Every finding on record at Burbank Parke Care Center

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure staff provided the appropriate level of supervision during mealtimes for residents at risk for choking. This affected one (Resident #49) of three residents observed for change in condition. Based on observation, staff interview, and review of the facility policy, the facility also failed to ensure medications were stored in a safe and secure manner. This had the potential to affect eight facility-identified cognitively impaired and independently mobile (Residents #18, #45, #57, #59, #61, #77, #78, #80.) The facility census was 74 residents. Findings include: 1.Review of the medical record for Resident #49 revealed an admission date of 04/16/24 with diagnoses including unspecified dementia, cerebral infarction, and acute and chronic respiratory failure. Review of the care plan for Resident #49 dated 10/06/25 revealed the resident had the potential for altered nutritional status. Interventions included following: monitoring eating ability, cut up meats, encourage resident to eat in main dining room for all meals every day and evening shift for choking risk. Review of the progress note for Resident #49 dated 01/08/26 at 1:02 P.M. per Licensed Social Worker (LSW) #303 revealed a care conference was completed which included Resident #49's two daughters. Resident #49's family requested a possible diet order change to a softer texture related to the resident's numerous missing teeth. Review of the physician's orders for Resident #49 revealed an dated 01/09/26 for carb controlled diet with cut up meats. Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 04/24/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #49 dated 06/05/26 at 3:16 P.M. per Licensed Practical Nurse (LPN) #331 revealed the resident was eating in her room, came out to desk and stated that she was coughing while eating with no choking noted. LPN #331 received a new order to encourage the resident to eat in the main dining room for all meals. Review of the Speech Therapy (ST) evaluation for Resident #49 dated 06/09/26 at 6:37 P.M. per Speech Therapist (ST) #481 revealed the resident's risk factors included documented physical impairments and associated functional deficits which caused the resident to be at increased risk for aspiration. Recommendations included supervision for oral intake including distant supervision. To facilitate safety and efficiency, it was recommended the patient use the following strategies and or maneuvers during oral intake: lingual sweep/swallow, alternation of liquid/solids, bolus sized modifications, upright position during meals. Observation on 06/10/2026 at 11:25 A.M. revealed Resident #49 was in her chair in her room alone eating her lunch and had completed about 50 percent (%) of the meal. Interview on 06/10/26 at 11:26 A.M. with Resident #49 confirmed the staff delivered her lunch tray, left the room, and had not returned. Resident #49 stated she had eaten breakfast earlier in the day in her bed without supervision. Phone interview on 06/10/26 at 1:34 P.M. with ST #481 confirmed she evaluated Resident #49 on 06/09/26 and recommended distant supervision during meals. ST #481 stated distant supervision meant observed supervision and for staff to have eyes on the resident. ST #481 verified after the ST evaluation on 06/09/26 she notified Registered Nurse (RN) #328 and the Certified Nursing Assistant (CNA) in the dining room of the recommendation for Resident #49 to have supervision during meals. Interview on 06/10/26 at 1:50 P.M. with Licensed Practical Nurse (LPN) #339 confirmed she was Resident #49's primary nurse and she was not aware the resident required observation or monitoring during meals. Interview on 06/10/26 at 1:57 P.M. with Certified Nursing Assistant (CNA) #372 confirmed she was Resident #49's primary CNA. CNA #372 stated Resident #49 mostly ate in her room and the aide was unaware the resident required observation during meals. Interview on 06/11/2026 at 2:55 P.M. with Resident #49 confirmed she had multiple missing teeth both to her upper and lower jaw. Resident #49 stated she has had trouble chewing food in the past due to so many missing teeth and has choked on food because can't chew hard food well. 2. Multiple observations on 06/08/26 and 06/09/26 between 8:00 A.M. and 4:00 P.M. revealed the Skills Room (located to the left side of a short hall between the main residential hall and the main dining room) was opened and unsecured with no staff in the room. Observation on 06/09/26 at 4:05 P.M. with the Administrator and the Director of Nursing DON revealed the Skills Room had an unlocked refrigerator which contained four boxes of insulin pens. Interview on 06/09/26 at 4:06 P.M. with the Administrator confirmed the insulin pens belonged to a staff member's husband who did not reside in the facility. Interview on 06/09/26 at 4:20 P.M with the DON confirmed the door to the Skills Room was often unlocked and the refrigerator also did not have a lock. The DON stated multiple residents passed by the room several times a day for meals and activities and had access to the refrigerator with the unsecured medication located in the room. Interview on 06/09/26 at 5:00 P.M. with the Administrator verified she spoke with Certified Nursing Assistant (CNA) #316 who confirmed she placed the insulin pens which belonged to the aide's husband in the unlocked refrigerator an undisclosed amount of time ago and she had forgotten she put them in there. Review of the facility policy titled Storage of Medications revised November 2020 revealed the facility stored all drugs and biologicals in a safe, secure, and orderly manner. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station or other secured location.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff notified the physician promptly of a change in resident condition. This affected one (Resident #56) of three residents reviewed for change in condition. The facility census was 74 residents. Findings include: Review of the medical record for Resident #56 revealed an admission date 11/29/22 with diagnoses including congestive heart failure, visual hallucinations and lack of coordination. Review of Minimum Data Set (MDS) assessment for Resident #56 dated 05/20/26 revealed the resident was cognitively impaired and required substantial/maximal assistance with personal hygiene. Review of the progress notes for Resident #56 dated 06/02/26 through 06/10/26 revealed they did not include documentation of drainage or redness to the resident's left eye. Observation on 06/08/26 at 10:00 A.M. of Resident #56 revealed the resident's left eye was red and droopy. Interview on 06/08/26 at 10:01 A.M. of Resident #56 confirmed the resident complained of occasion itching to the left eye. Observation on 06/09/26 11:28 A.M. of revealed Resident #56's left eye was red and the lashes had dried crust on the upper and lower lids. Interview on 06/09/26 at 11:30 A.M. with Licensed Practical Nurse (LPN) #339 confirmed Resident #56 received eye drops three times a day for dry eyes, and she would assess Resident #56's left eye for redness and drainage. Interview on 06/10/26 at 8:16 A.M. with Physician #425 confirmed he was not notified about the redness and drainage to Resident #56's left eye. Interview on 06/10/26 10:39 A.M. with LPN #339 confirmed she had taken a wet washcloth and cleaned Resident #56's eye to see if the redness and drainage would resolve on its own. LPN #339 verified she had not notified Resident #56's provider of the resident's left eye being red and crusty. LPN #339 stated if a change in condition was noted, she normally will give it a day to see if she should notify the physician. Interview on 06/10/26 10:56 A.M. with the Director of Nursing (DON) confirmed if there was a change of condition with a resident she would expect the nurse to call her or text her. The DON verified staff should notify the physician when a change of condition was identified. Review of the facility policy titled Change in a Resident's Condition or Status dated 2001 revealed nurses will notify the resident, resident's attending physician or provider and the resident representative of changes in the resident's condition and/or status.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide timely incontinence care for dependent residents. This affected one (Resident #69) of The facility census was 74 residents. Findings include: Review of the medical record for Resident #69 revealed an admission date of 11/09/18 with diagnoses including Parkinson's disease and dementia. Review of the care plan for Resident #69 initiated 11/13/18 and updated 05/26/26 revealed Resident #69 had a potential for alteration in skin integrity related to immobility, diagnosis of diabetes mellitus, anemia and bowel and bladder incontinence. Interventions included the following: provide treatments per the physician's order, weekly skin assessment for skin irritation, redness, bruises, scratches, open areas, check every two hours and as needed for incontinence. Review of the Minimum Data Set (MDS) assessment for Resident #69 dated 05/15/26 revealed the resident was severely cognitively impaired, was always incontinent of bowel and bladder, required assistance with toileting and personal hygiene. Observation on 06/09/26 at 2:50 P.M. of incontinence care for Resident #69 per Certified Nursing Assistants (CNAs) #351 and #356 revealed the resident's incontinence brief was saturated with urine and stool and an open area to the resident's coccyx was covered with stool. Interview on 06/09/26 at 3:21 P.M. with CNA #351 confirmed she was Resident #69's primary aide and she had laid the resident down to change her incontinence brief at 10:00 A.M. when she started the shift. CNA #351 stated Resident #69 had a open area to her coccyx and she noted there was no dressing present to the wound. CNA #351 further confirmed she did not notify the nurse there was no dressing present to the wound nor had she checked or changed the resident between 10:00 A.M. and 2:50 P.M. because the resident required two people for incontinence care and there was not enough staff. Review of the facility policy titled Wound Prevention undated revealed staff would provide skin hygiene daily with cleanser, rinse and dry thoroughly as needed to keep local areas of skin clean, dry and free of body wastes such as urine, feces, perspiration and wound drainage.

