Every finding on record at Brunswick Pointe Transitional Care

Based on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions and proper glove use. This affected two residents (Resident #16 and Resident #69) and had the potential to affect all 78 residents who resided in the facility.Findings include:1.Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, clostridium difficile, chronic obstructive pulmonary disease, malnutrition, anxiety, depression. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/08/26 revealed the resident had impaired cognition. The resident was dependent with transfers. Review of the physician orders dated 04/08/26 revealed an order for contact isolation due to diagnosis of Clostridioides difficile (C-diff). Review of Resident of the care plan dated 04/08/26 revealed the resident was in contact isolation requiring staff and visitors to donn a gown and gloves prior to entering Observation on 04/27/26 at 9:38 A.M. or Resident #16's room revealed a sign on the door that read contact precautions everyone must: Clean their hands before room entry and discard gloves before room exit. Put on a gown before room entry and discard gloves before exit. Reusable equipment must be cleaned and disinfected. Licensed Practical Nurse (LPN) #288 was in Resident #16 room administering medications. LPN #288 was not wearing a gown and was wearing gloves. LPN #288 walked to the door and took off her gloves, exited the room and then sanitized her hands with hand sanitizer. Interview on 04/27/26 at 9:40 A.M. with LPN #288 stated she only needed to wear gloves and not gown to administer medications. LPN #288 stated gowns are only needed if providing direct care with Resident #16. LPN #288 stated she used hand sanitizer to clean her hands. Observation on 04/27/26 at 9:42 A.M. of Resident #16's room revealed Certified Nursing Assistant (CNA) #248 and #246 were preparing to enter the room with the mechanically transfer device. CNA #248 and #246 put on a gown and gloves and entered the room. The resident was transferred from the bed to the chair. CNA #248 removed her gown and gloves and left the room with mechanical left device. CNA #248 did not wash her hands or wipe down the mechanical left machine. CNA #246 removed her gown and gloves and sanitized her hand after exiting the room with hand sanitizer. Observation on 04/27/26 at 9:55 A.M. revealed CNA #248 and #246 coming out of a room on the 500 hall with the mechanical lift device. Interview on 04/27/26 at 9:55 A.M. with CNA #248 verified she did not wash her hands prior to exiting the room, however she sanitized her hands at the nurse's cart located down the hall. CNA #248 stated she did not wipe the machine down after uses in contact isolation room. There were no wipes available and CNA #248 had not been trained to wipe down the mechanical device. Interview on 04/27/26 with CNA # 246 verified she did not wash her hands however she sanitized them as she left the room. CNA #246 stated she was not trained to wipe down the mechanical lift after use in a isolation room. Review of the facility policy titled Standard and Transmission-based Precautions revealed contact precautions are measures that are intended to prevent transmission infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Review of the facility policy titled Hand Hygiene dated 11/28/17 stated after removing personal protective equipment staff will perform hand hygiene. Hand washing with soap and water is required when there is a Clostridium difficile or Norovirus outbreak or high rates of infection in the facility. Review of the Center of Disease Control and Prevention guidance titled Preventing C-diff' stated in a healthcare setting all healthcare professionals will clean their hands before and after care. While caring for patients with C-diff infection, healthcare professionals will use certain precautions like wearing a gown and gloves. This will prevent the spread of C-diff to themselves and other patients. 2. Resident #69 was admitted to the facility on [DATE] with re-entry on 06/30/25 with diagnoses that included dementia, heart failure, heart disease, chronic kidney disease, need for assistance with personal care, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 was cognitively intact, did not reject care, required maximal assistance for toileting hygiene, and she was frequently incontinent of bowel and bladder. Review of the care plan dated 02/22/26 revealed Resident #69 required assistance with activities of daily living with a goal to have her needs met, interventions included provide assistance based on needs, peri-care with each incontinent episode, and assistance needed with toileting care. An observation on 04/03/26 at 2:43 P.M. with CNA #251 and #324 of incontinence care for Resident #69 revealed after incontinence care was completed and without changing her contaminated gloves CNA #251 proceeded to immediately touch the bed control to adjust the bed for Resident #69, with the same gloves CNA #251 picked up the basin containing the water from the procedure and dumped it into the toilet, with the same gloves CNA #251 touched the paper towel dispenser and then wiped out the basin, and then CNA #251 removed her gloves and washed her hands. An interview on 04/03/26 at 3:01 P.M. with CNA #251 verified the above findings. Review of the facility policy titled Hand Hygiene, dated 11/28/17 revealed hand hygiene assisted in preventing the spread of infection, staff were to perform hand hygiene when indicated, staff were to perform hand hygiene before and after resident contact, after contact with bodily fluids or contaminated surfaces, and hand hygiene was to be completed after contact with objects and surfaces in the resident's environment.

Based on observation and interview, the facility failed to prepare and distribute food and ice under sanitary conditions. This had the potential to affect all residents who received meal trays and drinks from the kitchen. The facility census was 78.Finding Include:Observation on 04/27/26 from 8:20 A.M. to 8:45 A.M. revealed two small ice scoops and one large ice scoop laying on top of the ice machine. To the right of the ice machine was a container on the wall that was used for placing the large ice scoop when not in use. Additional observation of the kitchen revealed the can opener had a buildup of a black substance with dirt particles on and around the blade area. Observation on 04/29/26 from 11:55 A.M. to 12:45 P.M. revealed Employee #358 placing her thumb in a plate of food while preparing the plate for service. Furthermore, when the plates were being prepared for distribution to the residents Employee #340 placed their thumb in a plate of food. Interview on 04/27/26 at 8:44 A.M. with Employee #233 during the kitchen tour confirmed that three ice scoops were laying on the top of the ice machine and a dirty black substance on and around the blade area of the can opener. Interview on 04/29/26 at 11:15 A.M. with Corporate Chef #341 confirmed Employee #358 and #341 placed their thumb in a plate of food. Corporate Chef #341 immediately approached both employees and asked them to put on a glove to plate the dishes. Review of the dietary cleaning schedule for the month of April 2026 revealed no sections for routine cleaning of the can opener.This deficiency represents non-compliance investigated under Complaint Number 2733312.

Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.14% and included two medication errors of 28 medication administration opportunities. This affected one resident (Resident #5) of four residents observed for medication administration.Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including constipation, stress incontinence, type 2 diabetes, heart failure, Dementia, anxiety. Chronic respiratory failure, and schizophrenia.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/13/26 revealed the resident was cognition was intact. The resident was dependent on activities of daily living and received insulin.Review of the physician orders for April 2026 revealed an order including but not limited to Humalog Kwik Pen to inject per sliding scale 201-250 give 4 units; subcutaneously before meals and at bedtime, and orders for Lantus Solostar pen injector inject 80 units once a day. Observation on 04/29/2026 at 7:22 A.M. of medication administration with Registered Nurse (RN) #329 for Resident #5 revealed RN #329 obtained Resident #5's blood sugar level of 228 and prepared the insulin. RN #329 took off the cap to the Lantus insulin pen, attached the needle and dialed 80 units. RN #329 prepared the Humalog quick pen; pulled off the cap, attached needle and dialed 4 units of insulin. RN #329 walked into the room and stated I'm going to prime the pen and turned the Lantus pen vertically and pushed the injector button releasing insulin and dialed the pen back to 80 units and injected the insulin into Resident's left lower abdomen. RN #329 primed the Humalog insulin pen by holding the pen vertically and releasing some insulin. RN #329 redialed the pen to 4 units and injected the insulin into the resident's left lower abdomen.Interview 04/29/26 at 7:30 A.M. with RN #329 verified she dialed the dose and then primed the pens. RN #329 state she did not know to hold the insulin pen in an upright position while priming to prime the pen prior to dialing the dose.Review of the manufacturer's instructions for Humalog pen revealed to prime the pen before each injection. Priming the pen meant removing the air from the needle and cartridge that may collect during normal use and ensured the pen was working properly. If you do not prime before each injection, you may get too much or too little insulin.Review of the manufacturer's instruction for Lantus solar pen revealed to attach the needle to the pen. Prime the pen by holding the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle to get the most accurate dose. Select the dose and inject subcutaneously.Review of the facility policy titled Safe Injection Practices dated 11/28/2017 revealed the policy did not address procedures to administer insulin by pen.

Based on interview, record review, and policy review the facility failed to ensure oxygen was administered per physician order for Resident #93. This affected one Resident (#93) of three reviewed for respiratory care. The census was 78. Findings include:Resident #93 was admitted to the facility on [DATE] and was discharged on 03/14/26 with diagnoses that included heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (COPD, a type of lung disease), atrial fibrillation (an abnormal heart rhythm), and diabetes.Review of the care plan revealed the following: Resident #93 had respiratory deficiencies with a goal to have a reduced risk of respiratory complications dated 12/25/25 with interventions that included administer oxygen as ordered, and monitor for signs and symptoms of impaired respiratory function; Resident #93 required oxygen with a goal for oxygen levels to be kept at desired levels as set by the physician dated 12/24/25, with interventions that included oxygen as ordered, medications as ordered, and observed for signs and symptoms of difficulty breathing. Review of the physician orders revealed Resident #93 was ordered oxygen one to five liters per minute (lpm) by nasal cannula to maintain oxygen saturation of 90 percent (%) every shift for COPD, dated 12/26/25.Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 was moderately cognitive impaired, did not reject care, required supervision to moderate assistance with activities of daily living, used supplemental oxygen, and utilized hospice care. Review of Resident #93's medical record from 02/28/26 to 03/14/26 revealed the record was absent of documentation that the resident's physician or hospice providers changed the oxygenation order for Resident #93.Review of the Medication Administration Record (MAR) from 03/01/26 to 03/14/26 revealed the following: on 03/03/26 night shift oxygen was documented at six lpm; on 03/04/26 day shift and night shift oxygen was documented at six lpm; on 03/07/26 day shift oxygen was documented at six lpm; on 03/08/26 day shift oxygen was documented at six lpm; on 03/10/26 night shift oxygen was documented at six lpm, on 03/11/26 day shift and night shift oxygen was documented at six lpm; and on 03/12/26 day and night shift oxygen was documented at six lpm. An interview on 05/04/26 at 9:43 A.M. with Regional Nurse #343 verified the above findings. An interview on 05/04/26 at 10:59 A.M. Licensed Practical Nurse (LPN) #325 revealed oxygen settings were to be checked to ensure it was at the correct setting; if a resident was unable to maintain blood oxygen saturation levels of greater than 90% with current physician orders a provider was to be notified; nursing staff were not to increase oxygen outside of order parameters. A review of the facility policy titled Oxygen Administration, dated 07/30/24 revealed oxygen was administered with professional standards of practice, oxygen was administered by physician order, and the physician was to be notified as needed for changes with the use of oxygen. This deficiency represents non-compliance investigated under Complaint Number 2791156.

