 07/02/18. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively impaired and required extensive assistance for activities of daily living. Review of Resident #2's census and MDS records revealed Resident #2 was sent to and subsequently admitted to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of both the electronic and hard chart medical record documentation revealed no documentation as to the reason and/or circumstances that led to Resident #2's hospitalization . Interview with the DON on 10/09/18 at 11:15 A.M. verified the lack of documentation regarding the resident's hospitalization s. The DON further indicated Resident #2 was admitted to the hospital from a community doctors appointment.

Based upon observation, record review and interview the facility failed to ensure the shared glucose meter was properly and adequately disinfected after use. This had the potential to affect two residents (Resident #185 and Resident #46) residing on the second floor A wing . The facility identified six residents as who required blood glucose testing. Findings include: An observation on 8/07/17 at 5:55 P.M. revealed Licensed Practical Nurse(LPN) #225 wiped the Arkay Assure Platinum blood glucose monitoring device with an alcohol swap and placed it back in the medication cart on the 2A hallway after using it to check the blood sugar of Resident #185. LPN #225 verified this via interview immediately when asked the proper procedure for cleaning and disinfecting the blood glucose monitoring device after use after she had placed it back inside the medication cart. LPN #225 responded that she had cleaned the device with an alcohol swab stating Didn't you just see me wipe it with alcohol? LPN #225 further explained she was new to the facility and that was what she had done previously so that was what she had been doing since she had begun working at the facility. She stated she was not familiar with the facility's policy for cleaning the blood sugar monitoring devices. Review of the manufacturer's guidelines for the Arkay Assure stated to use a germicidal wipe or solution to disinfect the device after use. It noted the use of a germicidal wipe as the preferred method and warned the facility could receive a citation for failure to follow this procedure. Review of the facility policy Cleaning Blood Glucose Meters, last revised 10/2016 revealed all nurses were to be trained and regularly inserviced on the importance of cleaning and disinfecting in prevention of disease and infection transmission. Germicidal disposable wipes were the preferred method but a solution with 1:10 Sodium Hypochlorite/water ratio could be used as an alternative. The policy stated Alcohol should not be used and was not an acceptable EPA registered detergent disinfectant. An interview on 08/10/17 at 2:04 P.M. with the Director of Nursing revealed the facility did not have any classroom or clinical orientation checklist completed for LPN #225 that included disinfection of a blood glucose monitoring device.

Based on observation and staff interview, the facility failed to safely store food and maintain a clean hood above the stove. This potentially affected 54 residents in the facility who ate food prepared in the kitchen. Findings include: The initial tour of the facility's main kitchen and pantry were conducted with Dining Services Director (DSD) #21 on 05/31/16 from 8:45 A.M. through 9:31 A.M. DSD #21 verified the following observations: 1. The main kitchen: The walk in freezer had six large drums of ice cream directly on the floor. Four of the containers did not have lids and the ice cream was exposed and dry. The other two ice cream drums lids were set askew and not completely on the drums of ice cream. DSD #21 indicated the ice cream freezer was broken and they were being stored in the walk in freezer. He verified the ice cream was to be covered. The walk in cooler contained multiple containers that were mislabeled or not labeled or dated at all. There was a container labeled pineapple but had an orange colored melon inside. DSD #21 indicated it was cantaloupe. There was another container labeled chicken salad but had purple grapes inside. DSD #21 confirmed it was grapes. DSD #21 confirmed containers of cucumbers, mandarin oranges, mixed bean salad, four steam table pans of pureed and mechanically soft chicken; pans with carrots, mushrooms and other salad bar fixings did not have labels or dates. There were two large pans of red gelatin and a half large pan of red gelatin that were not covered, labeled or dated. The reach in cooler had pans of cooked bacon, hot dogs, and mechanical and pureed sausage that were not labeled or dated. There were two containers of cheese without labels or dates. DSD #21 verified the food was not labeled or dated. The hood vents above the stoves were thick with dust and lint. DSD #21 verified the condition of the vents. 2. The first floor pantry: The reach in cooler contained mandarin oranges without labels or dates. This was confirmed by DSD #21. DSD #21 confirmed the ice machine in the first floor pantry had brown residue on the inner plastic slide where the ice was guided into the bin.