Based on medical record review, observation, staff interview, and review of the facility policy, the failed to provide appropriate care and treatment to a resident with a pressure ulcer. This affected one (Resident #69) of two residents reviewed for pressure ulcers. The facility census was 74 residents. Findings include: Review of the medical record for Resident #69 revealed an admission date of 11/09/18 with diagnoses including Parkinson's disease and dementia. Review of the care plan for Resident #69 initiated 11/13/18 and updated 05/26/26 revealed Resident #69 had a potential for alteration in skin integrity related to immobility, diagnosis of diabetes mellitus, anemia and bowel and bladder incontinence. Interventions included the following: provide treatments per the physician's order, weekly skin assessment for skin irritation, redness, bruises, scratches, open areas, check every two hours and as needed for incontinence. Review of the Minimum Data Set (MDS) assessment for Resident #69 dated 05/15/26 revealed the resident was severely cognitively impaired, was always incontinent of bowel and bladder, required assistance with activities of daily living (ADLs), was at risk for developing pressure ulcers, and had no wounds. Review of the pressure ulcer risk assessment for Resident #69 dated 05/15/26 completed by Registered Nurse (RN) #306 revealed the resident was at high risk for the development of pressure ulcers. Review of the physician's orders for Resident #69 revealed an order dated 05/27/26 to cleanse the area to the coccyx with normal saline, pat dry, apply Medihoney and cover with dry dressing three times weekly on Tuesday, Thursday, and Saturday and as needed. Review of the weekly skin wound note for Resident #69 dated 06/03/26 at 3:13 P.M. per Wound Care Nurse Licensed Practical Nurse (WCN/LPN) #480 revealed the resident had an open area to her buttocks first identified on 05/26/26 which measured 1.2 (centimeters (cm) in length by 0.8 cm in width by 0.1 cm in depth. An order was obtained to cleanse the area with normal saline, pat dry, apply Medihoney, and cover with a dry dressing three times per week and as needed. Review of the Treatment Administration Record (TAR) for Resident #69 dated June 2026 revealed the order to cleanse the open area to the resident's coccyx with normal saline, pat dry, apply Medihoney, and dry dressing was due to be completed on 06/09/26 but had not been signed off. The last time the dressing was signed off as completed was on 06/06/26. Observation on 06/09/26 at 2:50 P.M. of incontinence care for Resident #69 per Certified Nursing Assistants (CNAs) #351 and #356 revealed the resident's incontinence brief was saturated with urine and stool and there was no dressing to the resident's coccyx wound nor was a dressing present in the brief. The wound was covered with stool. As the CNAs were finishing completion of incontinence care LPN # 339 and WCNLPN #480 entered the room. WCN LPN #480 measured the wound to the resident's coccyx and noted it measured 0.5 cm in length by 0.3 cm in width by 0.2 cm in depth with inflamed surrounding tissue measuring 0.3 cm. Interview on 06/09/26 at 3:01 P.M. with LPN #339 confirmed Resident #69 had an order for a dressing to the coccyx wound but there was no dressing present to the wound. Interview on 06/09/26 at 3:01 P.M. with WCN/LPN #480 verified the open area to Resident #69's coccyx was a pressure ulcer which should have been covered with a dressing, and she was unsure why the dressing was not present. WCN/LPN #480 stated maybe the dressing had fallen off and no one had notified the nurse. Interview on 06/09/26 at 3:21 P.M. with CNA #351 confirmed she was Resident #69's primary aide and she had started her shift at 10:00 A.M. CNA #351 stated at 10:00 A.M. when she laid Resident #69 down to change the resident's brief she noted there was no dressing present to the wound on the resident's coccyx. CNA #351 further confirmed she did not notify the nurse there was no dressing present to the wound nor had she checked or changed the resident between 10:00 A.M. and 2:50 P.M. Review of the facility policy titled Wound Prevention undated revealed the facility would provide care, services and documentation related to the occurrence, treatment, and prevention of pressure and non-pressure related wounds. During daily routine care the CNA will observe the resident's skin. When abnormalities were noted this would be communicated to the licensed nurse. Staff would provide skin hygiene daily with cleanser, rinse and dry thoroughly as needed to keep local areas of skin clean, dry and free of body wastes such as urine, feces, perspiration and wound drainage.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to don appropriate personal protective equipment (PPE) during care activities for residents with orders for enhanced barrier precautions (EBP.) The affected two (Residents #6 and #69) of the residents reviewed for EBP. The facility census was 74 residents. Findings include: 1.Review of the medical record for Resident #6 revealed an admission date of 02/21/25 with diagnosis including chronic kidney disease and obstructive and reflux uropathy. Review of the care plan for Resident #6 dated 10/18/24 revealed the resident was at increased risk for infection and or trauma related to use of foley catheter due to history of prostate cancer and recurrent urinary tract infections. Interventions included an indwelling catheter and EBP. Review of the physician's orders for Resident #6 revealed an order dated 11/19/25 for a foley catheter and EBP. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 04/27/26 revealed the resident was cognitively intact and had an indwelling catheter. Interview on 06/08/26 at 11:26 A.M. with Resident #6 confirmed staff did not wear PPE when they emptied his catheter. Observation on 06/09/26 at 11:11 A.M. of catheter care for Resident #6 per Certified Nursing Assistant (CNA) #383 revealed the aide did not don a gown prior to entering the resident's room to provide care. There was a sign posted on Resident #6's doorway indicating the resident was on EBP. Interview on 06/09/26 at 11:15 A.M. with CNA #383 confirmed Resident #6 had a sign on the door indicating he was on EBP. CNA #383 stated she did not wear a gown during catheter care for Resident #6. 2. Review of the medical record for Resident #69 revealed an admission date of 11/09/18 with diagnoses included Parkinson's disease and dementia. Review of the MDS assessment for Resident #69 dated 05/15/26 revealed the resident was severely cognitively impaired and required assistance with activities of daily living. Observation on 06/09/26 at 2:50 P.M. of incontinence care for Resident 69 per CNAs #351 and #356 revealed the resident did not have a sign on the door indicating her was on EBP nor were isolation gowns available outside the room. CNAs #351 and #356 did not don gowns while providing care. Observation of incontinence care revealed Resident #69 had and open wound to the coccyx. Licensed Practical Nurses (LPNs) #339 and #480 then entered Resident #69's room to measure the wound and complete wound care. LPNs #339 and #480 did not don gowns while providing care. Interviews on 06/09/26 at 3:10 P.M. with LPNs #339 and #480 confirmed Resident #69 had a pressure ulcer to the coccyx first identified 05/26/26. LPNs #339 and #480 confirmed they had not donned gowns while providing wound care to Resident #69. Observation on 06/11/26 at 9:28 A.M. with the Director of Nursing (DON) revealed there was no EBP sign on or near the doorway to Resident #69's room nor was there PPE readily available for staff to use. Interview on 06/11/26 at 9:30 A.M. with the DON confirmed Resident #69 should be on EBP and staff should don appropriate PPE when providing care. Review of the facility policy titled Enhanced Barrier Precautions undated revealed EBP were used as an infection prevention and control intervention to reduce the transmission of multi drug resistant organisms (MDRO's) to residents. EBP's employed targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions did not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity. Examples of high contact resident care activities requiring the use of gown and gloves for residents on EBP included the following: transferring, providing hygiene, changing briefs or assisting with toileting, device care or use (including urinary catheter), wound care.