Based on observation, interview, and record review the facility failed to ensure proper infection control measures were implemented for care and treatment of Resident #6's urinary catheter and failed to ensure Resident #5 urinary tract infection was addressed timely. This affected two residents (Resident #5 and #6) of three reviewed for urinary catheters. The census was 78.Findings include:1.Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including constipation, stress incontinence, type 2 diabetes, heart failure, dementia, anxiety, chronic respiratory failure, and schizophrenia. Review of the progress note dated 04/10/26 at 10:20 A.M. revealed an order received to perform straight catheterization for urine collection due to incontinence. The procedure was performed using sterile technique and the urine specimen was sent to the lab. Review of the lab results final report revealed the specimen was collected at 4/10/26 at 12:00 A.M. and was received in the lab on 04/11/26 at 12:00 A.M. with the final results approved on 04/15/26 at 11:30 A.M. The urine analysis preliminary report resulted on 04/13/26 with mixed flora present. The final report identified the Kiebsiella pneumoniae as the organism. There was no evidence the resident's physician was notified of the final results on 04/15/26. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/13/26 revealed the resident was cognition was intact. The resident was dependent on activities of daily living. Review of the progress note dated 04/16/26 at 10:54 A.M. revealed the Nurse Practitioner (NP) was notified of the urinary analysis results and gave an order for Levoflaxin 750 milligram (mg), an antibiotic, for three days. Review view of the pharmacy log for the automatic medication delivery system revealed on 04/16/26 there was was only one Levoflaxin for 250 mg available to pull. Review of the Medication Administration Record (MAR) for April 2026 revealed Levoflaxin 750 mg was sign off as administered on 04/17/26 at rise. Interview on 04/30/26 at 10:08 A.M. with Licensed Practical Nurse (LPN) #296 stated she took the order from the NP for Levoflaxin and sent it into the pharmacy, but did not order the antibiotic to be STAT. Interview on 04/30/26 at 2:00 P.M. with the Director of Nursing (DON) verified the results were received on 04/15/26 at 11:30 A.M. and the physician was notified until 4/16/26 at 10:54 A.M. The DON stated the results were sent by fax. The facility receives so many faxes and it takes a while to get through all the faxes. The DON stated the facility has automatic medication delivery system at the facility. The system held one Levoflaxin in 250 mg and did not have enough pills to complete the 750 mg dose, confirming the first dose of antibiotic was given on 04/17/26. 2. Resident #6 was admitted to the facility on [DATE] with a re-entry date of 05/26/24 with diagnoses that included heart disease, kidney disease, chronic obstructive pulmonary disease (lung disease), prostate cancer, obstructive and reflux uropathy (blocked urine flow along the urinary tract), and urine retention. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired, did not reject care, was dependent for toileting hygiene, required moderate assistance for personal hygiene, and had an indwelling urinary catheter (a catheter that is left in place to continually drain the bladder). Review of the care plan dated 04/10/26 revealed the following: Resident #6 required extensive assistance with activities of daily living with a goal have his needs met, interventions included to provide catheter care as ordered; Resident #6 had alteration in elimination related to urinary retention and urinary catheter with a goal to be free from complications due to the urinary catheter, interventions included catheter as ordered and as needed, drainage bag in place as needed, and monitor for signs and symptoms of a urinary tract infection. Review of the physician orders revealed the following an order for a 16 French (catheter size) Coude (a special type of catheter used to get across blockages) catheter with a 30 milliliter (ml) balloon to continuous drainage dated 11/24/25. Review of the nursing progress notes from 04/05/26 to 04/28/26 revealed absence of documentation related to Resident #6 manipulating his urinary catheter drainage bag and if the drainage bag was secured to the bed. An observation on 04/27/26 at 11:53 A.M. revealed Resident #6 was raising his bed vertically and the catheter drainage bag was noted to be dangling in the air not secured to the bed, Resident #6 then lowered his bed back down. An interview on 04/27/26 at 11:57 A.M. with Registered Nurse (RN) #221 verified the catheter drainage bag was not secured to the bed. An observation on 04/28/26 at 3:11 P.M. revealed Resident #6's catheter drainage bag was lying on the floor. An interview at 3:11 P.M. with Licensed Practical Nurse (LPN) #288 verified the catheter drainage bag was lying on the floor. This deficiency represents non-compliance investigated under Complaint Number 2697149 and Complaint Number 1400716.

Based on record review and interview the facility failed to ensure residents were comprehensively assessed to determine the level of (staff) assistance required for mechanical lift transfers and failed to ensure resident care plans were in place to ensure an appropriate level of assistance was provided to prevent an accident/injury. This affected three residents (#20, #61, and #79) of three residents reviewed for accidents. The facility identified 34 additional residents (#2,#3, #4, #5, #6, #9, #10, #12, #13, #16, #21, #24, #28, #34, #37, #38, #42, #43, #48, #49, #50, #51, #59, #62, #63, #66, #69, #73, #76, #80, #82, #84, #95 and #96) who required a mechanical lift for transfers. The census was 78.Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 01/14/26 with diagnoses including nondisplaced comminuted fracture of left patella, osteoarthritis, chronic obstructive pulmonary disease and restless legs syndrome. Resident #20 was cognitively intact.Review of the April 2026 orders for Resident #20 revealed an order for mechanical lift for all transfers. The order did not specify if one or two people were required to assist with the mechanical lift transfer. Review of the April 2026 treatment administration record (TAR) revealed Resident #20 had an order for mechanical lift for all transfers. The administration record did not specify if one or two people were required to assist with the mechanical lift transfer. Review of the care plan, initiated on 01/14/26, for Resident #20 revealed she required a mechanical lift, but it did not specify if one or two people were required to assist with the mechanical lift transfer. Review of the Kardex, information provided to certified nursing assistants on a resident's activity of daily living (ADLs) needs, initiated on 01/15/26, revealed Resident #20 used a mechanical lift for mobility needs. It did not specify if one or two people were required to assist with the mechanical lift. Review of the transfer task for Resident #20 revealed the resident was totally dependent (on staff) for transfers except for a couple marked entries as extensive assistance or activity did not occur. The task documentation noted the resident needed two-person assistance, primarily as occurring three or more times per shift and using a mechanical lift.Interview on 04/27/26 at 10:34 A.M. with Resident #20 revealed the facility sometimes used one person to help with mechanical lift transfers, stating it's sometimes hard to find someone.2. Review of the medical record for Resident #61 revealed an admission date of 07/28/24 with diagnoses including fusion of spine, hemangioma of intra-abdominal structures, congestive heart failure, need for assistance with personal care and Parkinson's Disease.Review of the quarterly Minimum Data Set (MDS) 3.0 Resident #61 was cognitively intact. Review of the April 2026 TAR for Resident #61 revealed he required a mechanical lift until 04/27/26 at night. It did not specify if one or two people were required to assist with the mechanical lift. Review of the Kardex initiated on 08/21/24 revealed Resident #61 used a mechanical lift for mobility needs. It did not specify if one or two people were required to assist with the mechanical lift. Review of the transfer task for Resident #61 revealed he was totally dependent for transfers and was marked as needing two-person assistance, primarily occurring twice a day using a mechanical lift.Interview on 04/27/26 at 10:42 A.M. with Resident #61 revealed the facility only had one person to help with mechanical lift at times. He stated he did not want to identify the staff who were doing (by themselves) it as he did not want to get them in trouble. The resident shared he believed there was only one staff to do the transfer because the facility did not have enough staff. 3. Review of the medical record for Resident #79 revealed an admission date of 01/29/26 with diagnoses including fibromyalgia, atrial fibrillation, diabetes with neuropathy and generalized anxiety disorder.Review of the quarterly MDS 3.0 dated 02/24/26 revealed Resident #79 was cognitively intact and dependent on staff for transfers.Review of the April 2026 TAR for Resident #79 revealed she required a mechanical lift for transfers every shift. It did not specify if one or two people were required to assist with the mechanical lift. Review of the Kardex initiated on 12/31/25 for Resident #79 revealed she used a mechanical lift for all transfers. It did not specify if one or two people were required to assist with the mechanical lift. Review of the transfer task for Resident #79 revealed transfers did not occur most of the time but when they did, the resident was totally dependent (on staff). The task data noted there were two staff members when they used the mechanical lift.Interview on 04/27/26 at 10:46 A.M. with Resident #79 revealed the facility just had one person assisting her when using the mechanical lift. Review of the manufacturer's guide for the mechanical lift, dated 2022, read although (mechanical lift company) recommends that two assistants be used for all lifting, preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case.Observation on 04/27/26 at 9:42 A.M. of Resident #16's room revealed Certified Nursing Assistant (CNA) #248 and CNA #246 entered the room with the mechanical lift device. CNA #248 and #246 together placed the pad under Resident #16 and hooked the sling to the mechanical lift. CNA #248 operated the lift while CNA #246 guided Resident #16 from the bed to the chair to ensure proper alignment while lowering into the chair. CNA #248 and #246 unhooked the sling from the mechanical device and left the room. Interviews on 04/27/26 from 10:31 A.M. through 11:30 A.M. with Licensed Practical Nurse (LPN) #264 and CNA #275, revealed they were told they must have two staff members to use a mechanical lift. CNA #275 revealed we normally had two people but a lot of times there was only one while using the mechanical lift.Interview on 04/29/26 at 3:13 P.M. with Regional Nurse (RN) #343 revealed it was staff preference to use two staff for mechanical lifts, but they could use one person for the mechanical lift per manufacturer guidelines. However, review of the sampled resident's medical records revealed no evidence of an assessment or evaluation of the health care professional for each individual case (as per the manufacturer's guide).Interview on 05/04/26 at 9:46 A.M. with CNA #284 revealed the Kardex for resident care just identified if a resident used a mechanical lift, not how many people should assist.Interview on 05/04/26 at 9:52 A.M. with RN #334 revealed while using a mechanical lift she uses two people she was not sure how staff would determine if a resident required one staff or two staff to assist with a mechanical lift transfer. Interview on 05/04/26 at 10:00 A.M. with LPN #272 revealed resident care plans did not specify how many people were required to assist each resident during a mechanical lift transfer; the care plan just noted which machine to use.Interview on 05/04/26 at 10:05 A.M. with ADON #330 revealed the facility did not complete resident assessments for transfer safety related to the use of the mechanical lift and the number of staff assistance required. The ADON indicated therapy helped determine assistance levels for walking and transfers but not for mechanical lift transfers.Interview on 05/04/26 at 10:32 A.M. with ADON #310 revealed the facility policy was to use two people to assist with lift transfers. The ADON stated the facility would not indicate one person for lift assistance so no assessment would be done to determine how many staff was better for a resident.Interview on 05/04/26 at 11:12 A.M. with DON revealed staff should use two people for mechanical lift transfers. There would be no distinction between one or two people for assistance as best practice was for two people to assist a resident during a mechanical lift transfer. The DON revealed if she knew a staff member was completing a mechanical lift transfer without a second person assisting, she would give a disciplinary action.Interview on 05/04/26 at 1:50 P.M. with Administrator revealed the facility did not have a facility policy for mechanical lifts. They followed the manufacturer's guidelines.Review of the DME checklist titled Power Lift Competency Checklist, dated 2017, revealed a list of yes no questions including identifying weight capacity and sling size as well as demonstrating maneuvering the lift; however, it did not distinguish if the staff demonstrated both one and two person transfers as part of the competency and/or how this determination would be made if applicable.This deficiency represents non-compliance investigated under Complaint Number 2697149.