Based on observation, record review, staff interview and policy and procedure review, the facility failed to ensure appropriate care and services were provided during catheter care to prevent possible infection. This affected one (Resident #231) of two residents reviewed for catheter care, of four residents in the facility with urinary catheters. Findings include: Review of the facility's Policy and Procedure titled Urinary Cath Care -CS-10-4, revised 01/20/16, stated the purpose of this procedure was to prevent infection of the resident's urinary tract. Policy Details included #16 - The following equipment and supplies will be necessary when performing catheter care (if cath care kit is unavailable): wash basin, soap, water, washcloth and towel, or container of disposable moist wipes, bed protector, bedside stand, or bed side table protector and personal protective equipment (gowns, gloves, mask, etc. as needed). The policy's steps for catheter care on a female resident included the following. Use a washcloth with warm water and soap, or a disposable moist cloth to cleanse the labia. Use one area of the washcloth or disposable moist cloth for each downward cleansing stroke. Change the position of the washcloth or disposable moist cloth with each downward stroke. Next change the position of the washcloth or disposable moist cloth and cleanse around the urethral meatus. Do not allow the washcloth or disposable moist cloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water or use a clean disposable moist cloth, using the above technique. Dispose of used cloths in designated container (not to be disposed of in toilet). Use a clean cloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Dispose of cloth in designated container. Wash and dry hands thoroughly. Review of the medical record revealed Resident #231 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #231 was moderately cognitively impaired, required extensive assist of one person for all activities of daily living (ADL's), and had a urinary Foley catheter in place. Review of a progress note dated 05/16/16 at 6:47 P.M. revealed Resident #231 continued on antibiotic therapy for urinary tract infection symptoms. Fluids continued to be encouraged, denied any complaints upon urination, had urology appointment, the physician had placed a size 16 french Foley catheter when the resident was in the office for new [DIAGNOSES REDACTED]. The physician ordered the Foley catheter to remain in place until his order to remove it. Review of the plan of care dated 05/25/16 related to Foley catheter care interventions included: Catheter care with soap and water every shift and as needed. Clean peri-area front to back. Monitor for signs and symptoms of discomfort due to catheter. Monitor/record/report to physician for signs and symptoms of a urinary tract infection. Staff to provide Foley care. Review of a physician order [REDACTED]. An interview with State tested Nurse Aide (STNA) #41 on 06/02/16 at 9:20 A.M. revealed she completed resident catheter care during the shower with a warm soapy wash cloth and a towel while the resident showered. STNA #41 stated she observed for drainage or leaking from the catheter and would report it to the nurse. STNA also verbalized signs and symptoms of urinary tract infections. An observation of Resident #231's catheter care on 06/02/16 at 2:15 P.M. by STNA #41 revealed the STNA assisted Resident #231 to the bathroom using the wheelchair. STNA #41 assisted the resident to stand, pulled the resident's pants and brief down and assisted her to sit on the toilet. STNA #41 removed her gloves, sanitized her hands and put on clean gloves. The STNA then helped the resident remove her clothes, assisted her into the wheelchair and wheeled her into the shower. STNA #41 assisted the resident into the shower chair. STNA # 41 turned on the hot water and walked away. After adjusting the hot water temperature, STNA #41 showered the resident. STNA #41 placed liquid soap on a wash cloth and cleaned the top section of the resident's body. After rinsing the top part of the resident's body, STNA #41 placed a towel on the floor of the shower and had the resident stand up holding onto the grab bars. STNA #41 took a clean wash cloth, put liquid soap on the washcloth and told the resident she needed to do her catheter care. As the resident stood in the shower, STNA #41 washed the left labia and used a second part of the wash cloth to clean the the right labia. STNA #41 then cleaned the catheter tubing from the labia in a downward fashion. The resident had not been dried off and stated she still needed cleaned down there in my crack. STNA #41 stated she cleaned from clean to dirty and dried the Foley catheter tubing. Pericare and proper cleansing of the meatus and Foley catheter tubing was not completed in a clean manner. The shower had not been completed prior to the catheter care. STNA #41 had stated it was difficult to complete the care in the shower. The STNA was unable to observe for leaking or redness. The lack of appropriate catheter care was verified with STNA #41 immediately following the observation.