Based on observation, record review and interview, the facility failed to ensure interventions to maintain skin integrity were implemented per the resident's care plan. This affected one (Resident #50) of five sampled residents. The facility census was 71. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, hypoxemia, severe dementia, delusional disorder, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was rarely understood, was receiving hospice services, and was dependent for activities of daily living. Review of Resident #50's physician orders for September 2024 revealed an order dated 10/17/23 for soft elbow pads implemented daily for skin protection. Review of Resident #50's care plan revealed Resident #50 had actual or potential for alteration in skin integrity related to diagnoses and resistance to care. An intervention dated 04/03/20 included elbow protectors at all times, may remove for hygiene. Observation and interview on 09/04/24 at 1:49 P.M. with Licensed Practical Nurse (LPN) #206 revealed Resident #50 sitting in the common area in a Broda chair. Resident #50's left arm was in a cast, covered in a blanket. Resident #50 did not have an elbow protector to her right elbow. LPN #206 stated an elbow protector was not on the left elbow related to the cast but verified Resident #50 should have an elbow protector on the right arm. This deficiency represents non-compliance investigated under Complaint Number OH00156928.

Based on observation, record review and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as required for Resident #65. This had the potential to affect ten residents (#55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) that resided on the same hall as Resident #65. Findings include: Review of Resident #65's medical record revealed the resident was admitted on [DATE] with diagnoses that included but not limited to Alzheimer's disease, angina pectoris, major depressive disorder, and atherosclerotic heart disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was severely cognitively impaired and required maximal assistance with activities of daily living. Review of the physician's orders for July 2024 revealed Resident #65 did not have a urinary catheter. Review of the physician orders dated 07/22/24 revealed that Resident #65 was ordered one gram of ertapenem sodium (antibiotic) for extended spectrum beta-lactamase (ESBL) intramuscularly (IM) once a day for five days. ESBL producing bacteria cannot be killed by many antibiotics used to treat infections making it harder to treat. Review of Resident #65's progress note dated 07/22/24 dated revealed Resident #65 was retested for the COVID-19 virus. Resident #65 was to remain in isolation for the full 10-day period and retest on 07/27/24. The note further indicated all services were rendered in room with no safety concerns at that time. The urine analysis and culture and sensitivity returned indicating positive for ESBL. The physician was notified and opted not to order antibiotic therapy at this time because Resident #65 was on an antiviral for COVID-19. Review of Resident #65's progress note dated 07/23/24 at 5:26 P.M. revealed Resident #65 was retested for the COVID-19 virus. Resident #65 was to remain in isolation for the full 10-day period and retest on 07/27/24. The urine analysis and culture and sensitivity returned positive for ESBL. The physician ordered an IM antibiotic after ensuring there were no interactions with the antiviral that was being administered. Observation and interview on 07/26/24 at 12:42 P.M. with Licensed Practical Nurse (LPN) # 303 revealed Resident #65 was not on isolation precautions or enhanced barrier precautions. LPN #303 verified Resident #65 was not on isolation precautions. LPN #303 stated she took Resident #65 off isolation precautions because the resident had a negative COVID-19 test and did not have to remain on isolation precautions. Interview on 07/26/24 at 1:40 P.M. with the Director of Nursing (DON) revealed although Resident #65 no longer required droplet precautions for COVID-19 the resident should have been on contact precautions because she was newly diagnosed with ESBL. Review of the Centers for Medicare and Medicaid QSO-24-08-NH memo dated 03/20/24 revealed enhanced barrier precautions (EBP) were indicated with any of the following: Infection of colonization with a CDC-targeted MDRO when contact precautions did not apply. Wounds and/or indwelling medical devices even if resident was not known to be infected or colonized with a multi drug resistant organism (MRDO). Review of the facility census dated 07/26/24 revealed Residents #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64 resided on the same hall as Resident #65. This deficiency represents non-compliance investigated under Complaint Number OH0015586.

Based on observation, interview and record review the facility failed to ensure staff followed appropriate hand hygiene and glove use when completing pressure ulcer treatments. This affected one of three residents (Resident #24) for pressure ulcer dressing changes. The census was 72. Findings Included: Review of the open medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included diabetes type 2 and Stage 4 pressure ulcer (Full-thickness skin and tissue loss). Review of the physician orders for July 2024 revealed a treatment to cleanse sacrum with normal saline, apply collagen sheet to wound bed, Skin prep peri wound and cover with border gauze dressing. Observation of Resident #24's dressing change on 07/26/24 at 9:31 A.M. with Licensed Practical Nurse (LPN) #303 and State tested Nurses Assistant (STNA) #366 revealed LPN #303 and STNA #366 both used hand sanitizer as they entered the room. LPN #303 setup the supplies needed for the dressing change. LPN #303 removed the old dressing and discarded the dressing and the gloves she was wearing. LPN #303 donned a clean pair of gloves without washing her hands or using hand sanitizer then cleansed the wound with normal saline, removed her gloves and donned clean gloves without washing her hands or using hand sanitizer. LPN #303 applied the new dressing, cleaned up the trash and removed her gown and gloves and used hand sanitizer as she was walking out of the room. Interview on 07/26/24 at 9:45 A.M. with LPN #303 verified she did not wash her hands or use hand sanitizer between glove changes while completing Resident #24's dressing change. LPN #303 verified she should have washed her hands or used hand sanitizer every time she changed her gloves. Review of the facility policy Dressings, Dry/Clean, dated 09/2013 revealed to wash and dry hands and put on clean gloves between removing old dressing, cleaning wound and applying new dressing. This deficiency represents non-compliance investigated under Complaint Number OH0015586.