Based on record review and interview with facility failed to ensure Resident #3 and Resident #21's care plan was revised and implemented. This affected two residents (Resident #3 and Resident #21) of 24 residents reviewed for care plans. Findings include:1.Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, heart failure, depression, irritable bowel syndrome, neuromuscular dysfunction of bladder, acute kidney disease, and anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognition was intact. The resident was dependent on activities of daily living. The resident did not receive antibiotic however had an intravenous (IV) access.Review of the April 2026 Medication Administration Record (MAR) revealed order for to flush peripherally inserted central catheter (PICC) line with 10 milliliter (ml) of normal saline, after medication administration and to flush PICC line worth 10 ml of normal saline before medication administration every shift.Review of the Care Plan for Resident #21 revealed there was no care plan for IV therapy and maintenance. Interview on 04/30/26 at 8:55 A.M. with the Director of Nursing (DON) verified there was no IV or maintenance care plan for Resident #21. 2. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, amyotrophic lateral sclerosis (ALS), edema, chronic obstructive pulmonary disease, tracheostomy status, and pneumonia.Review of the compressive Minimum Data Set (MDS) assessment, dated 02/27/26 revealed the resident had was really understood and memory problems. The resident was dependent on activities of daily living and was incontinent of bowel and bladder.Review of the physician orders for April 2026 revealed orders dated 04/24/26: Catheter Care ever shift. Change indwelling catheter for signs of infection as needed, monitor foley catheter stabilization device daily.Observation on 04/27/26 at 10:54 A.M. revealed Resident #3 was laying in bed on a ventilator, tube feed running, and foley draining.Review of the Care Plan dated 02/20/26 revealed Resident #3 has an alteration in elimination due to being incontinent of bowel and indwelling catheter place due to wound and diuretic use. The care plan was not updated to reflect the catheter until 04/28/26.Interview on 04/30/26 at 8:55 A.M. with the DON revealed Resident #3's care plan for indwelling catheter was updated during chart audits on 04/28/26.

Based on interview and record review the facility failed to ensure Resident #3's representative was notified the resident was transferred to the hospital. This affected one resident (Resident #3) of one resident reviewed for notification.Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, amyotrophic lateral sclerosis (ALS), edema, chronic obstructive pulmonary disease,, tracheostomy status, and pneumonia.Review of the compressive Minimum Data Set (MDS) assessment, dated 02/127/26 revealed the resident had was really understood and memory problems. The resident was dependent on activities of daily living.Review of the profile page revealed Resident #3 was her self-representative. Emergency Contact #1 had a phone number and email address. Emergency Contact #2 had a phone number.Review of the progress notes dated 04/23/26 revealed Resident #3 was sent via 911 to the emergency room (ER). The note indicated the nurse attempted to call daughter and would continue to try to contact. The note did not indicate if a message could be or was left with the daughter.Interview on 04/27/26 at 3:39 P.M. with Resident #3's Emergency Contact #1 revealed she was upset due to Resident #3 being sent to the hospital and there was no notification provided. Emergency Contact #1 revealed she received a phone call from the hospital stating the resident was in the emergency room.Interview on 04/28/26 at 12:20 A.M. with Registered Nurse #225 revealed she sent Resident #3 to the ER. RN #225 stated she called the Emergency Contact #1 twice and was unsuccessful with notification and she did not leave a message after each call. RN #225 stated she did not think about leaving one. RN #225 stated Emergency Contact #2 did not have a number listed on the profile page.Interview on 04/28/26 at 3:08 P.M. with Social Service Designee (SSD) #249 revealed there was no power of attorney (POA) listed on file. The Emergency Contact #1 would be the person to notify.Review of the facility policy titled Change of Condition dated 10/18/2001 revealed the Charge Nurse will notify the resident, physician and guardian/interested family member of an emergence of unstable condition or disease.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure adequate weekend staffing. This finding had the potential to affect all 89 residents residing in the building. The facility census was 89. Findings include: Review of the Staffing Data Report information for the fourth quarter (07/01/24 to 09/30/24) revealed the facility triggered for excessively low weekend staffing. Interview on 04/04/25 at 9:33 A.M. with the Administrator confirmed the facility triggered for excessively low weekend staffing for the fourth quarter on the Staffing Data Report form. The Administrator indicated this staffing issue was fixed when the facility hired new staff for the building. Interview on 04/04/25 at 10:09 A.M. with Regional Human Resources (HR) Director #950 indicated the facility had reported the accurate hours for the Staffing Data Report form for the fourth quarter but the facility had hired additional staff to correct the issue and added 24-hour nursing staff. Interview on 04/04/25 at 10:55 A.M. with the Administrator revealed the facility had adequate staffing but the acuity increased due to the additional residents in the vent unit which triggered the low weekend staffing on the Staffing Data Report for the fourth quarter. The deficient practice was corrected on 01/15/25 when the facility implemented the following corrective actions: On 07/01/24, the Administrator added 24 additional hours of nursing staff (2 extra nurses, one on nightshift and one on dayshift for 12-hour shifts). The facility received the Staffing Data Report form in 01/2025. On 01/15/25, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #829 and HR Director #901 started to conduct meetings every Monday to review the master schedule and daily staffing schedules to make sure they were accurate, filling gaps in the schedule, sending out shifts for staff to pick up shifts and making plans to fill shifts. On 01/15/25, the Administrator, DON, and ADON #829 began to complete weekly audits on the staffing schedules to ensure adequate staffing. The Administrator and Regional HR Director #950 confirmed the facility hired 16 additional staff members from 10/18/24 to 03/26/25 including Registered Nurse (RN) #827 on 10/18/24, RN #920 on 01/31/25, RN #896 on 02/04/25, RN #924 on 02/12/25, RN #840 on 03/14/25; Licensed Practical Nurse (LPN) #871 on 12/12/24; Certified Nursing Assistant (CNA) #810 on 12/09/24, CNA #892 on 02/12/25, CNA #856 on 02/26/25, CNA #865 on 03/03/25; CNA #923 on 03/06/25, CNA #850 on 03/07/25, CNA #807 on 03/10/25, CNA #820 on 03/14/25, CNA #838 on 03/14/25, and CNA #908 on 03/26/25. Per the Administrator, LPN #801 was promoted to nightshift supervisor on 01/31/25 and she would work the floor depending on the day. On other days, LPN #801 would be a free-floating supervisor to work the floor as a support and to audit and assist the CNA's with their work and the nurses with their work including admissions. This deficiency represents non-compliance investigated under Complaint Number OH00162469.