Based on observation and staff interview, the facility failed to ensure all medications were stored in a secure manner. This affected one (Resident #57) of 13 residents that received medications on the A hall on the second floor of the facility. Findings include: An observation on 06/02/16 at 8:39 A.M. revealed an bottle of Lumigan eye drops (a medication used for glaucoma) for Resident #57 was on top of a medication cart unsecured. This was verified at 8:43 A.M. with Licensed Practical Nurse #22, who promptly secured the eye drop medication.

Based on observation, record review, policy review and staff interview, the facility failed to ensure proper infection control was implemented to prevent the development and transmission of infection during catheter care and cleaning. This affected one (Resident #231) of two residents reviewed for urinary catheter use, of four residents in the facility with urinary catheters. Findings include: Review of the facility's Policy and Procedure titled Urinary Cath Care -CS-10-4, revised 01/20/16, stated the purpose of this procedure was to prevent infection of the resident's urinary tract. Policy Details included #16 - The following equipment and supplies will be necessary when performing catheter care (if cath care kit is unavailable): wash basin, soap, water, washcloth and towel, or container of disposable moist wipes, bed protector, bedside stand, or bed side table protector and personal protective equipment (gowns, gloves, mask, etc. as needed). The policy's steps for catheter care on a female resident included the following. Use a washcloth with warm water and soap, or a disposable moist cloth to cleanse the labia. Use one area of the washcloth or disposable moist cloth for each downward cleansing stroke. Change the position of the washcloth or disposable moist cloth with each downward stroke. Next change the position of the washcloth or disposable moist cloth and cleanse around the urethral meatus. Do not allow the washcloth or disposable moist cloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water or use a clean disposable moist cloth, using the above technique. Dispose of used cloths in designated container (not to be disposed of in toilet). Use a clean cloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Dispose of cloth in designated container. Wash and dry hands thoroughly. Review of the medical record revealed Resident #231 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #231 was moderately cognitively impaired, required extensive assist of one person for all activities of daily living (ADL's), and had a urinary Foley catheter in place. Review of a progress note dated 05/16/16 at 6:47 P.M. revealed Resident #231 continued on antibiotic therapy for urinary tract infection symptoms. Fluids continued to be encouraged, denied any complaints upon urination, had urology appointment, the physician had placed a size 16 french Foley catheter when the resident was in the office for new [DIAGNOSES REDACTED]. The physician ordered the Foley catheter to remain in place until his order to remove it. Review of the plan of care dated 05/25/16 related to Foley catheter care interventions included: Catheter care with soap and water every shift and as needed. Clean peri-area front to back. Monitor for signs and symptoms of discomfort due to catheter. Monitor/record/report to physician for signs and symptoms of a urinary tract infection. Staff to provide Foley care. Review of a physician order [REDACTED]. An interview with State tested Nurse Aide (STNA) #41 on 06/02/16 at 9:20 A.M. revealed she completed resident catheter care during the shower with a warm soapy wash cloth and a towel while the resident showered. STNA #41 stated she observed for drainage or leaking from the catheter and would report it to the nurse. STNA also verbalized signs and symptoms of urinary tract infections. An observation of Resident #231's catheter care on 06/02/16 at 2:15 P.M. by STNA #41 revealed the STNA assisted Resident #231 to the bathroom using the wheelchair. STNA #41 assisted the resident to stand, pulled the resident's pants and brief down and assisted her to sit on the toilet. STNA #41 removed her gloves, sanitized her hands and put on clean gloves. The STNA then helped the resident remove her clothes, assisted her into the wheelchair and wheeled her into the shower. STNA #41 assisted the resident into the shower chair. STNA # 41 turned on the hot water and walked away. After adjusting the