Based on medical record review, observation, resident interview, staff interview and review of the facility policy, the facility failed to ensure residents were transferred in a safe manner and in accordance with the plan of care in order to prevent injury. This affected one (Resident #10) of three residents reviewed for assistance with activities of living (ADLs). The facility census was 68. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses included hemiplegia, cerebral infarction, aphasia, diabetes mellitus, osteoarthritis, intervertebral disc degeneration, major depressive disorder, and aftercare joint replacement surgery. Review of the physician order for Resident #10 dated 10/20/23 revealed the resident was a stand-pivot transfer with assistance of one staff using hemi-walker for transferring and could use a mechanical lift as needed every shift for transfers. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 01/18/24 revealed the resident had moderate cognitive impairment, mobilized with an assistive device, and required the assistance of one staff with ADLs including transfers and showers. Review of the physician's order for Resident #10 dated 01/19/24 revealed the resident could independently transfer (stand pivot transfer) to the toilet but would call for help getting off the toilet and back to the wheelchair. Review of the shower sheet for Resident #10 dated 01/19/24 signed by State tested Nursing Assistant (STNA) #100 revealed the resident's skin was intact with no bruising noted. Review of the shower sheet for Resident #10 dated 01/22/2024 signed by STNA #100 revealed the resident had a red bruise to the right arm. Interview on 01/24/24 at 4:20 P.M. with Registered Nurse (RN) #210 confirmed Resident #10 required the assistance of one staff with transfers, and staff should use a gait belt when transferring the resident to prevent injury. Review of the physician assessment for Resident #10 dated 01/25/24 revealed the resident was paralyzed to her right arm and had no pain sensation to the extremity. Resident #10 had a bruise observed to the right upper arm. Further review of the note revealed based on the location of the bruise it probably occurred while someone was helping the resident get off the toilet seat. Interview on 01/25/24 at 11:00 A.M. with Therapy Manager (TM) #250 confirmed staff should use a gait belt when assisting residents with stand and pivot transfers to prevent injuries. Observation on 01/25/24 at 3:15 P.M of Resident #10 revealed resident had a red and yellow bruised area to the medical aspect of the right upper arm. Interview on 01/25/24 at 3:15 P.M. with Resident #10 confirmed on 01/19/24 sometime in the afternoon STNA #100 assisted the resident with a transfer from toilet to wheelchair. Resident #10 confirmed the STNA #100 did not transfer her with a gait belt but grabbed onto her right arm instead. Resident #10 confirmed it took three attempts for STNA #10 to successfully transfer her from the toilet to the wheelchair. Resident #10 further confirmed her right arm was paralyzed from a stroke and she had no pain to her arm. Resident #10 confirmed she believes the bruise to her right arm was caused when STNA #100 assisted her with transfer on 01/19/24. Interview on 01/25/24 at 4:20 P.M. of STNA #100 confirmed the facility policy was for aides to use a gait belt when transferring residents. STNA #100 confirmed on 01/19/24 sometime in the afternoon she assisted Resident #10 with a transfer from the toilet seat to wheelchair and it took three attempts before she was successfully able to transfer the resident. STNA #100 confirmed she did not use a gait belt when transferring Resident #10 on 01/19/24 but she grabbed onto the resident's right arm instead. STNA #100 further confirmed Resident #10 developed a bruise to her right arm which could have possibly occurred when grabbing the resident's arm during the transfer on 01/19/24. Review of the facility policy titled Safe Lifting and Movement of Residents dated July 2017 revealed the facility staff would promote the safety and well-being of staff and residents by use of appropriate techniques and devices to lift and move residents. This deficiency is an example of continued non-compliance from the survey dated 12/29/23.

Based on observation and interview, the facility failed to ensure cold, perishable food (milk) was maintained a proper temperatures. This had the potential to affect all 66 residents in the facility. Findings include: Interviews on 12/27/23 between 9:28 A.M. and 11:01 A.M. with Residents #34, #42, and #66 complained of the food temperatures of the meals when they received them in their rooms. Observation on 12/28/23 at 11:44 A.M. of tray line services for halls trays revealed three silver, open meal carts set up with meal trays that had pre-poured beverages including milk. Observation on 12/28/23 at 12:38 P.M. of the last tray served for the hall meal trays. At this time the test tray was preformed and revealed the beef stew and green beans very warm to hot and tasted very good. The pre -poured glass of milk tempted at 55 degrees Fahrenheit. Interview at this time with Dietary Manager (DM) #836 stated the milk should be colder. Reviewed policy Food Preparation and Service revised November 2022 revealed food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Under food preparation, cooking, and holding time/temperature revealed the danger zone for food temperatures is above 41 degrees Fahrenheit and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. Therefore, PHF must be maintained at or below 41 degrees Fahrenheit or at or above 135 degrees Fahrenheit.

Based on observation and interviews, the facility failed to maintain a clean and sanitary nursing unit refrigerator and failed to ensure milk was stored safely to maintain proper temperature during meal service. This had the potential to affect all 66 residents. Findings include: 1. Observation on 12/28/23 between 8:16 A.M. and 8:28 A.M. of the nursing unit refrigerator on the 700 and 800 hall revealed in the freezer a large brownish frozen food splatter and in the refrigerator various food splatter and a black residue on the inside back wall. Interview at this time with Dietary Manager (DM) #836 verified the observations. 2. Observation on 12/28/23 at 8:38 A.M. of Registered Dietitian (RD) #805 passing breakfast trays on the 500 hall. Observed on the beverage care a gallon of opened milk sitting out on the cart. Interview at this time with RD #805 verified the observation and stated they take the milk out of the refrigerator on unit and it was usually out for about hour while meal trays were being passed. RD #805 stated then the milk was put right back into the refrigerator after the trays were passed. Observation on 12/28/23 at approximately 8:40 A.M. of State tested Nurse Aide (STNA) #823 passing breakfast trays on the 800 hall and observed a gallon of opened milk sitting out on the beverage cart. Interview at this time with STNA #823 verified the observation and stated that was normal practice. Observation on 12/28/23 at 11:44 A.M. of tray line services for halls trays revealed three silver, open meal carts set up with meal trays that had pre-poured beverages including milk.

