Every finding on record at Carlisle Manor Health Care Inc

Based on observation, resident and staff interviews and record review, the facility failed to maintain exterior exit egress stairs. This affected Resident #9 and #13 and had the potential to affect all 45 residents residing in the facility. Findings include:Review of the facility's State Fire Marshal report dated 03/19/26 revealed the facility received a violation for exit accesses, exits and a exit discharge not being maintained. The report stated the exterior exit staircase was breaking apart.Review of the facility's undated exit egress map revealed the exterior stairwell that was crumbling was an exit egress for residents.Interview with Resident #9 on 05/26/26 at 10:21 A.M. revealed Resident #9 was concerned the facility had an exterior cinderblock and concrete staircase that was crumbling. Resident #9 stated he and other resident council members had discussed the staircase with the facility, but it had not been fixed.Interview with Resident #13 on 05/26/26 at 12:00 P.M. revealed Resident #13 was concerned the facility had an exterior cinderblock and concrete staircase that was crumbling. Resident #13 stated he and other resident council members had discussed the staircase with the facility, but it had not been fixed.Observation of the facility's exterior cinderblock and concrete staircase to the second floor on 05/26/26 at 5:06 P.M. revealed the staircase was visibly crumbling.Interview with Maintenance Director #65 and the Administrator on 05/27/26 at 4:50 P.M. verified the exterior cinderblock and concrete staircase or egress was crumbling. The Administrator reported the facility was cited by the State Fire Marshal for the staircase breaking apart. The Administrator verified that the facility had no scheduled repairs and no repairs had been made to the staircase since the facility was cited by the State Fire Marshal on 03/19/26.

Based on record review, policy review and staff interview, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) was accurate and included the resident's mental health diagnoses. This affected one (#36) of one resident reviewed for PASARR. The facility census was 45. Findings include:Review of Resident #36's medical record revealed Resident #36 admitted to the facility on [DATE]. Diagnoses included with dementia severe with other behavioral disturbance, anxiety disorder, and psychosis not due to a substance or known physiological condition. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired. Review of the PASARR dated 04/26/24 revealed Resident #36 did not have any diagnoses of any mental health disorders and Resident #36's diagnoses of anxiety disorder and psychosis not due to a substance or known physiological condition were not listed on the PASARR.Interview with the Administrator on 05/27/26 at 9:58 A.M. verified Resident #36's PASARR dated 04/26/24 did not list Resident #36's diagnoses of anxiety disorder and psychosis not due to a substance or known physiological condition. The Administrator verified the facility did not have any additional PASARRs on file that included Resident #36's diagnoses of anxiety disorder and psychosis not due to a substance or known physiological condition. Review of the facility's undated Resident Assessment Coordination with the PASARR Program policy revealed the facility coordinated assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or related condition received care and services in the most integrated setting appropriate to their needs.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's medical record was accurate reflecting the route of medications were administered. This affected one (#25) of 14 residents reviewed for accuracy of medical records. The facility census was 45.Findings include:Review of Resident #25's medical record revealed Resident #25 admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, shortness of breath, dementia without behavioral disturbance and anxiety, gastro esophageal reflux disease without esophagitis (GERD) and hyperlipidemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was moderately cognitively impaired and did not have a feeding tube. The progress note dated 03/05/26 at 5:55 P.M. revealed Resident #25 went out of the facility for a feeding tube removal on 03/05/26 at 12:00 P.M.Review of Resident #25's medication administration record (MAR) from 05/01/26 to 05/26/26 revealed the following medications were ordered to be administered through the route of percutaneous endoscopic gastrostomy (PEG) tube and were documented as administered through the PEG tube when the PEG tube was discontinued on 03/15/26. Resident #25 was documented as administered via PEG tube: Lexapro oral tablet 10 milligrams (mg) give one tablet by one time a day for depression; omeprazole oral tablet delayed release 20 mg give one tablet one time a day for GERD; metoprolol tartrate oral tablet 25 mg give one tablet two times a day for hypertension, venlafaxine 75 mg give one tablet two times a day for depression, gabapentin 400 mg give one capsule three times a day for neuropathy, and meclizine 25 mg give one tablet three times a day for vertigo. Interview with Assistant Director of Nursing (ADON) #87 on 05/27/26 at 10:43 A.M. verified Resident #25's PEG tube was removed on 03/05/26. ADON #87 confirmed Resident #25's physician orders were inaccurate and the MAR was inaccurate reflecting administration of medications were through PEG tube. ADON #87 confirmed the route of administration should have been by mouth.Review of the facility's Medication Administration policy dated 08/22/22 revealed the medication source was to be compared with the MAR to verify the resident name, medication, dose route and time.

Based on record review and staff interview, the facility failed to maintain updated communication with a resident's hospice provider and updated documentation of a resident's care plan from a resident's hospice company. This affected one (#25) of one resident reviewed for hospice. The facility census was 45. Findings include:Review of Resident #25's medical record revealed Resident #25 admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease with esophagitis (GERD), cerebral infarction and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was moderately cognitively impaired and was on hospice services.Review of the hospice care plan written by the facility dated 01/12/24 revealed Resident #25 was on hospice related to COPD. Interventions included coordinate the plan of care with the resident, family and hospice, communicate changes in condition to hospice, and encourage visitors.Review of the hospice face sheet revealed Resident #25 was admitted to hospice on 01/12/24 with COPD, cerebral infarction, anxiety disorder and GERD .The hospice care plan from Resident 25's hospice company dated 01/15/24 revealed facility would notify hospice of changes and would have ongoing health needs met.The medical record from 01/16/26 to 05/28/26 revealed it did not contain any hospice notes or documentation of Resident #25's hospice visits. There was no updated hospice care plan from Resident #25's hospice company since 01/15/24.Review of Resident #25's hospice visit sign in log from 03/09/26 to 05/28/26 revealed Resident #25 received a visit from hospice on 03/09/36, 04/03/26, 04/07/26, and 05/07/26. No additional hospice visits were listed.Interview with Registered Nurse (RN) #86 on 05/28/26 at 10:07 A.M. verified Resident #25's hospice visit sign in log was not up to date in the resident's medical record. RN #86 stated Resident #25 was seen by hospice weekly. RN #86 verified there were no hospice notes or documentation of Resident #25's hospice visits in Resident #25's medical record. RN ##86 verified there was no updated hospice care plan from Resident #25's hospice company since 01/15/24.Review of the hospice contract with Resident #25's hospice provider dated 02/02/15 revealed hospice shall promote open and frequent communication with the facility and shall provide the facility with sufficient information to ensure the provision of facility services under the hospice agreement in accordance with the hospice resident's plan of care, assessments, treatment planning and care coordination. At a minimum, hospice should provide information to the facility for each hospice resident residing in the facility including the most recent plan of care, medication information and physician orders specific to each resident.