Based on record review, interview, and policy review the facility failed to ensure a safe and orderly discharge for Resident #3. The affected one resident (#3) of three residents reviewed for discharge planning. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included type two diabetes, other chronic osteomyelitis, right ankle, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/17/24, revealed Resident #3 had intact cognition. Review of the discharge care plan dated 10/04/24 revealed Resident #3's plan was to discharge home. Review of the physician order dated 08/22/24 revealed an order for tirzepatide (Mounjaro) 7.5 milligrams (mg) weekly for diabetes. Review of the discharge summary dated 10/04/24 revealed Resident #3 was discharged with instructions provided and services set up. All medications were sent with the resident except Mounjaro 7.5 mg. Review of the Discharge Medication Receipt dated 10/04/24 revealed staff provided all medications except Mounjaro 7.5 mg. Interview on 11/02/24 at 9:30 A.M. with Resident #3 revealed the facility failed to supply the Mounjaro 7.5 mg injections when he discharged . Resident #3 stated he received an injection on 10/03/24 and then on 10/11/24 which was a day later than scheduled due to not having the medication. The pharmacy filled a prescription for Mounjaro 7.5 mg on 09/24/24 which included four injections. The pharmacy where he went for his medications upon discharge would not refill the medication after his discharge because the refill date was 10/24/24. After several calls to the pharmacy and insurance company, the pharmacy was able to provide the Mounjaro on 10/11/24. Interview on 11/02/24 at 10:15 A.M. with the Administrator and Director of Nursing revealed the nurse who discharged Resident #3 did not look in the refrigerator for any unused Mounjaro belonging to Resident #3 because he received an injection the day before he was discharged . The Administrator said the facility destroyed all medications left behind due to the facility policy. Documentation was provided and reviewed which confirmed Resident #3's Mounjaro was destroyed after his discharge from the facility. The Administrator stated that once the facility was aware of the problem, Resident #3's pharmacy was contacted regarding refilling the prescription. Interview on 11/02/24 at 10:25 A.M. with Licensed Practical Nurse (LPN) #205, the nurse who discharged Resident #3, confirmed she did look in the refrigerator for Resident #3's remaining Mounjaro injections and therefore the unused Mounjaro was not provided to Resident #3 upon Resident #3's discharge. LPN #205 did not look for the remaining doses of Mounjaro because Resident #3 received a Mounjaro injection the day before. LPN #205 stated the injections were scheduled once weekly so she figured the prescription would be filled by the resident after discharge. Interview on 11/02/24 at 11:33 A.M. with the owner of Resident #3's pharmacy revealed he did not refill the Mounjaro prior to 10/11/24 because the refill was dated 10/24/24. However, after contacting Resident #3's insurance company and the nursing home's pharmacy the pharmacist was able to override the prescription and refill the medication. Review of the facility policy titled, Discharge Process for Planned Discharges, dated 2018 revealed all medications except for controlled medications were to be provided to the resident at discharge. This deficiency represents non-compliance investigated under Complaint Number OH00158955.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident interview, staff interview, review of hospital records, review of the facility investigation and review of facility policy, the facility failed to ensure residents were safely secured during transportation in the facility van. This resulted in Actual Harm on 07/15/24 when Resident #56's wheelchair was not safely secured in the facility van and tipped during transportation. Resident #56's weight rested on the left seatbelt shoulder strap, resulting in a fracture to her left upper arm. This affected one resident (#56) of three residents reviewed for transportation safety. The facility census was 89. Findings include: Review of Resident #56's medical record revealed an admitted [DATE]. Diagnoses included diabetes, end stage renal disease and unspecified dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was moderately cognitively impaired. Review of Resident #56's progress notes revealed on 07/15/24, upon return from dialysis, the resident reported increased left shoulder pain and X-rays were ordered. Review of a progress note dated 07/16/24 revealed the X-ray identified a fracture to the left upper arm with diffuse osteopenia. The physician ordered an orthopedic consult and sling to the arm. Resident #56 stated the fracture occurred during transport back to the facility from dialysis. On 07/18/24, Resident #56 complained of increased pain, had increased confusion, and attempted to self-transfer. Resident #56 was sent to the hospital for further evaluation. Review of hospital documents revealed Resident #56 was admitted on [DATE] for a left humerus fracture. An orthopedic consult on 07/18/24 revealed there was no bruising, swelling, or other injury around the fracture site and recommended the arm to be non-weight bearing with a sling on at all times. Further review revealed a head computed tomography (CT scan) was completed with no abnormalities noted. Resident #56 was treated for a urinary tract infection (UTI) and discharged back to the facility on [DATE]. Interview on 08/01/24 at 9:10 A.M. with the Administrator confirmed on 07/15/24 there was an incident on the facility van in which Resident #56 tipped in her wheelchair during transportation. The Administrator stated one of the wheelchair straps was loose and Resident #56's wheelchair leaned to the side when the driver turned into the facility parking lot. The Administrator stated the seatbelt shoulder strap prevented Resident #56 from completely tipping over. The Administrator denied Resident #56 hit the side of the van or the floor, but verified the resident suffered a left humerus low impact fracture as a result of the incident. Interview on 08/01/24 at 9:15 A.M. with Resident #56 revealed she was riding the facility van, returning from dialysis, and was not properly secured. Resident #56 stated this caused her to fall sideways and hit her left arm on the wall, causing a fracture. Resident #56 stated there was no shoulder strap over her arm and she was unsure if there were any security straps on her wheelchair. Following the event, Resident #56 stated she had pain in her arm and was sent to the hospital, where she learned she had a fracture. Concurrent observation confirmed Resident #56's left arm was in a sling. Interview on 08/05/24 at 11:12 A.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #501 revealed the facility investigated the incident involving Resident #56 and were not able to determine if the resident impacted anything when her wheelchair tilted in the van. The facility investigation identified one of the wheelchair anchor straps was loose, allowing the right wheel of the wheelchair to raise off the ground during a sharp turn. The facility believed the fracture resulted from the pressure of leaning against the seatbelt shoulder strap when the wheelchair tilted. Interview on 08/01/24 at 12:44 P.M. with Transport Aide (TA) #201 revealed, while turning into the facility parking lot on 07/15/24, Resident #56 cried out that she was tilting. TA #201 stopped the van and found Resident #56's wheelchair was tilting and the right wheel was approximately one inch off the ground. TA #201 stated Resident #56 had a seatbelt on and the shoulder strap was over the resident's left arm/shoulder. TA #201 stated she repositioned Resident #56 and denied the resident hit the wall or the floor of the van during the incident. TA #201 did not know how the wheelchair was able to tilt and speculated she did not strap the wheelchair anchors tightly enough. Interview on 08/05/24 at 8:56 A.M. with Nurse Practitioner (NP) #801 revealed on 07/15/24, the facility reported Resident #56 bumped her arm and an X-ray was ordered. NP #801 assessed Resident #56 the following day and identified no sign of injury on her head or arm. NP #801 stated the fracture did not require hospitalization and an orthopedic consult was ordered. One or two days later, Resident #56 presented as confused and she was sent to the hospital for further evaluation to rule out a head injury. Resident #56 returned to the facility the following day. A head CT was completed at the hospital and there was no evidence of a head injury. NP #801 stated Resident #56 was diagnosed with a UTI, which was likely the cause of the confusion. Review of the facility investigation, initiated on 07/15/24, revealed an X-ray dated 07/15/24 identified Resident #56 had a minimally impacted fracture of the left upper arm with diffuse osteopenia. The investigation documentation noted Resident #56's wheelchair tilted when the van was turning into the facility. The seatbelt held her in place and the resident did not make contact with the side of the van. Resident #56 complained of increased shoulder discomfort and NP #801 was notified. A range-of-motion assessment revealed the resident was guarded with her left shoulder. Resident #56's son said she told him she hit her head, and the facility performed neurological checks with no negative findings. Notes completed by NP #801 revealed a X-ray identified the resident had an arm fracture, which was assessed by the physician to be nonemergent. The medical team ordered her arm to be non-weight bearing in a sling and an orthopedic consult. No wounds or bruises were noted on assessment. On 07/18/24, NP #801 noted there were conflicting stories about the course of events and it was possible the resident hit their head. NP #801 sent the resident to the emergency room for evaluation, and a follow-up note revealed Resident #56 was returned to the facility the next day with no evidence of head injury. Review of the facility policy titled Bus/Van Transportation Policy, revised June 2019, revealed residents transported in wheelchairs must have lap belts applied and be secured using at least four lockdown straps allowing no more than a quarter inch of chair wheel movement. As a result of the incident, the facility took the following actions to correct the deficient practice by 07/19/24: On 07/15/24, Resident #62 was assessed for injuries, an X-ray was ordered, and neurological checks initiated. On 07/15/24, the Administrator or designee re-educated TA #201 on the facility bus and van transportation policy. On 07/15/24, the Administrator audited all residents who received transportation in the facility van in the two weeks prior to the event on 07/15/24. No similar concerns were identified. On 07/16/24, Maintenance Director (MD) #401 provided a competency test to TA #201, which included demonstration of proper securement of wheelchairs in the van. On 07/16/24, MD #401 examined the facility van and identified no mechanical problems with the wheelchair securement devices. Beginning on 07/17/24, and completed on 07/19/24, RRN #501 and Regional Maintenance Director (RMD) #402 re-educated and competency tested all staff who drive the facility van on proper safety measures. On 07/17/24, RMD #402 examined the van and verified there were no mechanical problems with the wheelchair securement devices. Beginning on 07/17/24, the DON audited one transportation service, one time daily for five days. This continued for two weeks with no negative outcomes or additional concerns identified. On 07/18/24, Resident #62 presented with confusion and was sent to the hospital for further evaluation for a head injury. CT scans showed no evidence of a head injury. Resident #62 was seen by orthopedics, with no additional treatment recommendations made related to the left upper humerus fracture. Resident #62 was diagnosed with a UTI and returned to the facility on [DATE]. On 07/19/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting was held to review the event, review corrective action, and review facility policies related to transportation. The committee meeting was attended by the Administrator, Medical Director and the DON. The Administrator will be responsible for on-going compliance and any areas of concern will be presented, and addressed, by the QAPI committee. This deficiency represents noncompliance investigated under Complaint Number OH00156271.