Based on observation, record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected four (Residents #15, #50, #51, and #64) of 24 residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted on [DATE] with anxiety disorder, depression and chronic obstructive pulmonary disease. Review of Resident #15's physician orders revealed an order dated 08/30/23 to admit to hospice services with a diagnosis of cerebral atherosclerosis. Review of Resident #15's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] under Section O - Special Treatments, Procedures, and Programs did not reflect the resident was receiving hospice services. Interview on 12/27/23 at 4:44 P.M. with Registered Nurse (RN) MDS #801 confirmed Resident #15's comprehensive assessment dated [DATE] did not reflect the resident's hospice services. 2. Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including obstructive and reflux uropathy, anxiety disorder and compression. Review of Resident #15's MDS 3.0 comprehensive assessment Section M - Skin Conditions dated 09/28/23 revealed the resident did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. Review of Resident #15's Wound Evaluation and Management Summary dated 12/13/23 revealed the resident had a stage four coccyx, full thickness pressure wound measuring 2.5 cm (centimeters) by 0.9 cm by 1.1 cm with 10% slough and 90% granulation tissue. Interview on 12/28/23 at 3:00 P.M. with RN MDS #801 confirmed Resident #15's MDS 3.0 Comprehensive assessment did not reflect the resident's stage four sacral pressure ulcer. 3. Review of Resident #50's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease as well as obstructive and reflux uropathy. Review of Resident #50's physician orders revealed an order dated 07/14/23 for an 18 French Foley catheter change every month and as needed. Review of Resident #50's MDS 3.0 comprehensive assessment Section H - Bladder and Bowel dated 09/28/23 revealed the resident exhibited intact cognition, did not have an indwelling catheter, was frequently incontinent of urine and always incontinent of bowel. Review of Resident #50's Bowel and Bladder Assessment form dated 10/01/23 revealed the resident was frequently incontinent but some control was present. The Bowel and Bladder Assessment form did not accurately reflect the resident's Foley catheter usage. Observation and interview on 12/27/23 at 9:06 A.M. with Resident #50 revealed the resident had a urinary catheter in place and the resident reported he was unaware of the reason for the use of the catheter. Interview on 12/27/23 at 4:44 P.M. with RN MDS #801 confirmed Resident #50's MDS 3.0 comprehensive assessment did not accurately reflect the resident's Foley catheter usage and the Bowel and Bladder Assessment form did not accurately reflect the resident's Foley catheter use. 4. Review of Resident #51's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, hallucinations and depression. Review of Resident #51's physician orders revealed an order dated 12/15/22 for Hydrocodone-Acetaminophen tablet 5-525 mg (milligrams) give one tablet by mouth every six hours for pain management due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #51's medication administration record from 12/01/23 to 12/15/23 revealed the resident was receiving the Hydrocodone-Acetaminophen narcotic tablets. Review of Resident #51's MDS 3.0 comprehensive assessment Section N - Medications dated 12/13/23 revealed the resident did not receive opioid narcotics. Interview on 12/28/23 at 10:50 A.M. with RN MDS #801 confirmed Resident #51's MDS 3.0 comprehensive assessment dated [DATE] did not accurately reflect the resident's narcotic medication administration. 5. Review of Resident 64's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including diabetes, acquired absence of the left leg above the knee and anxiety disorder. Review of Resident #64's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. The medical record did not reveal evidence of a discharge comprehensive assessment. Review of Resident #64's social service progress note progress note dated 09/26/23 at 12:36 P.M. revealed the staff successfully moved the resident to the new assisted living unit per his choice. Interview on 12/28/23 at 8:58 A.M. with RN MDS #801 confirmed Resident #64 was discharged to the assisted living and the facility should have completed a discharge return not anticipated MDS for this resident which was not completed. 39969 6. Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included cerebral infarction, vascular dementia with other behavioral disturbance, psychosis, major depressive disorder, and anxiety. Review of the physician orders for December 2023 revealed orders for Lorazepam (antianxiety) tablet 0.5 milligrams (mg) to give one tablet by mouth three times a day for anxiety with a start date of 08/31/23. Review of the medication administration records for October 2023 and November 2023 revealed Resident #56 received Lorazepam (anti-anxiety) tablet 0.5 mg as ordered. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #56 had impaired cognition and did not receive any anti-anxiety medications during the seven day look back period. Interview on 12/28/23 at 10:51 A.M. with MDS Nurse #801 verified she marked no for anti-anxiety medication use and that it should be yes. MDS Nurse #801 stated Resident #56 received the medication routinely.

Based on observation, interview, and record review the facility failed to ensure accurate serving sizes were served for the pureed meal. This affected two residents (#3 and #39) but had the potential to affect all 10 residents (#1, #3, #9, #12, #19, #23, #36, #39, #47, and #55) residents who received pureed diet. The facility census was 66. Finding included: Review of menu and menu spreadsheet dated 12/28/23 revealed for the pureed meal was #6 scoop serving for the pureed beef stew, #16 scoop serving for the pureed green beans, and #30 scoop serving for the pureed biscuit. Observation on 12/28/23 at 11:44 A.M. of tray line service revealed grey handled scoops placed in each of the pureed beef stew, pureed green beans, and pureed biscuits. Observed at 11:57 A.M. of Cook #885 prepare a pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on the tray on the second meal cart for hall trays. Observed at 12:04 P.M. Cook #885 prepare another pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on tray on the third/last meal cart for hall trays. Interview on 12/28/23 at 12:05 P.M. with Cook #885 verified the gray handled scoops were #8 scoops used to serve the pureed meals and were not correct serving utensils according to the menu spreadsheet. Review of the facility list of resident diets revealed Resident #1, #3, #9, #12, #19, #23, #36, #39, #47, and #55 received pureed foods. Review of the Portion Control Chart posted on the reach in refrigerator across from the steam table next to the ice machine revealed a color coded scoop chart. The chart indicated the #8 scoop was a gray handled scoop and provided four ounce servings. The #6 scoop was a white handle scoop that provided five and one third ounce serving and should had been used for the pureed beef stew; the #30 scoop was a black handled scoop that provided one ounce serving and should had been used to serve the pureed biscuit; and the #16 scoop was a blue handled scoop that provided two ounce serving. Review of the facility policy titled Kitchen Weights and Measures, revised April 2007 revealed food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. Recipes will specify consistent use of metric or U.S. measurement guidelines. Serving utensils used will be consistent with choice of metric or U.S. measure used. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color coded) on utensils will be prominently displayed for reference.