Based on medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, observations, interviews, and policy review, the facility failed to don appropriate personal protective equipment (PPE) when providing high contact resident care activities for a resident on enhanced barrier precautions (EBP) and when in a resident's room under contact and droplet precautions. This affected two (#5 and #11) of five residents reviewed for infection control. The facility census was 45.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 06/14/24. Diagnoses included osteomyelitis of vertebra and sacral region. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment. Review of the care plan dated 11/04/25 revealed Resident #5 required enhanced barrier precautions (EBP) related to suprapubic catheter. Interventions included clean hands before entering and when leaving resident room, do not wear the same gloves and gown for the care of more than one resident, and gloves and gowns to be worn when providing high-contact resident care activities (dressing, bathing, transferring, changing linens, providing hygiene, toileting, giving care to central lunes, urinary catheter, and feeding tubes).Observation on 05/27/26 at 11:02 A.M. revealed Registered Nurse (RN) #86 provided suprapubic catheter care to Resident #5. RN #86 provided hand hygiene and donned gloves but did not wear a gown while completing suprapubic catheter care.Interview on 05/27/26 at 11:09 A.M. with RN #86 verified she did not wear a gown when providing suprapubic catheter care to Resident #5.Review of the facility policy titled Enhanced Barrier Precautions revised 07/13/22 revealed the facility was to implement EBP for preventing transmission of novel or targeted multidrug-resistant organisms. EBP referred to the use of gown and gloves for certain residents during specific high-contact resident care activities that had been found to increase risk of transmission of multidrug-resistant organisms.Review of the CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Review of the medical record for Resident #11 revealed an admission date of 09/01/20. Diagnoses included hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, major depressive disorder, and schizoaffective disorder.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident was assessed to require setup with eating, dependent with toileting, and substantial assistance with bathing, dressing, and transfers.Review of the physician order dated 05/19/26 revealed Resident #11 was ordered contact and droplet precautions through 05/31/26 for Norovirus.Observation on 05/26/2026 at 9:26 A.M. revealed Resident #11's door only had enhanced barrier precautions sign prior to entering the room. When in the room, Certified Nursing Assistant (CNA) #40 instructed to put on a mask because Resident #11 had norovirus.Interview on 05/26/2026 at 9:59 A.M. with Licensed Practical Nurse (LPN) #70 verified Resident #11 was in contact and droplet precautions (donning down and gloves before entering the room) until 05/31/26 for Norovirus.Interview on 05/26/26 at 10:31 A.M. with Assistant Director of Nursing (ADON) #87 who was also the infection preventionist, verified Resident #11 returned from the hospital on [DATE] after testing positive in the hospital for Norovirus. ADON #87 verified Resident #11 was supposed to be in droplet and contact precautions but did not have the correct signage on the door since returning from the hospital.Review of the facility policy titled Infection Control and Prevention Policy and Guidelines revised on 01/2025 revealed the facility had established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Passive screening, such as signs, were posted in the facility to alert family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. Isolation signs were used to alert staff, family members and visitors of transmission-based precautions.Review of the CDC's undated guidance titled Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings revealed patients with norovirus gastroenteritis should be on contact precautions. Personal protective equipment (PPE) should be gowns and gloves upon entry.

Based on staff interview., review of job description, and personnel file review, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 45 residents residing in the facility. Findings include:Review of Activities Director (AD) #47's personnel file revealed AD #47 was hired as the activities director at the facility on 04/14/26. Further review of AD #47's personnel file revealed AD #47 did not hold any licenses, certificates or registrations in any professional capacity. AD #47's resume did not indicate that AD #47 had two years of experience in social or recreational programming.Interview with AD #47 on 05/28/26 at 9:07 A.M. verified AD #47 was the activities director at the facility. AD #47 confirmed she did not hold any licenses, certificates or registrations in any professional capacity. AD #47 also verified she did not have two years of experience in social or recreational programming and verified she was not a qualified occupational therapist or occupational therapy assistant and had not taken any training course approved by the state. Review of the facility's activities director job description dated 05/22/17 revealed the activities director must possess at minimum two years of college. The activities director must be a qualified therapeutic recreation specialist or an activities professional who was licensed by the state was eligible for certification as a recreation specialist or as an activities professional or must have two years of experience in social or recreation program within the last five years one of which was full time in a patient activities program in a health care setting or must be a qualified occupational therapist or occupational therapy assistant or must have completed a training course approved by the state.