Based on record review, interview, and policy review the facility failed to provide treatment in a timely manner for Resident #20. Actual Harm occurred when resident complained of pain to buttock on 08/14/22 and an open area was noted on 08/16/22. Treatment to Resident #20's buttocks was not started until 08/19/22 when the area was identified as a deep tissue injury (DTI). The DTI developed into a Stage III pressure ulcer to Resident #20's left buttock on 08/23/22. Resident #20 also developed moisture associated skin damage (MASD) to right buttock on 08/23/22. This affected one (Resident #20) of three residents reviewed for pressure. Facility census was 85. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] revealed Resident #20 was admitted with no pressure ulcers. Resident #20 had surgical incisions to mid sternum, abdomen, and right knee. Review of the Braden scale for predicting pressure ulcers/injuries dated 08/11/22 revealed Resident #20 was at risk due to slightly limited sensory perception, being occasionally moist, being chairfast, slightly limited mobility, and the potential for friction and shearing. Review of physical therapy note dated 08/14/22 revealed Resident #20 reported buttock pain and discomfort. The nurse was notified of the resident's complaints. Review of the medical record revealed no assessment or treatment. Review of shower/bath sheet dated 08/16/22 revealed Resident #20 had an open area to left inner buttock. Review of treatment administration record (TAR) revealed a skin assessment for Resident #20 was completed on 08/18/22. There was no documentation of what the skin assessment revealed. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/18/22, revealed Resident #20 had intact cognition. The resident required extensive assistance of two for bed mobility and transfers. Resident #20 required extensive assistance of one for toilet use. Resident #20 was occasionally incontinent of urine and always continent of bowel. Resident #20 had no pressure, venous, arterial ulcers, or MASD. Resident #20 did have surgical wounds. Review of Resident #20's shower/bath sheet dated 08/19/22 revealed buttocks were circled and marked there were open areas. Review of the skin grid pressure document dated 08/19/22 revealed Resident #20 had a DTI to left buttock that measured 6.5 centimeters (cm) long and 1.5 cm wide. There was serosanguineous (thin and watery fluid with a light red or pink hue) drainage. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for Resident #20 revealed the left buttock was to be cleansed with normal saline, patted dry, [MEDICATION(S)] applied, followed by calcium alginate, and covered with a foam dressing every shift and as needed. Review of the skin pressure note dated 08/19/22 at 2:30 A.M. revealed Resident #20 was dependent for bed mobility and did not assist in bed mobility in any manner. Resident #20 received assistance of two for bed mobility. Review of the plan of care dated 08/22/22 revealed Resident #20 was at risk for alteration in skin integrity related to incontinence, mobility impairment, [CONDITION(S)], surgical incisions, MASD to right buttock. Interventions included to encourage and assist the resident to turn and reposition as needed. Review of the skin grid non-pressure documentation dated 08/23/22 revealed Resident #20 had a new area of MASD to right buttock. The area measured 6.8 cm long, one cm wide, and 0.1 cm deep. There was a small amount of serosanguinous drainage noted. Review of skin grid-pressure documentation dated 08/23/22 revealed the DTI to Resident #20's left buttock was now classified as a Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia) pressure ulcer that measured 7 cm long, 2.7 cm wide, and 0.2 cm deep. The wound bed had slough (necrotic tissue) and a small amount of serosanguinous drainage. The wound nurse practitioner would follow the wounds. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was also received to evaluate and assess pressure area to left buttock every shift. The status of the dressing, the area surrounding the pressure ulcer, and pain was to be assessed every shift. Review of the plan of care dated 08/25/22 revealed Resident #20 had alteration in skin integrity as evidenced by pressure ulcer present at left buttock. Interventions included assess area for size, color, drainage weekly and as needed. Encourage and assist resident to turn and reposition as needed, keep linen dry and as wrinkle free as possible, and provide treatment as ordered. Review of the Treatment Administration Record (TAR) revealed a skin assessment for Resident #20 was completed on 08/26/22. There was no documentation of what the skin assessment revealed. Review of the shower/bath sheet dated 08/26/22 revealed the buttocks was circled and was marked Resident #20 had open areas. Review of the shower/bath sheet dated 08/29/22 revealed the buttocks was circled and was marked Resident #20 had open areas. Interview on 10/12/22 at 3:03 P.M. with Assistant Director of Nursing (ADON)/Registered Nurse (RN) #104 verified Resident #20 had a DTI to buttock on 08/19/22. The facility wound nurse was notified on 10/23/22 when the area to Resident #20's left buttock was changed to a Stage III pressure ulcer. ADON/RN #104 thought barrier cream had been ordered at admission as a treatment to Resident #20's buttocks but was not sure if the cream had been applied. Interview on 10/12/22 at 4:41 P.M. with the Director of Nursing (DON) verified there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also stated the nurses marked the TAR that skin assessments were completed but only documented what was seen if there was any impairment noted. The DON verified there was no documentation of skin impairment when skin assessments were completed on 08/18/22 and 08/26/22. The DON verified a therapy note dated 08/14/22 revealed Resident #20 complained of pain to buttocks and the shower sheet dated 08/16/22 revealed Resident #20 had an open area to left buttock. The DON verified no treatments to Resident #20 buttocks was completed until 08/19/22 and verified after the DTI was identified to the left buttock on 08/19/22 the resident developed MASD to right buttock and the area to the left buttock was changed to a Stage III pressure ulcer. Review of Skin Assessment policy and procedure, dated September 2017, revealed it was the policy of the facility to prevent the development of pressure ulcer(s) in a resident who was admitted without a pressure ulcer, unless the development was clinically unavoidable and to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Procedures included the resident to be evaluated for special needs related to skin care. Resident response to preventative efforts was monitored and evaluated. Approaches were revised as appropriate. Areas of alteration in skin that were present, or which developed subsequently to admission, were treated according to medical direction, and were conscientiously followed. Factors placing the resident at risk of developing a new pressure ulcer or placing him/her at risk of experiencing a non-healing or delayed healing pressure ulcer (including specific conditions, causes and/or problems, needs and behaviors) were assessed. This deficiency substantiates Complaint Number OH 208.

Based on record review and interview, the facility failed to provide adequate treatment when [CONDITION(S)] (swelling) was noted which lead to skin impairment for Resident #20. This affected one (Resident #20) out of three residents reviewed for skin impairment. Facility census was 85. Finding include: Review of the medical record for Resident #20, revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/22, revealed Resident #20 had intact cognition. The resident required extensive assistance of two for bed mobility and transfers. The resident had no pressure, venous, arterial ulcers, or moisture associated skin damage (MASD). The resident did have surgical wounds. Review of the admission nursing assessment dated [DATE] revealed Resident #20 was admitted with a surgical incision to mid sternum that measured 20 centimeters (cm) long, 0.2 cm wide, and 0.1 cm deep. The resident also had a surgical incision to abdomen that measured 2 cm long, 0.2 cm wide, and 0.1 cm deep, and a surgical incision to right knee that measured 2 cm long, 0.1 cm wide, and 0.1 cm deep. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A head-to-toe skin checks was to be completed every week on day shift. Resident #20 was also ordered [MEDICATION(S)] (diuretic) 20 milligrams (mg) as needed for [CONDITION(S)]. Review of the shower/bath sheet dated 08/16/22 revealed Resident #20 had blisters to bilateral shins. Review of skin grid non-pressure document dated 08/16/22 revealed Resident #20 had a fluid filled blister to the right shin that measured 3.2 cm long and 4.5 cm wide. A fluid filled blister to left shin measured 5.4 cm long and 5.5 cm wide. The skin grid revealed no documentation of [CONDITION(S)]. Orders were received on 08/16/22 at 4:23 P.M. for left and right shin to be wrapped with Army Battle Dressing (ABD) and covered with woven gauze every day and as needed. Review of physical therapy note dated 08/17/22 revealed Resident #20 had slight pitting [CONDITION(S)] in bilateral lower extremities that was worse on the right. Review of treatment administration record (TAR) revealed skin assessment for Resident #20 was completed on 08/18/22. There was no documentation of what the skin assessment revealed. Review of Resident #20's shower/bath sheet dated 08/19/22 revealed bilateral shins were circled to indicate skin impairment. Review of skin grid non-pressure document dated 08/23/22 revealed Resident #20 had a blister to right shin that measured 6.2 cm long, 5.5 cm wide, and 0.1 cm deep. There was a large amount of sanguineous (fresh blood produced by an open wound) drainage. The blister to Resident #20's left shin measured 6.8 cm long, 5.5 cm wide, and 0.1 cm deep. There was a large amount of sanguineous drainage. The skin grid revealed no documentation of [CONDITION(S)]. New orders were received for Resident #20's right and left shins to be cleansed with normal saline, patted dry, Mesalt (stimulates the cleansing of heavily discharging wounds in the [CONDITION(S)] phase by absorbing exudate, bacteria and necrotic material) applied to wound bed followed by silver alginate (a broad-spectrum antimicrobial), then covered with ABD, wrapped with woven gauze, and all cotton elastic (ACE) light compression wraps applied every day and as needed. Review of TAR revealed a skin assessment for Resident #20 was completed on 08/26/22. There was no documentation of what the skin assessment revealed. Review of the shower/bath sheet dated 08/26/22 revealed bilateral shins were circled to indicate skin impairment. Review of shower/bath sheet dated 08/29/22 revealed bilateral shins and buttocks circled to indicate skin impairment. Interview on 10/12/22 at 1:55 P.M. with Assistant Director of Nursing (ADON)/Registered Nurse (RN) #104 revealed Resident #20 had [CONDITION(S)] which probably caused the blisters. ADON/RN #104 thought compression hose were ordered but was unsure when. ADON/RN #104 verified there was no documentation by the nurses of [CONDITION(S)] or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/12/22 at 4:41 P.M. with the Director of Nursing (DON) verified there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified the blisters to Resident #20's shins was probably due to [CONDITION(S)]. The DON verified the blisters were discovered on 08/16/22 and there was no documentation by the nurses of [CONDITION(S)]. The DON also verified Resident #20 had an admission order for as needed [MEDICATION(S)] 20 mg for [CONDITION(S)] that was not administered until 08/24/22. The DON also stated the nurses marked the TAR that skin assessments were completed but only documented when there was any skin impairment noted. The DON verified there was no documentation of skin impairment when skin assessments were completed on 08/18/22 and 08/26/22. This deficiency substantiates Complaint Number OH 208.