Based on observation, record review and interview, the facility failed to ensure Resident #51's fall interventions were implemented according to the physician orders and care plans. This finding affected one (Resident #51) of five residents reviewed for accidents and hazards. Findings include: Review of Resident #51's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and unspecified dementia. Review of Resident #51's physician orders revealed an order dated 10/29/22 to keep the bed in the lowest height when in bed and an order dated 12/04/23 for a perimeter mattress to the bed for safety. Review of Resident #51's Fall Investigation form dated 11/21/23 revealed the State tested Nursing Assistant (STNA) found the resident on the floor by the bed. The resident could not state what he was doing. The fall interventions listed included a non-skid floor mat at the bedside and a low bed. The new intervention included to call hospice for a perimeter air mattress. Review of Resident #51's fall care planned interventions revealed interventions including the pressure relieving perimeter mattress to maintain safer bed boundaries, the bed in a low position and non skid footwear. The fall care planned interventions did not include a non-skid floor mat at the bedside. Review of Resident #51's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited intact cognition and had two or more falls with injury except major. Observation on 12/27/23 at 10:13 A.M. revealed Resident #51 was asleep on an air bed and no fall bolsters were present. His non-slip fall mat was observed pushed away from the bed in the middle of the room. Observation on 12/27/23 at 11:05 A.M. revealed Resident #51 was in bed sleeping. His fall mat was in the middle of the room and his bed appeared to be elevated at a normal height. Observation on 12/28/23 at 9:24 A.M. revealed Resident #51's bed was elevated to normal height, his overbed table was in front of him and he appeared to be sleeping. His non-slip fall mat was in the middle of the room. Observation on 12/28/23 at 9:44 A.M. with Licensed Practical Nurse (LPN) #811 revealed Resident #51's bed was at normal height and his non-slip fall mattress was in the middle of the room. Further observation revealed the resident was on an air mattress which did not have a perimeter overlay. Observation and interview on 12/28/23 at 9:52 P.M. with LPN Wound Nurse #802 confirmed Resident #51 was ordered a perimeter air mattress by hospice services and they sent bolsters which were to be put on underneath of the sheet. She stated the staff were unaware of what the bolsters were and did not implement them. Interview on 12/28/23 at 9:58 A.M. with the Director of Nursing (DON) stated she started to put in the order and the care planned intervention for the fall mat and she got busy. She stated the intervention was implemented and was not care planned timely. Review of the :Managing Falls and Fall Risk policy revised 03/2021 revealed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

Based on observation, record review and interview, the facility failed to ensure Resident #15's sacral pressure ulcer wound dressing was in place. This finding affected one (Resident #15) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral atherosclerosis, depression and anxiety. Review of Resident #15's physician orders revealed an order dated 11/17/23 to cleanse the area to the coccyx with normal saline, apply a collagen sheet to the wound bed, apply calcium alginate, apply skin prep to the peri wound and cover with a silicone super absorbent border foam dressing three times a week and as needed every Monday, Wednesday and Friday for wound care. Review of Resident #15's wound progress note dated 12/13/23 revealed the resident had a stage four full thickness coccyx pressure wound which measured 2.6 cm (centimeters) by 0.9 cm by 1.1 cm with 10% slough and 90% granulation tissue. Observation on 12/27/23 at 3:09 P.M. with Licensed Practical Nurse (LPN) #811 and State tested Nursing Assistant (STNA)/Transport #826 of Resident #15's coccyx pressure ulcer dressing change revealed the resident was turned to her side and the coccyx pressure ulcer dressing was not in place at the time of the observation. Interview on 12/27/23 at 3:14 P.M. with LPN #811 confirmed she was unsure what happened to Resident #15's dressing but it was not in place at the time of the observation. Review of the undated Pressure Ulcers/Skin Breakdown Clinical Protocol policy indicated the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc) and application of topical agents.

Based on record review and interview, the facility failed ensure Resident #51's narcotic pain medications were administered as ordered and failed to adequately monitor and assess Resident #51's pain levels prior to and following administration of the narcotic pain medications. This finding affected one (Resident #51) of two residents reviewed for pain management. Findings include: Review of Resident #51's medical record revealed the resident wad initially admitted on ,d+[DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, pulmonary hypertension and hospice services. Review of Resident #51's Pain Level Summary form from 12/01/23 to 12/28/23 revealed the resident's pain was monitored on 12/16/23 at 12:33 A.M. with a pain level of ten (one being the least pain and ten the worst pain); on 12/16/23 at 7:51 A.M. with a pain level of five and on 12/28/23 at 12:34 P.M. with a pain level of eight. No other documentation was available related to assessment and monitoring of the resident's pain level. Review of Resident #51's physician orders revealed an order dated 12/15/22 for Hydrocodone-Acetaminophen tablet 5-325 mg (milligrams) give one tablet by mouth every six hours for pain management due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #51's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed no evidence the resident was administered the Hydrocodone-Acetaminophen narcotic pain medications on 12/03/23 at 6:00 A.M., 12/04/23 at 6:00 A.M., 12/05/23 12:00 A.M. and 6:00 A.M., 12/15/23 at 6:00 P.M., 12/17/23 at 12:00 A.M. and 6:00 A.M., 12/18/23 at 12:00 A.M. and 6:00 A.M., 12/24/23 at 6:00 A.M., 12/26/23 at 6:00 A.M. and 12/27/23 at 6:00 A.M. The MARS did not have evidence the resident's pain was monitored pre or post administration of the narcotic pain medication. Attempted interview on 12/28/23 at approximately 9:40 A.M. with Resident #51, who was awake and alert, and the resident was not able to appropriately answer questions. Interview on 12/28/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #802 indicated the nurse from hospice services monitor Resident #51's pain once weekly and the facility staff did not consistently monitor and assess the resident's pain level as the narcotic pain medications were scheduled and not ordered as needed. LPN Wound Nurse #802 also confirmed Resident #51's MARS revealed no evidence the resident was administered 12 does of the narcotic pain medication from 12/01/23 to 12/28/23. Review of the Pain Assessment and Management policy revised 03/2020 indicated the purposes of the procedure was to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain.

Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administering Resident #3 and Resident #53's anti-anxiety medication. This finding affected two (Residents #3 and #53) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, neuromuscular dysfunction of the bladder and low back pain. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #3's physician orders revealed an order dated 05/06/23 for Lorazepam (anti-anxiety medication) 0.5 mg give one tablet by mouth every four hours as needed for agitation and anxiety. Review of Resident #3's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed the resident received the as needed anti-anxiety medication on 12/1/23 at 1:05 P.M., 12/01/23 at 5:24 P.M., 12/13/23 at 9:27 A.M., 12/19/23 at 1:36 P.M., 12/22/23 at 9:11 P.M., and 12/23/23 at 4:38 A.M. Review of Resident #3's medical record and progress notes from 12/01/23 to 12/28/23 did not reveal evidence the resident was provided non-pharmacological interventions were provided to the resident prior to administering the anti-anxiety medication. Interview on 12/29/23 at 8:20 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #802 confirmed Resident #3's medical record did not have evidence non-pharmacological interventions were implemented prior to administering the anti-anxiety medication. 39333 2. Review of Resident #53's medical record revealed the resident was admitted on [DATE] readmitted on [DATE] with diagnoses included but not limited to dementia, chronic obstructive pulmonary disease, and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's physician orders revealed an order dated 05/06/23 for Lorazepam (anti-anxiety medication) 0.5 mg give one tablet by mouth every twenty-four hours as needed for anxiety. Review of Resident #53's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed the resident received the as needed anti-anxiety medication on 12/20/23 at 9:28 A.M. Review of Resident #53's medical record and progress notes from 12/01/23 to 12/28/23 did not reveal evidence the resident was provided non-pharmacological interventions were provided to the resident prior to administering the anti-anxiety medication. Interview on 12/29/23 at 11:28 A.M. with the Administrator confirmed Resident #53's medical record did not have evidence non-pharmacological interventions were implemented prior to administering the anti-anxiety medication. Review of the Psychotropic Medication Use policy revised 07/22 revealed non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). Twenty-five medications were observed with two errors for a medication error rate of 8%. This finding affected one (Resident #53) of four residents observed for medication administration. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia and primary generalized osteoarthritis. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's physician orders revealed an order dated an order dated 08/04/22 to give one scoop of fiber powder by mouth one time a day for diarrhea; an order dated 08/23/22 for Brimonidine Tartrate solution 0.2% (percent) instill one drop in the left eye two times a day related to unspecified glaucoma and an order dated 12/13/22 for a regular diet, regular texture with a nectar consistency. Observation on 12/28/23 at 7:33 A.M. with Registered Nurse (RN) #809 of Resident #53's morning medication administration revealed ten medications were administered with two errors. The facility administered the Brimonidine eye drop in both eyes and the order was for the left eye. The nurse also administered the fiber powder in water and the resident was on nectar thickened liquids. Interview on 12/28/23 at 8:02 A.M. with RN #809 confirmed Resident #53's eye drops were administered to both eyes in error and the fiber powder was mixed with thin water instead of nectar thickened water as required. Twenty-five medications were observed with two errors for a medication error rate of 8%. Review of the Medication Administration policy revised 11/22 indicated a medication administration record is used to document all medications administered.

Based on observation, staff interview and policy review, the facility failed to ensure basic infection control practices were maintained related to catheter bag placement for Resident #5. This affected one resident (Resident #5) of one resident reviewed for catheter care. The facility census was 67. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia and neuromuscular dysfunction of the bladder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact, required extensive assistance of one staff person for completing her activities of daily living and the use of indwelling foley catheter to empty her bladder. Observation of Resident #5 on 12/27/23 at 10:29 A.M. revealed Resident #5 was up and sitting in her recliner. Resident #5's foley catheter bag was uncovered, touching the floor and hanging on a trash can next to the recliner with trash inside the can. Interview at this time with Licensed Practical Nurse (LPN) #811 verified Resident #5's foley catheter bag was uncovered, touching the floor and hanging on a trash can next to the recliner with trash inside the can. Interview with Resident #5 on 12/27/23 at 10:33 A.M. revealed facility staff hangs the catheter bag from the trash can all the time. Review of the policy titled, Catheter care, Urinary Policy, dated 08/01/22, revealed staff should observe tubing and drainage bag to prevent contact with the floor.

Based on record review, observation and interview the facility failed to ensure Resident #25 and #40 received assistance shaving their facial hair. This affected two residents (Resident #25 and #40) of three reviewed for activities of daily living (ADLs). The facility census was 81. Findings included: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included heart failure, hypertension, protein-calorie malnutrition, convulsions, aphasia, insomnia, benign prostatic hyperplasia, peripheral vascular disease, severe intellectual disabilities, epilepsy and cataracts. Review of the shower sheets from 12/01/22 to 02/24/23 revealed no documentation Resident #25 had been shaved. Review of the progress notes from 12/25/22 to 02/24/23 revealed no documentation Resident #25 refused to be shaved. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had severely impaired cognition and required total assistance for personal hygiene. Observation on 02/24/23 at 9:23 A.M. and 10:40 A.M. revealed Resident #25 needed to be shaved. He had long whiskers on his face. On 02/24/23 at 10:05 A.M. an interview with the Director of Nursing (DON) revealed the men were to be shaved on shower days and they received showers two the three times weekly. On 02/24/23 at 10:45 A.M. an interview with DON verified Resident #25 needed to be shaved and indicated she would have someone shave him. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included epilepsy, dementia, major depressive disorder, COVID-19, right and left-hand contractures, traumatic brain injury, conversion disorder with seizures, spastic hemiplegia and intracranial injury. Review of the shower sheets from 12/01/22 to 02/24/23 revealed Resident #40 was shaved on 12/01/22 and 12/22/22. There was no other documentation he had been shaved. Review of the progress notes from 12/25/22 to 02/24/23 revealed no documentation Resident #40 refused to be shaved. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 had severely impaired cognition and required total assistance with personal hygiene. Observation on 02/24/23 at 9:20 A.M. and 10:42 A.M. revealed Resident #40 needed to be shaved. He had long whiskers on his face. On 02/24/23 at 10:05 A.M. an interview with the Director of Nursing (DON) revealed the men were to be shaved on shower days and they received showers two the three times weekly. On 02/24/23 at 10:45 A.M. an interview with DON verified Resident #40 needed to be shaved and indicated she would have someone shave him. Review of the facility policy titled, Shaving the Resident, dated 10/10 revealed the purpose was to promotes cleanliness and to provide skin care. This deficiency is based on incidental findings discovered during the course of the investigation of Complaint Number OH00140227.