Based on medical record review, resident and staff interviews, review of police department report, review of the facilities Self-Reported Incidents (SRI) and policy review, the facility failed to report an allegation of misappropriation to State Survey Agency. This affected one (#22) of three residents reviewed for misappropriation. The facility census was 45. Findings include:Review of the medical record for Resident #22 revealed an admission date of 09/25/25. Diagnoses included left femur fracture, diabetes mellitus, depression, chronic ischemic heart disease, and anxiety.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact.Review of the police department report dated 10/05/25 revealed Resident #22 called 911 and reported a theft of $1,000. The police report stated Resident #22 stated he had over $1,000 in cash but could not recall the date the cash went missing. The police report stated Unit Manager #207 stated she had not seen the cash since 09/30/25 after Resident #22 refused to put the money in a locked box. Unit Manager #207 stated Resident #22 had visitors on 09/30/25 and 10/01/25. Per the report, the police department were unable to determine if the cash was stolen or if Resident #22 had given the money to a visitor. Review of the facilities SRI from 10/05/25 to 11/19/25 revealed there were no allegations of misappropriation involving Resident #22 reported to the State Survey Agency.Interview on 11/20/25 at 8:32 A.M. with Resident #22 stated he had a bunch of cash stolen about three weeks ago. Resident #22 stated he had about $1,000 in cash that he gave to a nurse to put in his nightstand and then the nurse later put the money in the bottom of her medication cart. Resident #22 stated the next day the nurse gave all his money to a visitor who was one of the two ladies who came to visit him, but he could not recall her name. Resident #22 stated he called the police department and filed a report. Resident #22 stated he had not received any money back.Interview on 11/20/25 at 9:05 A.M. with Social Service (SS) #215 stated she received a message on 10/05/25 that Resident #22 stated he was missing money. SS #215 stated she interviewed Resident #22 on 10/06/25 who stated he was missing $1,000 and that he had filed a police report. SS #215 stated a soft file was started for the allegation of misappropriation by the management staff which included witness statements by the Director of Nursing (DON), Certified Nursing Assistant (CNA) #205 and Unit Manager #207. SS #215 stated she was not aware if any other residents were interviewed for concerns related to misappropriation.Interview on 11/20/25 at 9:15 A.M. with the Administrator confirmed the facility had not reported the allegation of misappropriation to the State Survey Agency.Review of the facility policy titled Abuse, Neglect, Exploitation revised 01/01/24 stated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent the abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of property meant the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The policy stated an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. The reporting of alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies should be done not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury.This deficiency represents non-compliance investigated under Complaint Number 2668565.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility to ensure staff provided timely incontinence care. This affected one (Resident #29) of three residents reviewed for incontinence care. This had the potential to affect 26 facility-identified incontinent residents. The facility census was 48 residents. Findings include: Review of medical records for Resident #29 revealed an admitted d 06/15/23 with diagnoses including dementia, depression, osteoporosis, atrial fibrillation, type two diabetes, chronic diastolic heart failure, and anxiety disorder. Review of Minimum Data Set (MDS) assessment for Resident #29 dated 07/18/24 revealed the resident was cognitively impaired and was dependent upon staff assistance with bathing and hygiene. Review of the care plan for Resident #29 dated 07/19/24 revealed the resident had bowel and bladder incontinence. Interventions included the following: be aware of changes in urinary elimination, inspect for skin breakdown and intervene when needed, obtain vital signs, provide incontinence care every two hours and as needed, apply house moisture barrier cream as ordered. Review of the care plan for Resident #29 dated 07/26/23 revealed the resident had a potential for alteration in skin integrity related to bowel and bladder incontinence. Interventions included the following: educate family and resident on skin breakdown, encourage to float heels while in bed, encourage to turn and position every two hours and as needed, pressure reducing mattress to bed, provide assistance with hygiene, including peri care as needed, use barrier cream with showers and with incontinent episodes. Observations on 09/03/24 from 10:45 A.M. through 1:42 P.M. revealed Resident #29 was sitting in her Geri chair in the common area during this time frame, and no staff approached the resident to offer incontinence care. Interview on 09/03/24 at 1:40 P.M. with State tested Nurse Aide (STNA) #206 confirmed Resident #29 was incontinent of bowel and bladder and was confused and should be checked for incontinence every two hours and changed as needed. STNA #206 confirmed she had not checked the resident for incontinence and offered care since 09/03/24 at 10:20 A.M. Observation of incontinence care on 09/03/24 at 1:48 P.M. for Resident #29 per STNA #206 revealed the resident's incontinence brief was saturated with urine and there was feces smeared in the brief. Interview on 09/03/24 at 1:48 P.M. with STNA #206 confirmed Resident #29 had a moderate saturation of urine and smear of feces in her incontinent brief. Interview on 09/03/24 at 1:55 P.M. with STNA #246 confirmed Resident #29 was incontinent of bowel and bladder and should be checked and changed every two hours at a minimum. STNA #246 further confirmed the last time she had checked Resident #29 for incontinence was over three hours prior at 10:20 A.M. Interview on 09/03/24 at 4:00 P.M. with the Director of Nursing (DON) confirmed the STNAs needed more education and were not timely in providing care. Review of facility policy titled Incontinence dated 07/01/24 revealed all residents who were incontinent would receive appropriate care and services. This deficiency represents noncompliance investigated under Complaint Number 00155967.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, hospital visit summary review, facility self-reported incident and investigation review, and staff interview, the facility failed to ensure residents were safely transported on and off the facility vehicle. Actual harm occurred on 06/05/24 when Resident #91, who was in a wheelchair, sustained a fall resulting in multiple fractures including a fracture to his left leg and fractures to his ribs on the left side when staff were assisting him off the facility bus. A space/gap was identified between the ramp platform and the bus and the resident's wheelchair turned and got stuck in there and the resident flipped out of his chair on to the ramp. The resident complained of pain as a result of the fall with injury and was subsequently transported to the emergency room for evaluation and treatment of his injuries. This affected one resident (#91) of four residents reviewed for safety concerns. The facility census was 45. Findings include: Review of the closed medical record for Resident #91 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included presence of an artificial knee joint, altered mental status, type two diabetes mellitus, and chronic pain. Review of the plan of care dated 04/16/19 revealed Resident #91 was at risk for experiencing pain/discomfort related to a long history of opioid use. Resident #91 received narcotic analgesic medication routinely for a long history of knee pain. Resident #91 received corticosteroid injections as needed. Interventions included administering pain medication as ordered and observing side effects and effectiveness, complete pain assessments, and observe for pain every shift. Review of the plan of care dated 05/03/19 revealed Resident #91 had a potential risk for falls related to a history of frequent falls. He has low tolerance and was very easily fatigued. He received narcotic analgesic and psychotropic medications routinely. He had fluctuations in cognition. Intervention includes ensuring Dycem to wheelchair to reduce risk of sliding, assist with transfers as needed, and use a Hoyer lift as needed for transfers. Review of Resident #91's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment for daily decision-making abilities. Resident #91 was noted to be free of bilateral upper or lower impairments and required the use of a wheelchair for mobility. Review of a witnessed fall investigation dated 06/05/24 created by Registered Nurse (RN) #126 revealed the nurse was notified Resident #91 had slipped out of his wheelchair when State tested Nursing Assistant (STNA) was attempting to assist the resident off the bus. Upon observation, Resident #91 was lying on his back complaining of left side back pain and tearful stating left knee pain. Nurse Practitioner (NP) #500 made aware. Immediate (STAT) X-ray of pelvis, bilateral hips and left knee was ordered. Vital signs revealed blood pressure at 120/70 millimeter of mercury (mmHg), pulse at 89 beats per minute, respiration at 18 breaths pre minute, oxygen saturation at 95 % room air, and temperature at 98.2 degrees Fahrenheit. Abrasion noted to the left knee measuring 6.0 centimeter (cm) in length by 0.6 cm in width and area was cleansed with normal saline, pat dry and a dry dressing applied. Resident #91 stated that he slid out of the chair. Review of the completed Skin Observation dated 06/05/24 at 4:00 P.M. revealed Resident #91 was noted to have an abrasion to his left front knee, measurements obtained, and treatment implemented. Review of a Pain Evaluation dated 06/05/24 at 4:10 P.M. for Resident #91 revealed the resident was complaining of pain noted to his left front knee. Pain was also noted using non-verbal pain rating indicating the resident's pain hurt a little more. Non-pharmacological interventions were attempted but not effective. Pain medication was administered. Continued review of investigation revealed an Interdisciplinary note dated 06/05/24 that revealed the family and Medical Director were made aware of the incident. New orders were obtained to cleanse the area to knee with normal saline cover with a clean dry dressing. Resident #91 was sent to the emergency room for evaluation. Fracture noted to left leg and ribs. Family made aware, medical director made aware. Statements provided state that Resident #91 slid forward out of his wheelchair on the bus ramp. Staff education provided. Review of the facility's timeline of events dated 06/05/24 revealed: At 3:00 P.M., Resident #91 fell while getting off the bus on the bus ramp. At 3:05 P.M., STNA with Resident #91 made sure that the resident was in a safe position and then came in to get nursing staff. At 3:10 P.M., Nursing staff came to assess Resident #91 and vital signs obtained. At 3:12 P.M., Assistant Director of Nursing (ADON) notified Power of Attorney (POA) of incident. At 3:15 P.M., Hoyer lift was taken outside and assisted Resident #91 back into his wheelchair. At 3:25 P.M., Resident #91 was assisted back to bed, nurse on the floor assessed skin and pain level, dressing applied to left knee and pain medication was administered. At 3:45 P.M., Medical Director notified, new order received to obtain STAT X-ray of bilateral hips and left knee. At 4:00 P.M., NP #500 was notified when she arrived at the facility. At 4:45 P.M., NP #500 assessed Resident #91. At 5:15 P.M. Family was notified by the ADON and NP#500 that the resident wanted to go to the emergency room for evaluation and was very adamant that he did not want to stay here. At 5:45 P.M.-6:00 P.M. Resident #91 left the facility. Review of the statement dated 06/05/24 created by Transporter #28 revealed Transporter #28 was helping to unload residents off the bus, Activity Director #48 and Transporter #28 were coming back from an outing and the Activity Director was taking another resident inside when Transporter #28 put the lift up and then proceeded to unhook Resident #91 from the locked belts and seat belt. Transporter #28 then unlocked Resident #91's wheelchair; and moved him into the front facing position. Resident #91 was grabbing onto the back of the seat handles and the lift bar, before Transporter #28 could see what was going on, his wheelchair got stuck on the lift and Resident #91 landed on his left side. Resident #91 denied hitting his head. Review of an undated statement created by Licensed Practical Nurse (LPN) #82 revealed at approximately 3:00 P.M., LPN #82 was notified by STNA (Transporter #28) that Resident #91 fell out of his chair onto the bus ramp. Upon arriving outside to the bus, LPN #82 noted Resident #91 was laying on his right side on the bus ramp. Resident #91 stated that he fell out of his chair, and he was complaining of left knee pain. STNA (Transporter #28) stated she was getting Resident #91 onto the ramp and his wheelchair caught the ramp's lip, and he slid out of his chair onto his buttock onto the legs of the wheelchair and then slid out to the ramp on his left side. This STNA (Transporter #28) stated she made sure the resident was in a safe position before she came in to get help. LPN #82 assessed Resident #91 and noted an abrasion to his left knee, vital signs were 120/70 mmHg, heart rate at 89 beats per minute, respiration at 18 breaths per minutes, oxygen saturations at 95% room air, temperature at 98.2 degrees F, and pain was noted to be a 5 out of 10 on the numeric pain scale, and pupils were equal, round, and reactive to light and accommodation (PERRLA). Resident #91 stated pain is in his left leg mainly in the left knee. Resident #91 responded appropriately. Staff assisted resident back to wheelchair via Hoyer lift with no complications, then back to his bed. Once Resident #91 was back to bed, the floor nurse administered resident medication including ordered pain medication. NP #500 notified. Power of Attorney (POA) notified. POA and NP #500 agreed to obtain in house STAT X-ray to bilateral hips and left knee. STAT X-ray ordered at approximately 3:45 P.M. Under further assessment from NP #500 at approximately 4:45 P.M., Resident #91 stated that he was in pain and that he wanted to go to the emergency room for evaluation. POA was notified and Resident #91 was sent to the emergency room . Resident #91 left the facility at approximately 5:45 P.M.-6:00 P.M. Review of Resident #91's hospital summary record dated 06/05/24 revealed a clinical impression including periprosthetic fracture around internal prosthetic left knee joint, closed nondisplaced fracture of medial malleolus of the left tibia, and closed fracture of the distal end of the left ulna. Review of the statement created by LPN #22 dated 06/06/24 revealed when LPN #22 walked out the front door of the facility, Resident #91 was lying with his head towards the building and bilateral lower extremities (BLE) was towards the bus in supine position. Staff slightly rolled resident to left side, placed a Hoyer pad under him, rolled slightly to the right side, placed Hoyer pad in the center of him. Staff placed the Hoyer lift around the resident and lowered it down to the resident and the ramp, placed the correct straps on the residents Hoyer pad to gently lift the resident up. Staff placed the wheelchair in the correct position and transferred him into the wheelchair via Hoyer lift with no further incidents noted. Resident #91 was then brought inside by staff. Review of the statement created by Admissions #98 dated 06/06/24 revealed that on 06/05/24 around 3:00 P.M. STNA #28 came into the office and requested assistance. She said Resident #91 had fallen out of his wheelchair and was on the lift. The nurse went outside with other staff. LPN #82 and floor nurses assessed Resident #91. He was lying on the lift; the lift was on the ground. His head was lying towards the end of the lift, with his feet towards the bus lying more on his right side, with complaints of pain to his left leg and hip area. The mechanical lift was brought out to the bus, the Hoyer pad was removed from his wheelchair to be placed under him. He was mechanically transferred into his wheelchair and taken back to his room. NP #500 visited with Resident #91 to assess his level of pain and injuries. Review of the statement created by Receptionist #38 dated 06/06/24 revealed that Receptionist #38 was a witness on 06/05/24. Resident #91 had a fall; however, she did not actually witness the fall. Receptionist #38 saw Resident #91 on the lift on the ground with nursing staff and the Administrator and they were assessing him and using a Hoyer lift to get him up safely. Review of the statement dated 06/06/24 created by Activities Director #48 revealed that on 06/05/24, they had come back from an outing, approximately 3:00 P.M. Activities Director #48 and Transportation #28 were on the outing. They had unloaded a resident off the lift, and Activities Director #48 went inside with the other resident to take her back to her room. When she came back out to the bus, Resident #91 was on his back on the lift and the lift had been lowered to the ground. Review of the statement created by Social Worker #128 revealed Transporter #28 came to the front door and asked for help to assist with Resident #91, Social Worker #128 observed him lying on the lift with a pillow under his head. Staff all helped with getting a lift and getting him back into his wheelchair. Nursing ordered a STAT x-ray for him. Review of an undated statement created by RN #126 revealed she was located in the admissions office speaking with LPN #82 when Transporter #28 came through the front door stating Resident #91 was on the ground. Upon assessment after exiting the front door, Resident #91 was observed lying on his back with his head towards the end of the ramp. Resident #91 stated his leg hurts. Unable to obtain blood pressure due to cuff malfunction. All other vital signs within normal limits. Transporter #28 advised resident did not hit his head. A call was placed to POA who declined for resident to be sent to the emergency room . All available staff assisted residents to turn side to side to place the Hoyer pad under the resident. Resident #91 was assisted back into the wheelchair via Hoyer. Resident #91 was taken to his room and assisted into bed via Hoyer lift. Upon assessment Resident #91 was noted with a 6 cm in length by 0.6 cm in width abrasion to the left knee. Area was cleansed with normal saline, pat dry and foam dressing applied. Small hematoma noted to left knee. Routine Norco (pain medication) administered at this time. LPN #82 was advised to obtain X-rays, orders placed in electronic charting system and X-ray provider contacted. NP #500 in facility and confirmed she was aware of the incident. At approximately 5:30-ish P.M., received call from NP #500 to send to the emergency room to evaluate and treat. Resident #91 sent to local ER via squad. Report called in to the ER and advised of incident. Interview on 06/28/24 at 10:42 A.M. with the DON revealed she was not at the facility when this incident with Resident #91 occurred but per her understanding staff was either assisting Resident #91 on or off the bus via wheelchair and using the buses wheelchair ramp. There was a very small space/gap between the ramp platform and the bus and the resident's wheelchair somehow turned and got stuck in there and the resident flipped out of his chair on to the ramp. Resident #91 did sustain fractures and the family felt best for the resident to reside at a different facility (following the incident), so the resident was discharged . Interview on 06/28/24 at 1:30 P.M. with Transporter #28 revealed the facility bus had just returned from an activity outing and she was assisting residents back into the facility. Resident #91 was still on the facility van so she made sure the van's wheelchair lift was up so she could assist the resident off the van. She stated she grabbed the resident's wheelchair handles and turned the wheelchair and proceeded to push the wheelchair off the van and onto the lift. The lift has a handrail on both sides and while she was pushing Resident #91's wheelchair onto the lift, he grabbed hold of the railing and proceeded to try and pull himself onto the van lift. There was a gap between the van and the lift and when she was turning the wheelchair, the wheels on the chair were sideways and got stuck in the gap. Due to the wheelchair wheels being stuck in this gap and Resident #91 pulling himself with the lift railing, he pulled himself right out of his wheelchair and onto the wheelchair lift. Transporter #28 stated she then made sure the resident was safe and lowered the lift to the ground so she could go get assistance. Interview on 06/28/2024 at 3:00 P.M. with Activity Director #48 revealed she was the one driving the bus the day this incident with Resident #91 occurred. She stated they had just gotten back from a group outing (going out to eat). Activity Director #48 claimed she was assisting residents off the bus and another staff member came out to assist. She was taking a resident into the facility and the other staff member was in the process of assisting Resident #91 off the bus via wheelchair and the bus wheelchair lift. Before she could come back out, she heard everyone saying the Resident #91 fell out of his wheelchair and they were going out to help get him back up. Upon returning to the bus, she said the bus wheelchair lift was on the ground level and Resident #91 was laying with his head away from the van side door and his legs were facing towards the van's side door. The deficient practice was corrected on 06/06/24 when the facility implemented the following corrective actions: On 06/05/24 the facility Administrator notified the Medical Director of actions taken. No additional orders or recommendations received. On 06/06/24, all staff education was given by Regional Nursing Director #600 for falls, notification, transportation, abuse and neglect, and safe transfers. On 06/06/24, all staff that transfer residents via bus were educated by Activity Director #48 with return demonstration. Audits performed with every transport, 1-2 transports daily for the month of July 2024, then weekly for the month of August 2025, September 2024, and October 2024. This deficiency represents non-compliance investigated under Complaint Number OH00154902.