Based on medical record review, staff interview, observation and policy review, the facility failed to notify guardian/interested family member of urinary tract infection and antibiotic use. This affected one (Resident #20) of three residents reviewed for notification of change. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE]/, revealed Resident #20 had intact cognition. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 0822/22 revealed Resident #20 was occasionally incontinent of bladder. Interventions included monitor for signs and symptoms of urinary tract infection ([CONDITION(S)]). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' notes from 08/18/22 to 08/28/22 revealed no documentation related to family notification regarding new antibiotic order or [CONDITION(S)] diagnosis. Interview on 10/12/22 at 3:58 P.M. with Licensed Practical Nurse (LPN) #58 verified no documentation family was notified of [CONDITION(S)]. Review of facility policy titled Nursing Policy/Procedure Manual, dated April 2013, revealed the unit supervisor or charge nurse was to notify the resident, guardian/interested family member of all changes. This deficiency substantiates Complaint Number OH 208.

Based on observation, record review, and interview, the facility failed to obtain physician's orders and comprehensively assess a newly identified pressure ulcer for Resident #23. This affected one of four residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 11/13/21 revealed Resident #23 was at risk for developing alteration in skin integrity related to impaired mobility, incontinence, use of oxygen, pain management needs, risk of medication side effects, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions dated 11/13/21 included for staff to complete skin assessments per facility policy, dietary consult, encourage and assist to elevate heels, encourage and assist to turn and reposition, inspect skin during routine care, keep linens dry and wrinkle free, pressure reducing mattress, and notify physician and representative of any changes. Review of the admission Braden Scale, an assessment for risk for pressure ulcer development, dated 11/13/21 revealed Resident #23 was high risk for pressure ulcer development. Review of the admission skin assessment dated [DATE] revealed Resident #23 was admitted with a skin tear to the right groin, abrasion to the peri-rectal area, and a skin tear to the left groin, and a surgical incision to the left knee. Review of the five-day Medicare Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #23 was alert, oriented and had intact cognition, required extensive assistance of two staff members for bed mobility, extensive assist of one staff member for toilet use and personal hygiene, was incontinent of bladder and bowel, did not have any pressure ulcers and was at risk for pressure ulcer development. Resident #23 had physician orders dated 11/13/21 for staff to apply house barrier cream to buttocks/coccyx after each incontinent episode, encourage and assist to turn and reposition, and for a pressure reduction cushion in the chair. There was a physician order dated 11/20/21 for Resident #23 to have a head-to-toe skin check every Saturday. Review of the December 2021 treatment administration record revealed Resident #23 had a head-to-toe assessment completed on 12/04/21 and 12/11/21 and no skin issues were recorded. Review of the Skilled Progress note dated 12/11/21 at 7:01 P.M. revealed Resident #23 had a skin assessment completed with no changes. Review of the December 2021 physician's orders revealed no treatment orders for any pressure ulcers. Observation of provision of incontinence care for Resident #23 on 12/13/21 at 6:35 A.M. with Registered Nurse (RN) #413 revealed Resident #23 had a border foam dressing on her coccyx. The dressing was dated 12/11/21 and RN #413 removed this dressing as it was soiled with feces. RN #413 verified the date on the dressing was 12/11/21 and it was the date the dressing was applied. Interview on 12/13/21 at 7:51 A.M. with RN #413 verified there were no physician orders for any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #23's coccyx dressing change and treatment on 12/13/21 at 2:48 P.M. with RN #507 revealed the pressure ulcer was quarter size, with a red center, white edges and pink/brown tissue surrounding the peri-wound. There was no odor or drainage noted. Interview on 12/13/21 at 12:50 P.M. with RN #507 revealed the pressure ulcer to Resident #23's coccyx was a new pressure ulcer. Review of the skin grid dated 12/13/21 at 2:25 P.M. revealed Resident #23 had a stage two pressure ulcer (a partial thickness skin loss into the dermis presenting as a shallow opening with a red/pink wound bed and may also present as a an intact or open/ruptured blister), to the coccyx which measured 2.7 centimeters (cm) long by 1.3 cm wide by 0.1 cm deep. Review of the Employee Education/Training Document dated 12/13/21 revealed RN #413 was educated on failure to adhere to policy and procedures of notifying and documenting new skin issues. Review of the facility policy titled, Skin Assessment, dated 09/17, revealed it was the facility policy to prevent the development of pressure ulcer in a resident who was admitted without pressure ulcers, unless the development was clinically unavoidable and to provide necessary treatment and service to promote healing, prevent infection and prevent new ulcers from developing. This deficiency substantiates Complaint Numbers OH 531, OH 708, and OH 613.

Based on observations, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff cleaned personal protective equipment (PPE) to prevent the spread of COVID-19 during medication administration. This affected one (Resident #37), and had the potential to affect 17 of 77 facility residents who would have received medications during this observation. Findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an order dated 03/15/21 for contact and droplet precaution for 14 days for new admission to the facility. The baseline assessment revealed the resident had intact cognition. Observation of medication pass on 03/17/21 at 8:03 A.M. with Registered Nurse (RN) #100 revealed the nurse prepared Resident #38's medications for administration. RN #100 was wearing a face shield that covered his eyes and part of his nose along with an N95 mask. He donned a gown and gloves, and walked into Resident #38 room and administered the medications. Prior to exiting the room RN #100 removed his gloves and gown and washed his hands. RN #100 exited the room and did not clean his face shield or change his mask. RN #100 prepared medication for Resident #37, who was on contact and isolation precautions, put on a gown and gloves ad entered Residents #37 and administered the medications. Interview on 03/17/21 at 8:55 A.M. with RN #100 revealed he was unaware that he did not clean his face shield or change his mask after exiting Resident's #38 room. Interview on 03/17/21 at 9:30 A.M. with the Director of Nursing verified these observations. Review of the policy titled Donning and Doffing PPE for COVID-19, dated 02/21/21 revealed the facility will implement the CDC guidelines for use of PPE when caring for residents with confirmed or suspected COVID-19. Review of the CDC's guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 dated 12/14/20 revealed to remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instruction prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. This deficiency resulted from incidental findings discovered during this complaint investigation.