hot water temperature, STNA #41 showered the resident. STNA #41 placed liquid soap on a wash cloth and cleaned the top section of the resident's body. After rinsing the top part of the resident's body, STNA #41 placed a towel on the floor of the shower and had the resident stand up holding onto the grab bars. STNA #41 took a clean wash cloth, put liquid soap on the washcloth and told the resident she needed to do her catheter care. As the resident stood in the shower, STNA #41 washed the left labia and used a second part of the wash cloth to clean the the right labia. STNA #41 then cleaned the catheter tubing from the labia in a downward fashion. The resident had not been dried off and stated she still needed cleaned down there in my crack. STNA #41 stated she cleaned from clean to dirty and dried the Foley catheter tubing. Pericare and proper cleansing of the meatus and Foley catheter tubing was not completed in a clean manner. The shower had not been completed prior to the catheter care. STNA #41 had stated it was difficult to complete the care in the shower. The STNA was unable to observe for leaking or redness. The lack of appropriate catheter care was verified with STNA #41 immediately following the observation. An interview with the Director of Nursing (DON) on 06/02/16 at 3:10 P.M. verified there was no policy or procedure for catheter care while in the shower. The DON verified that proper catheter care should be completed after the resident completed their shower, ensuring proper peri care and cleansing of the meatus and catheter tubing.

Based on observation, interview and record review, the facility failed to ensure infection control practice during wound care for Resident #50. This affected one of two residents observed for wound care. The facility census was 46. Findings include: Resident #50 was admitted [DATE] with [DIAGNOSES REDACTED]. A stage III pressure ulcer is defined as full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. It may include undermining or tunneling. An observation of wound care was completed on 03/25/15 at 10:30 A.M. Resident #50 had been incontinent of a large amount of liquid stool. State tested Nurse Aide (STNA) #3 and STNA #4 provided incontinence care. The wound dressing remained in place but was soiled with liquid stool. Licensed Practical Nurse (LPN) #8 washed her hands and set up wound supplies on the overbed table. LPN #8 realized she would need another pair of gloves and asked STNA #4 to get her another pair of clean gloves. STNA #4 returned with clean gloves and placed the gloves on the resident's bed pad, adjacent to the soiled wound dressing. LPN #8 removed the gloves from the bed and added them to the clean supplies on the overbed table. LPN #8 washed her hands, applied the first pair of gloves, removed and discarded the soiled dressing. The exposed wound measured 3.0 centimeters (cm) length by 3.8 cm width by 2.5 cm in depth. The wound had approximately 30 percent slough. A bright, red rash covered the surrounding tissue including the buttocks, groin and peri-anal area, Without changing her gloves and washing her hands, LPN #8 used gauze to clean the wound and surrounding tissue. LPN #8 discarded the gauze. LPN #8 removed and discarded the gloves but did not wash her hands. LPN #8 applied the gloves she had picked up from the resident's bed. LPN #8 used a Q-tip to apply a [MEDICATION NAME] agent to the base of the wound. With the gloved hands, LPN #8 packed the wound with a 4 by 4 gauze square and covered the wound with a dressing. Wearing the same gloves, LPN #8 used a marker to date the dressing and placed the marker on the top of the treatment supply cart. LPN #8 removed her gloves, washed her hands and applied clean gloves. LPN #8 cleaned the marker and returned it to the medication cart. However, LPN #8 did not clean the top of the treatment cart. An interview was completed with LPN #8 at 10:49 A.M. LPN #8 verified the observation. LPN #8 said she should have washed her hands each time she changed her gloves and should have changed her gloves after removing the soiled dressing. Review of the facility policy and procedure for Wound Care revised 2010 revealed consecutive steps: "Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thouroughly". Review of the Center for Disease Control (CDC) Guidelines for Preventing Infection revealed the single most important action to prevent infection is handwashing. The same guidelines revealed gloves do not replace handwashing.