Based on observation, staff interview, and record review, the facility failed to cover residents' catheter bags to promote privacy and dignity. This affected four (Residents #192, #33, #34, and #39) of four residents reviewed for dignity. The facility's census was 42. Findings include: 1. Review of the medical record revealed Resident #192 admitted to the facility on [DATE] and had diagnoses of type II diabetes, non-pressure chronic ulcer, unspecified major depressive disorder, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident # 192 was a two-person assist, was independent with eating, and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of the care plan dated 02/13/23 revealed Resident #192 had the potential for complications related to the use of a Foley catheter. Interventions included change catheter as needed, change Foley collection bag as per policy, position catheter bag and tubing below the level of the bladder, ensure tubing is not under the resident's legs, obtain output every shift, encourage fluids, observe/report signs of infection, report abnormal labs, and provide Foley catheter care per policy. Observation on 02/21/23 at 11:20 A.M. revealed Resident #192 had a urine collection bag in a clear trash liner attached to the right side of the bed and visible from the hallway. Interview on 02/21/23 at 11:52 A.M. Licensed Practical Nurse (LPN) #308 verified Resident #192's catheter bag was hanging from bed in a clear trash liner and should have been in a dignity bag (a bag used to cover the catheter bag showing any urine drainage). LPN #308 stated the aides had asked about dignity bags that morning and she had told them if they could not locate them in the storage room, they should use pillowcases to cover the urine collection bags. 47058 2. Medical record review revealed Resident #33 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, retention of urine, mononeuropathy, benign prostatic hyperplasia without lower urinary tract symptoms, heart failure, and diabetes mellitus. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #33 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder, and was incontinent of bowel, wore briefs, and required peri care every two hours and as needed. Observation on 02/21/23 at 12:13 P.M. of Resident #33 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a privacy (dignity) bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. 3. Medical record review revealed Resident #34 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, cerebral infarction, hyperlipoidemia, and obstructive and reflux uropathy. Review of Resident #34's entry Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #34 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder and a colostomy for bowel. Observation on 02/21/23 at 12:15 P.M. of Resident #34 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a dignity bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. 4. Medical record review revealed Resident #34 admitted to the facility on [DATE] with essential hypertension, urinary tract infection, hematuria, other retention of urine, hyperlipidemia, and tachycardia. Review of Resident #39's entry Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #39 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder, was incontinent of bowel and required peri care every two hours and as needed. Observation on 02/21/23 at 12:35 P.M. of Resident #39 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a dignity bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. Interview on 02/22/23 at 09:30 A.M. with the Director of Nursing (DON) verified Foley catheter bags were to be covered with privacy (dignity) bags per policy. Review of policy titled, Catheter Care, dated 08/22/22 revealed privacy (dignity) bags will be available, and catheter drainage bags will be covered at all times while in use.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were disposed of safely. This had the potential to affect four (Residents #11, #30, #34, and #36) who the facility identified as independently mobile and cognitively impaired. The facility census was 42. Findings include: Observation on 02/22/23 at 8:08 A.M. revealed Registered Nurse (RN) #312 threw away medications in the trash can on the 200-Hall medication cart. Medications thrown away included isosorbide 60 mg, amlodipine 5 mg, metoprolol 100 mg, metoprolol 50 mg, losartan 50 mg, and dicyclomine 20 mg. Interview on 02/22/23 at 8:09 A.M. RN #312 verified she had thrown the medications in the trash can and stated she always threw medications away in the trash can and emptied the trash when she was finished with her medication pass because they were no longer allowed to throw medications away in the sharp's container. Review of policy titled, Storage of Controlled Medications, dated 06/2017 revealed nurses were responsible for the storage and safe handling of medications.