Based on record review and interview, the facility failed to ensure respiratory services were implemented timely. This finding affected one (Resident #71) of three records reviewed for respiratory services. Findings include: Review of Resident #71's hospital critical care addendum dated 01/21/21 indicated the resident was discharged from the hospital on 01/19/21 where she was an inpatient for nine days for respiratory failure status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The addendum said Resident #71 would need a polysomnogram (sleep study) with likely bilateral positive airway pressure machine ([CONDITION(S)]) titration as an outpatient. [CONDITION(S)] machines provide non-invasive ventilation of the lungs for airway support. Review of Resident #71's hospital Pulmonology Consultation form dated 01/25/21 indicated plans were made for her to have a polysomnogram as an outpatient. She was alert and appropriate and amenable to [CONDITION(S)] therapy at night. Review of Resident #71's hospital discharge paperwork dated 01/27/21 indicated the resident was seen by pulmonology who recommended a [CONDITION(S)] while sleeping at night and a sleep study. The resident maintained good oxygen levels and required placement at a skilled nursing facility (SNF) to help initiate the [CONDITION(S)] treatment. Review of Resident #71's medical record at the nursing facility revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #71's physician orders from admission on 01/27/21 through 01/30/21 revealed no physician orders for a sleep study or [CONDITION(S)] therapy. Review of Resident #71's progress note dated 01/27/21 at 11:12 P.M. indicated the resident arrived at the facility and the physician orders were verified. No documentation was found to indicate nursing staff contacted the physician regarding the recommendations from the pulmonologist for a sleep study and [CONDITION(S)] therapy. Review of Resident #71's progress note authored by Nurse Practitioner (NP) #811 on 01/28/21 directed nursing staff to continue the [CONDITION(S)] (was written [CONDITION(S)] instead of [CONDITION(S)]) per pulmonology. Review of Resident #71's progress note dated 01/29/21 at 4:35 P.M. indicated the resident's son called the facility and stated he was going to pick up his mother tomorrow at 11:00 A.M. to take her home. He stated she could do what she was doing at the facility at home. He voiced a concern that she did not wear her [CONDITION(S)] last night. Resident #71 was agreeable with the son's concerns. Resident #71 left against medical advice on 01/30/21 at 10:52 A.M. Interview on 02/23/21 at 8:42 A.M. with NP #811 indicated she assessed Resident #71 on 01/28/21 and the resident was a new admit for respiratory failure. NP #811 confirmed the pulmonologist at the hospital recommended a [CONDITION(S)] and she documented on her progress note dated 01/28/21 to continue the [CONDITION(S)] per pulmonology. Interview on 02/23/21 at 8:51 A.M. with the Director of Nursing (DON) indicated Resident #71 had to follow up with pulmonology for a sleep study for the recommended [CONDITION(S)] settings. The DON indicted the facility placed a [CONDITION(S)] machine in the resident's room but did not have the settings for the [CONDITION(S)]. The DON confirmed Resident #71's medical record did not contain physician orders for the sleep study and [CONDITION(S)] therapy. Interview on 02/23/21 at 12:59 P.M. with the Administrator indicated Receptionist #812 and Driver #813 had to coordinate Resident #71's appointment for the sleep study so that an aide could accompany the resident. The Administrator indicated she gave the paperwork to the front desk staff to make the appointment but Resident #71 left against medical advice before the appointment was made. Interview on 02/23/21 at 3:00 P.M. with Receptionist #812 indicated she did not make the outside appointments for residents and said Driver #813 completed that task. Interview on 02/23/21 at 3:33 P.M. with Driver #813 indicated he received the paperwork to set up Resident #71's sleep study on 01/28/21 and said he set up the appointment on 01/29/21. He indicated he went to deliver the appointment to the front desk and nursing staff on 01/30/21 and found out the resident was already discharged . Driver #813 could not recall the date of the appointment and indicated he shredded the documentation for the appointment because the resident was discharged . There was no documentation found to indicate physician orders were properly obtained for a sleep study and for the use of the [CONDITION(S)] for Resident #71 as recommended by the hospital pulmonologist while she was at the nursing facility. This deficiency substantiates Complaint Number OH 780.

Based on observation, interview and record review, the facility failed to ensure proper infection control procedures were followed during meal service on the 200 unit. This had the potential to affect 16 (Residents #7, #8, #9, #12, #14, #15, #22, 32, #33, #36, #38, #44, #45, #54, #59, and #63) of 16 residents who resided on the 200 unit who ate food served from that pantry. The facility census was 76. Findings include: Observation on 08/06/20 at 8:02 A.M. revealed Dietary Aide (DA) #102 was in the pantry serving breakfast and did not have all her hair in her hairnet. DA #102 with her gloved hands put the rest of her hair into her hairnet and proceeded to resume her duties. She took toast out of the toaster with the same gloves on her hands that she touched her hair with. DA #102 changed her gloves after she was reminded without washing her hands and proceeded to touch the same toast from the toaster. Interview on 08/06/20 at 8:48 A.M. with Dietary Manager #103 revealed that DA #102 should have known better. DA #102 was in-serviced on food safety when it came to hair net, gloves and hand washing. Review of the policy entitled Infection Control-Dietary/Food Handling dated 03/2016 revealed Food handlers must wash hands before putting on gloves and hairnets must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on observation, interview and record review the facility failed to ensure adequate staffing levels to ensure two residents, Residents #6 and #12, out of eight residents, Residents #3, #4, #6, #8, #10, #11, #12, and #16, who required two staff for activities of daily living (ADL) were provided two staff as planned. The facility also failed to provide two staff for mechanical lift transfers for nine residents, Residents #3, #4, #8, #10, #11, #12, #16, #17 and #99, out of 24 residents, Residents #3, #4, #6, #8, #10, #11, #12, #16, #17, #99, #114, #209, #211, #214, #407, #413, #414, #505, #506, #508, #515, #520, #525 and #526, who requiried two staff for mechanical lift transfers, The facility census was [AGE]. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the modified quarterly minimum data set (MDS) 3.0 dated 01/29/20 revealed the resident was cognitively intact but was totally dependent on two staff for transfers and extensively dependent on one staff for toileting. The resident had not had a toileting trial and was not on a toileting program and was always incontinence of bowel and bladder. The resident required a mechanical lift for transfers. Review of the 01/30/20 care conference revealed there was a concern related to not being toileted as desired. On 03/01/20 at 10:47 A.M., interview with STNA #100 revealed no residents were on a toileting program and were checked for incontinence as able but if they were able to ask they were provided assistance when asked by the resident as was Resident #6. On 03/01/20 at 11:10 A.M., interview with STNA #101 revealed no residents were on a toileting program and were checked for incontinence as able but if the resident was able to ask they were provided assistance when asked by the resident as was Resident #6. On 03/01/20 at 11:20 A.M., interview with Licensed Practical Nurse (LPN) #102 revealed she was not aware of any residents on a toileting program. On 03/01/20 at 11:25 A.M., interview with Resident #6, with family present, revealed she had incontinence episodes at times waiting too long for staff to assist her. Staff did not ask her about toileting needs but came when she put on her light but sometimes it took too long either because there was not enough staff because she needed mechanically lifted by two staff for toileting or there was not a mechanical lift available at the time she needed it. On 03/01/20 at 7:56 P.M., interview with the DON and Administrator verified the facility did not have toileting programs unless the resident was on a restorative program. The DON was not able to provide a list of any residents on a restorative toileting program. The DON verified Resident #6 was not on a toileting program and had not had a tracker completed in an attempt to determine if the resident had a pattern to ensure the resident remained as continent as possible. 2.Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 01/30/20 revealed Resident #12 was severely cognitively impaired. The resident had not had a toileting trial was always incontinence of bowel and bladder and was not on a toileting program. The resident was totally dependent on two staff for transfers using a mechanical lift and needed extensive assistance of one staff for toileting. Review of the current bowel and bladder care plan revealed Resident #12 was to be provided incontinence care. On 03/01/20 at 10:47 A.M., interview with STNA #100 revealed no residents were on a toileting program and were checked for incontinence as able but if the resident was able to ask they were provided assistance as soon as possible when asked by the resident as was Resident #12. On 03/01/20 at 11:10 A.M., interview with STNA #101 revealed no residents were on a toileting program and were checked for incontinence as able but if the resident was able to ask they were provided assistance as soon as possible when asked by the resident as was Resident #12. On 03/01/20 at 5:20 P.M., Resident #12 was in the dining room and requested assistance to use the restroom. Resident #12 was taken to her room and told staff would come in to assist her. The surveyor went to the room to wait with the resident. On 03/01/20 at 5:22 P.M., interview with Resident #12 revealed staff did not ask her if she needed to use the restroom she just informed them when she needed to go but at times they took too long and was had incontinent episodes. Resident #12 indicated she needed the assistance of two staff with the mechanical lift and either two staff were not able to assist or the mechanical lift was in use. As of 5:55 P.M., no staff had entered the room to assist the resident. On 03/02/20 while STNA #106 was being interviewed in the hall outside Resident #12's room, Resident #12 activated her call light, STNA #106 responded and the resident stated she had to use the restroom. STNA #106 stated she was going to assist with the transfer but she was not scheduled to work today and was only at the facility because she was called in because of the complaint. On 03/01/20 at 7:56 P.M., interview with the DON and Administrator verified the facility did not have toileting programs unless the resident was on a restorative program. The DON was not able to provide a list of any residents who were on a restorative toileting program. The DON verified Resident #12 was not on a toileting program as indicated in the bowel and bladder assessment. No tracker had been completed in an attempt to determine if the resident had a pattern to ensure the resident remained as continent as possible. The DON verified there was no policy with the available toileting programs or how the facility would attempt to determine the type of program a resident would benefit from or the procedure to determine a program. The only policy related to toileting was the restorative nursing programs policy. 3. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) 3.0 dated [DATE] revealed Resident #3 was cognitively intact. Review of the physicians order dated 02/11/20 revealed the resident was to use a mechanical lift for all transfers. On 03/01/20 at 10:43 A.M., interview with Resident #3 revealed he could not get in and out of bed when he wanted because he needed two staff and the mechanical lift and there was not always enough staff to assist with the transfers. 4. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 12/14/19 revealed Resident #4 was not interviewable and needed extensive assistance of two staff for all transfers. Further review of the current care plan revealed the resident needed the assistance of two staff for all transfers. On 03/01/20 at 10:50 A.M., interview with Resident #4's family revealed the resident needed two staff for transfers and there was not always enough staff to transfer her in and out of bed according to the plan of care. On 03/01/20 at 11:06 A.M., State tested Nurse Aide (STNA) #100 and #101 were observed transferring Resident #4 out of bed. On 03/01/20 at 11:10 A.M., interview with STNA #101 revealed resident's, including Resident #4, may have to wait to be transferred longer than they want especially with call offs (like today), during meal times and/or if another aid was giving a shower. There were supposed to be two STNA's on each hall but do to the call off there was 1.5 STNA's on the two halls. 5. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physicians order dated 03/01/20 revealed Resident #8 was to be transferred by two staff with the use of the mechanical lift. On 03/01/20 at 11:25 A.M., interview with Resident #8 and her family, revealed she was was not always transferred or toileted timely due to not having enough staff to operate the mechanical lift. 6. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current plan of care revealed the resident needed extensive assistance of two staff for all transfers. On 03/01/20 at 2:10 P.M., interview with Resident #10 she did not always get transferred as she wanted because there was not enough staff. 7. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 dated 02/09/20 revealed Resident #11 was cognitively intact and needed two staff for transfers. Review of the physicians order dated 03/01/20 reveled the resident was to be transferred by two staff with the use of a mechanical lift. On 03/01/20 at 2:15 P.M., interview with Resident #11 revealed she frequently had to wait longer than she wanted to be transferred because there was not enough staff to assist especially after 6:00 P.M. 8. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the modified quarterly MDS 3.0 dated 01/31/20 revealed Resident #16 was severely cognitively impaired. Review of the physicians order dated 03/01/20 revealed the resident was to be transferred by two staff with the use of the mechanical for. On 03/01/20 at 4:59 P.M., Resident #16 was observed in bed. On 03/01/20 at 5:00 P.M., interview with Resident #16 revealed the STNA's respond to the call light, turn it off, say they are busy and will come back as soon as they can. Resident #16 stated staff forget so she has to keep activating the call light to get transferred. Resident #16 stated he had been waiting all morning to get out of bed. 9. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. affected her left side. Review of the physicians order dated 10/11/19 revealed Resident #12 was to be transferred by two staff with the use of the mechanical lift. Review of the quarterly MDS 3.0 dated 01/30/20 revealed Resident #12 was severely cognitively impaired. On 03/01/20 at 5:20 P.M., Resident #12 was observed in the dining room and informed staff she needed to use the restroom. Resident #12 was taken to her room and was told the STNA's would be coming soon. The surveyor went to Resident #12's room and interviewed Resident #12 for over 20 minutes. No staff came to the room during the interview. Resident #12 revealed she was frequently not assisted timely when wanting to be transferred or when having to use the restroom. The surveyor then went and stood in the dining room area where the room could be observed; no one was observed to enter the room. At 5:58 P.M., during interview with STNA #106, they revealed Resident #12 requested assistance and STNA #106 went and found another STNA to assist in the transfer with the mechanical lift. Interview with STNA #106 revealed she was not scheduled to work on 03/01/20 but was called in to assist due to the complaint survey. She verified if she was not at the facility, Resident #12 would still not have been assisted. On 03/01/20 at 7:56 P.M., interview with the Director of Nursing (DON) and Administrator reviewed the above concerns. 10. On 03/01/20 at 10:47 A.M., interview with STNA #100 revealed the residents who need two staff would have to wait until the additional staff member was available to assist them with the activities of daily living (ADL) requiring two staff. 11. On 03/01/20 at 11:42 A.M., confidential interview the Resident #99 verified he needed assistance of two staff with the mechanical lift and some times had to wait long periods of time to get the assistance he requested. 12. On 03/01/20 at 6:02 P.M., interview with Resident #17 revealed frequently she would have to wait long periods of time, occasionally a couple of hours, to get assistance she needed because she needed two staff with some ADL's. The STNA's will respond to the call light and turn it off, say they are busy and will come back as soon as possible but they don't come back. Resident #17 verified the residents had complained during resident council meetings but nothing changes. Resident #17 explained that this morning she asked LPN #102 to get her out of bed because she had company coming in about an hour and LPN #102 stated she would inform the STNA's. Resident #17 verified her company came and she was still in bed and was very upset about it but would told there was a call off and they were doing the best they could. On 03/01/20 at 6:17 P.M., interviews with STNA #100, #101 and LPN #102 verified the above but it was during the time the STNA's were getting other residents ready for lunch and residents needed to be fed and they were not able to assist Resident #17 timely as she requested. STNA #100, #101 and LPN #102 verified Resident #17 waited over [AGE] minutes to be assisted after she requested. 13. On 03/01/20 at 7:46 P.M., interview with LPN #107 revealed there was not enough staff on night shift to timely meet the needs of the residents, especially the residents who needed two staff for ADL's. LPN #107 verified she had been requesting additional assistance from management since Spring of 2019 but there had been no response. 14. On 03/01/20 at 7:50 P.M., interview with STNA #108 revealed there was not enough staff on night shift to timely meet the needs of the residents, especially the residents who needed two staff for ADL's. STNA #108 verified she had been requesting additional assistance but there had been no response. On 03/01/20 at 7:56 P.M., interview with the Administrator verified she was looking at staffing and just created a night nurse supervisor position that had not started as of yet. She felt the day shift was staffed appropriately according to the census despite the high number of resident's needing two staff assistance for some ADL's. This deficiency substantiated Complaint #OH 224.

Based on interview, record review and policy review, the facility failed to ensure an appropriate toileting program was attempted in order to keep Resident #6 and #12 as continent as possible. This affected two of two residents who had concerns of being incontinent at times due to waiting too long for staff assistance. The facility census was 82 Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 10/25/19 bowel and bladder assessment revealed Resident #6 was always incontinence of bowel and bladder with functional incontinence because the resident could not manage her clothing, had pain and needed assistance with mobility. It was recommended the resident continue an incontinence program. Review of the modified quarterly minimum data set (MDS) 3.0 dated 01/29/20 revealed the resident was cognitively intact but was totally dependent on two staff for transfers and extensively dependent on one staff for toileting. The resident had not had a toileting trial and was not on a toileting program and was always incontinence of bowel and bladder. The resident required a mechanical lift for transfers. Review of the 01/30/20 care conference revealed there was a concern related to not being toileted as desired. On 03/01/20 at 10:47 A.M., interview with State tested Nurse Aide (STNA) #100 revealed no residents were on a toileting program and residents were checked for incontinence as able by staff but if they were able to ask, they were provided assistance. On 03/01/20 at 11:10 A.M., interview with STNA #101 revealed no residents were on a toileting program and were checked for incontinence as able but if the resident was able to ask they were provided assistance when asked as was Resident #6. On 03/01/20 at 11:20 A.M., interview with Licensed Practical Nurse (LPN) #102 revealed she was not aware of any residents on a toileting program. On 03/01/20 at 11:25 A.M., interview with Resident #6, with family present, revealed she had incontinence episodes at times due to waiting too long for staff to assist her. Staff did not ask her about toileting needs but came when she put on her light. She stated sometimes it took too long either because there was not enough staff because she needed mechanically lifted by two staff for toileting or there was not a mechanical lift available at the time she needed it. On 03/01/20 at 7:56 P.M., interview with the Director of Nursing (DON) and Administrator verified the facility did not have toileting programs unless the resident was on a restorative program. The DON was not able to provide a list of any residents on a restorative toileting program. The DON verified Resident #6 was not on a toileting program and had not had a tracker completed to determine if the resident had a pattern to ensure the resident remained as continent as possible. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the bowel and bladder assessment completed 04/27/19 revealed Resident #12 had functional incontinence because she needed assistance with mobility and had pain. The resident was to be put on a retraining program. Review of the quarterly MDS 3.0 dated 01/30/20 revealed Resident #12 was severely cognitively impaired. The resident had not had a toileting trial; was always incontinence of bowel and bladder and was not on a toileting program. The resident was totally dependent on two staff for transfers using a mechanical lift and needed extensive assistance of one staff for toileting. Review of the current bowel and bladder care plan revealed Resident #12 was to be provided incontinence care. On 03/01/20 at 10:47 A.M., interview with STNA #100 revealed no residents were on a toileting program. The residents were checked for incontinence as able but if the resident was able to ask, they were provided assistance. On 03/01/20 at 11:10 A.M., interview with STNA #101 revealed no residents were on a toileting program. The residents were checked for incontinence as able but if the resident was able to ask they were provided assistance when asked as was Resident #12. On 03/01/20 at 11:20 A.M., interview with LPN #102 revealed she was not aware of any residents on a toileting program. On 03/01/20 at 5:20 P.M., Resident #12 was in the dining room and requested assistance to use the restroom. Resident #12 was taken to her room and told staff would come in to assist her. The surveyor went to the room to wait with the resident. On 03/01/20 at 5:22 P.M., interview with Resident #12 revealed staff did not ask her if she needed to use the restroom; she just informed them when she needed to go but at times they took too long and had incontinent episodes. Resident #12 indicated she needed the assistance of two staff with the mechanical lift. As of 5:55 P.M., no staff had entered the room to assist the resident. On 03/02/20 while Human Resource Personnel (HRP) #106 was being interviewed in the hall outside Resident #12's room, Resident #12 activated her call light, HRP #106 responded and the resident stated she had to use the restroom. HRP #106 stated she was going to assist with the transfer but she was not scheduled to work today and was only at the facility because she was called due to the complaint. On 03/01/20 at 7:56 P.M., interview with the DON and Administrator verified the facility did not have toileting programs unless the resident was on a restorative program. The DON was not able to provide a list of any residents who were on a restorative toileting program. The DON verified Resident #12 was not on a toileting program as indicated in the bowel and bladder assessment. No tracker had been completed in an attempt to determine if the resident had a pattern to ensure the resident remained as continent as possible. The DON verified there was no policy with the available toileting programs or how the facility would attempt to determine the type of program a resident would benefit from or the procedure to determine a program. The only policy related to toileting was the restorative nursing programs policy. Review of the restorative nursing programs policy, dated August 2016, revealed residents would be provided with maintenance and restorative services designed to maintain or improve their highest practicable level including formalized bladder retraining/prompting voiding programs. There was no further procedure on how this would be completed. The deficiency substantiated Complaint #OH 224.