Based on medical record, staff interview and policy review, the facility failed to provide adequate care and treatment to a resident's pressure ulcers. This affected one (#242) out of two residents reviewed for wound care. The facility census was 42. Findings include: Review of the Resident #242's chart revealed Resident #242 was admitted to the facility on [DATE] with diagnoses including non st elevation myocardial infarction, sepsis, paroxysmal atrial fibrillation, depression, multiple sclerosis, hyperlipidemia, anxiety disorder, obstructive sleep apnea, personal history of urinary tract infections, hypertension, congestive heart failure and type two diabetes mellitus. Resident #242 discharged from the facility 12/26/22. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #242's cognition was not assessed. The resident required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #242 required total dependence with transfers and Resident #242 was independent with eating. Resident #242 had a stage four pressure ulcer present upon admission. Review of the wound care note dated 12/13/22, completed by a different facility prior to Resident #242's admission to the current facility, revealed the resident had a stage four pressure ulcer to his sacrum measuring 8.52 centimeters (cm) in length by (x) 11.51 cm in width x 5.0 cm in depth. Additional review revealed the resident had a stage one pressure ulcer to the left heel measuring 4.61 cm in length x 4.76 cm in width, and a suspected deep tissue injury to the right heel measuring 2.45 cm in length x 3.55 cm in width. Resident #242 was ordered to have his right and left heels cleaned with wound cleanser and have skin barrier wipes applied with a foam bordered dressing. Review of the progress note dated 12/22/22, revealed Resident #242 arrived at the current facility at approximately 9:00 P.M. The Director of Nursing (DON), family, and physician were made aware of Resident #242's arrival. Review of the Braden score assessment dated [DATE] revealed Resident #242 was at low risk for developing pressure ulcers. Review of the admission assessment and baseline care plan dated 12/23/22, revealed Resident #242 had a pressure area to the left heel measuring 2.0 cm in length x 1.5 cm in wide x 0.01 cm in depth, a pressure area to the right heel measuring 4.5 cm in length x 4.0 cm in width x 0.01 cm in depth, and an unstageable pressure ulcer to the sacrum that was 11.5 cm in length x 9.0 cm in width x 0.5 cm in depth. Review of the wound progress note dated 12/26/22, revealed Resident #242 had a deep tissue injury to his left heel that was 3.0 cm x 2.0 cm, an unstageable deep tissue injury to the right heel measuring 4.5 cm x 4.0 cm, with a small amount of blood pooled and was palpable under the skin. Additionally, the resident had a stage four sacrum wound measuring 9.0 cm x 14 cm x 4.0 cm. The physician was in to see the resident. Review of the progress notes dated 12/26/22, revealed Resident #242's wife was at the facility requesting Resident #242 be sent out to the hospital for evaluation. The resident was sent to the hospital per request. Review of Resident #242's physician progress note dated 12/26/22, revealed Resident #242 was seen by the physician and the resident wanted to go home with home health. Resident #242 had a rectal tube and Foley catheter. Resident #242 had a stage three to the sacrum. Review of Resident #242's physician orders from 12/22/22 to 12/26/22 revealed Resident #242 did not have any wound treatment orders in place for the pressure ulcers on his right and left heels. Interview on 02/24/23 at 3:38 P.M. with Wound Care Licensed Practical Nurse (WC LPN) #366 verified Resident #242 did not have any treatment orders in place for his pressure areas on his right and left heel and stated skin prep could have been continued from his prior facility. WC LPN #366 reported Resident #242's pressure ulcers on his heels were not opened on 12/26/22 and she felt that the nurse that did Resident #242's admission assessment incorrectly recorded depth on Resident #242's pressure areas to his heels. WC LPN #366 also stated she notified Physician #900 of Resident #242's pressure ulcers on his right and left heel on 12/26/22 but was not sure if the physician was notified of the areas to Resident #242's heels prior to 12/26/22. WC LPN #366 stated she was not sure if Resident #242 had heel boots on when she assessed him on 12/26/22. Review of the undated negative pressure wound therapy policy revealed the facility will provide evidenced based treatments in accordance with current standards of practice and physician orders. Review of the facility's wound care policy dated November 2018 revealed the facility will provide therapeutic treatment to heal wounds. Treatments implemented by a nurse require a physician order. This deficiency represents non-compliance investigated under Complaint Number OH00138942.

Based on medical record review, observations, staff interview, and review of facility policy, the facility failed to limit access to areas of the facility with Coronavirus Disease 2019 (COVID-19) positive residents and failed to post signs displaying staff personal protective equipment (PPE) requirements for isolation quarantine rooms to potentially prevent the spread of COVID-19. This had the potential to affect all 37 residents residing in the facility. The census was 37. Findings include: 1. During tour of the facility on 11/23/20 at 10:50 A.M. the surveyor was stopped by Licensed Practical Nurse (LPN) #150 and asked not to go past the nursing station in the 100 hallway past rooms [ROOM NUMBERS] because residents positive for COVID 19 resided in that area. This section of hallway contained rooms numbered 108 through 115. Observations revealed there was no physical barrier or signs posted noting this area had COVID-19 positive residents. Isolation carts containing PPE were observed in front of rooms and room doors were closed. On 11/23/20 at 11:12 A.M. LPN #150 and State tested Nursing Assistant (STNA) #200 were observed exiting to the outside of the facility through a door located between rooms [ROOM NUMBERS]. The staff was observed wearing a N95 and eye protection but no other PPE (gown or gloves). On 11/23/20 at 11:27 A.M. two staff members were observed exiting to the outside of the facility through a door located between rooms [ROOM NUMBERS]. The staff was observed wearing a N95 and eye protection but no other PPE (gown or gloves). Interview with LPN #150 on 11/23/20 at 11:47 A.M. revealed the door was used by staff to exit the building for use of a smoking patio. On 11/23/20 at 11:48 A.M. two staff members were observed entering the building through the door located between rooms [ROOM NUMBERS]. The staff was observed wearing a N95 and eye protection but no other PPE (gown or gloves). Interview with the Administrator on 11/23/20 at 1:05 P.M. confirmed that staff had been exiting and re-entering from the smoking patio through the door located at the end of the 100 hallway located between rooms [ROOM NUMBERS]. The Administrator confirmed that section of the hallway is where COVID-19 positive residents reside including Resident #7, #9, and #17. The facility confirmed staff passing through this area which is the COVID-19 unit wear a N95 and eye protection when walking through the COVID-19 but no other PPE (gown or gloves). Review of three (#7, #9, and #17) residents medical records revealed the had tested positive for COVID 19 and resided in the 100 hallway between rooms 108 through 115. 2. During tour of the the facility on 11/23/20 at 10:40 A.M. isolation carts containing PPE were observed at the room entrance doors for Resident #7, #9, #17, #29, #30 and #33. A sign noting STOP see nurse before entering was posted on each door. No signs were displayed noting what transmission-based precautions or what specific PPE was required by staff to enter room was observed posted. Review of medical records revealed Resident #7, #9, and #17 tested positive for COVID-19 and were in droplet isolation precautions. Review of Resident #29, #30, and #33 medical records revealed they were in droplet precaution quarantine related to COVID-19 potential exposure. Interview with LPN #100 on 11/23/20 at 12:05 P.M. confirmed the entrance of Resident #7, #9, #17, #29, #30 and #33 rooms did not have any signs posted noting what precautions were to be taken or what PPE was required by staff. Review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions dated January 2012 revealed when transmission-based precautions are initiated the Infection Preventist (or designee) shall post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse for additional information about the situation before entering the room. The facility's process for notification is ___________ (area for process was left blank).

Based on medical record reviews, observations, review of the Food and Drug Administration guidelines, and staff interview, the facility failed to ensure residents had side rails/enabler bars that were the size recommended for safety to prevent entrapment. This affected four residents (#6, #13, #29 and #33) of 14 identified as having side rails or enabler bars in the facility. The facility census was 45. Findings included: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment completed on 06/14/18 revealed Resident #6 had severe cognitive impairment. She required extensive assist of two staff for bed mobility. Observation of Resident #6 with the Administrator on 09/10/18 at 12:56 P.M, revealed the resident was in bed with an enabler bar, with a large opening on her right side. The Administrator measured the opening. The gap measured 15 inches, by 13 inches. The facility placed a cover over the bar to prevent entrapment. 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment completed on 07/03/18 revealed the resident had severe cognitive impairment. She was totally dependent on two staff for bed mobility, transfer and locomotion. Review of Resident #13's side rail assessment dated [DATE] revealed a recommendation for bilateral side rails to be used with an air mattress. Observation of Resident #13 with the Administrator on 09/10/18, at 12:57 P.M., revealed the resident was in bed on an air mattress with bilateral side rails. There was a large opening at the center of the side rails. The Administrator measured the opening in the side rail and found it was seven inches by seven and a half inches. She covered the opening by placing bilateral rail padding on the inside. 3. Medical record review revealed Resident #29 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment completed on 07/26/18 revealed the resident had moderate cognitive impairment. He required extensive assist of one staff for bed mobility. Observation of Resident #29 with the Administrator 09/10/18 at 12:59 P.M., revealed the resident was in bed with an enabler bar to his right side measuring 14 inches wide, by 12 inches from the top, to the mattress. A cover was placed over the enabler bar immediately covering the large opening. 4. Medical record review revealed Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's annual MDS assessment completed on 08/09/18 revealed the resident was cognitively intact. He required limited assistance of one staff for bed mobility. Observation of Resident #33 with the Administrator on 09/10/18 at 1:03 P.M., revealed the resident had an enabler bar with a large opening to his right side against the wall. The facility placed a cover immediately over the opening to prevent entrapment. Interview with the Director of Nursing (DON) on 09/10/18 at 12:55 P.M., revealed she was monitoring the distance between the mattress and rails, however was unaware there were safety recommendations regarding the space within the rails. She confirmed this had not been monitored. She confirmed there had never been any residents entrapped in a rail. Review of the FDA Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/16, revealed to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The recommendations for the dimension was to be no more than 4 3/4 inches.

Based on medical record reviews, resident interview, and staff interview. the facility failed to ensure residents received a transfer notice prior to going to the hospital. This affected two (#29 and #37) of three residents reviewed for hospitalization . The facility census was 45. Findings included: 1. Medical record review revealed Resident #29 was admitted to the facility originally on 06/02/17 and was readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment completed on 07/26/18 revealed the resident had moderate cognitive impairment. Continued medical record review revealed Resident #29 was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was provided a transfer notice upon transfer to the hospital. Interview with Resident #29 on 09/11/18 at 10:21 A.M., revealed he had not received a transfer notice during his last hospitalization . 2. Medical record review revealed Resident #37 was admitted to the facility originally on 06/07/12, and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment completed on 08/22/18 revealed the resident was cognitively intact. Continued medical record review revealed the resident was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was given a transfer notice upon discharge to the hospital. Interview on 09/11/18 at 6:15 P.M., with the Administrator, confirmed there was no evidence Residents #29, or #37 were given a transfer notice when they both were transferred to the hospital.

Based on medical record reviews, resident interview, and staff interview, the facility failed to ensure residents received a bed hold notice prior to going to the hospital. This affected two (#29 and #37) of three residents reviewed for hospitalization . The facility census was 45. Findings included: 1. Medical record review revealed Resident #29 was admitted to the facility originally on 06/02/17 and was readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment completed on 07/26/18 revealed the resident had moderate cognitive impairment. Continued medical record review revealed Resident #29 was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was provided a bed hold notice upon transfer to the hospital. Interview with Resident #29 on 09/11/18 at 10:21 A.M., confirmed he had not received a bed hold notice during his last hospitalization . 2. Medical record review revealed Resident #37 was admitted to the facility originally on 06/07/12, and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment completed on 08/22/18 revealed the resident was cognitively intact. Continued review of Resident #37's medical record revealed the resident was discharged to the hospital on [DATE], and was readmitted on [DATE]. There was no evidence the resident was given a bed hold notice upon discharge to the hospital. Interview on 09/11/18 at 6:15 P.M., with the Administrator confirmed there was no documentation Residents #29, or #37 were given a bed hold notice.

Based on observation, interview and policy review, the facility failed to ensure the facility's low temperature dish machine had the correct concentration to sanitize resident dishes and utensils to prevent food borne illness. This has the potential to affect 42 of the facility's 44 residents who eat their meals from the main kitchen. Findings include: During tour of the facility's main kitchen on 02/17/15 at 9:30 A.M. revealed Food Service Worker (FSW) #12 was washing resident dishes in a low temperature dish machine. On request of the surveyor, FSW #12 tested the concentration of chloride sanitizer in the machine. The concentration measured less then 50 parts per million (PPM). FSW #12 verified the concentration was below the required 50 PPM and stated she had not checked the concentration prior to using the machine that morning. During interview on 02/17/15 at 10:30 A.M. Dietary Manager #8 confirmed the concentration should be above 50 PPM and stated the machine should be checked prior to each use. Review of the facility's policy for Dish Machine Temperatures undated indicated that prior to each period of use a test strip should be run through the dishwasher. Review of the facility's dish machine temperature log for indicated for chemical sanitizing the chlorine solution should be 50-200 PPM.

Based on closed record review and staff and family interviews, the facility failed to ensure residents discharge from the facility were provided appropriate notice of the discharge. This affected one (#1) of three residents sampled for admission, transfer and discharge. The facility census was 45. Findings include: Review of the closed medical record of Resident #1 revealed the resident was readmitted to the facility on [DATE]. Further review of the closed record revealed the resident was sent to the emergency room due to a low oxygen saturation. The resident did not return to the facility and was discharged from the facility. There was no evidence in the closed record the resident and/or family was provided a notice of discharge from the facility. During telephone interview on 03/04/14 at 12:18 PM, the resident's Power of Attorney (POA) stated the resident was readmitted to facility on 02/07/14. The POA stated Licensed Practical Nurse (LPN) #20 called her and informed her Resident #1 was sent to the emergency room due to her oxygen saturation being low. The POA stated LPN #20 stated they could not get the resident's oxygen saturation back up after the resident fell . The POA stated LPN #20 told her the facility could not care for resident because the resident continuously wanted to get out of the bed. The POA further stated while the resident was at the hospital on [DATE] the hospital nurse informed her they could not get in contact with the facility's Head of Nursing and that the staff at the facility could not take the resident back. The POA stated a staff member from the facility called her on 02/08/14 and informed her they were unable to take the resident back from the hospital because they were unable to provide what she needed. The POA stated the facility did not give her any notice of the discharge. During interview on 03/04/14 at 2:11 PM, the Director of Nursing (DON) stated Resident #1 was hardly able to be kept in the bed. The DON stated the evening of 02/08/14 she got a call from the hospital to see if they could send the resident back. The DON stated she them the hospital staff the facility could not keep the resident safe in the building and it was not in the facility's best interest to keep the resident there. The DON stated they talked about getting a sitter for the resident but they did not think that would be effective. She verified the facility did not accept the resident back from the hospital or give the resident a notice of discharge. This certification deficiency substantiates Complaint Control Number OH 606.

Based on observation, staff and resident interview, and review of the facility dining services policy, the facility failed to provide residents with a homelike environment while dining in the main dining room. This had the potential to affect more than a limited number of residents who used the main dining room for meals, including 19 of the 41 facility residents observed in the main dining room during the noon meal on 11/12/13. Findings include: 1. On 11/12/13, at 12:09 P.M., facility residents were observed seated around the ten tables in the main dining room of the facility. None of the residents had yet been served. The residents were sitting at tables void of any beverages, napkins, silverware, condiments or table dressing/decoration of any kind. At 12:14 P.M. facility staff began serving the residents their lunch when the trays of food arrived on utility carts in the dining room. There were 19 resident in the main dining room at that time. The trays used to transport and hold the resident's hot and cold food items were individual compartment trays which were covered. The large, square compartment trays held the individual's plate of food, small bowls of side dishes, and silverware/napkin which fit into slots on the tray. Individual cartons and containers of beverages were iced down and served from the serving area in the dining room directly to residents. After the first cart full of trays arrived nursing staff began serving the residents by taking the entire compartment tray, with the lid removed, and setting it in front of the residents. The plates, bowls of salad/desserts, and silverware and napkin were all left within the confines of the compartment trays when they were served; and while they ate. Nursing staff also served resident milk and milk shake supplements in the paper cartons. Opening the cartons for the residents and leaving the cartons on the tray/table. The milk and supplements were not poured into cups for the residents. The residents had to drink the milk and/or supplements directly from the cartons. Some of the resident were provided straws to drink from the cartons, some were not. Resident #11 was observed drinking her milk out a the carton. She was queried about drinking her milk of the carton. Resident #11 shared a straw would be easier, and that you could get one if you asked. Resident #53, who was cognitively impaired, was picking up her opened carton of national supplement looking at it and turning it around in her hand repeatedly, then set it down without drinking it. She picked it up again and set it down on top of her container of ice cream. At 1:00 P.M. State tested Nurse Aide (STNA) #21 sat down at the table occupied by Residents #16 who was cognitively impaired, and Resident #53. Resident #16 stated to STNA #21 that she was finished eating. The nurse aide then encouraged her to drink her beverages, sitting the opened carton of supplement in front of her and telling her that it was her "milk shake". The confused resident stated "oh is that what that is" and began drinking out of the carton. On 11/12/13, at 5:55 P.M., the same procedure was used to served the supper meal. The compartment trays were placed directly on the tables in front of the residents with all the dishes and utensil left in the slots in the compartment tray. The resident then ate their meals from the dishes within the confines of slots in the tray. The aforementioned observations were shared with the Director of Nursing (DON) and Administrator on 11/14/13 at 8:35 A.M. The Administrator and DON were queried if they had identified that serving the residents their meal in the large compartment trays appeared very institutional versus homelike; they reported they had not. The DON stated the facility has always been serving residents in the dining room this way. The Administrator and DON did voice agreement that it could potentially appear institutional versus homelike. The facility's dining program policy was reviewed on 11/14/13 at 3:35 P.M. The dining program policy did not address the facility's current practice of serving resident meals in the compartment trays.

Based on review of the facility policy for medication storage, observations, and staff interview, the facility failed to ensure that insulin was stored properly in a locked area. This affected ten residents identified by the facility who received insulin that was not secured ( Resident #40, #25, #27, #32, #30, #5, #17, #28, #23, and #36) of the 47 residents residing in the facility and receiving medications. Findings include: Observations were made on 04/01/11 at 4:20 P.M. of a unlocked tackle box on top of the treatment cart which contained 22 bottles of opened insulin and lancets. Licensed Practical Nurse (LPN) # 8 left the unlocked tackle box in the hallway, which contained the 22 vials of insulin and lancets, turned, walked into a residents room, and shut the door. On 04/01/11 at 4:20 P.M. LPN #8 was interviewed. She affirmed she had left the unlocked tackle box on top of the treatment cart which contained 22 bottles of opened insulin and lancets. She affirmed she had turned her back, walked into a residents room, and shut the door. On 04/03/11 at 8:30 A.M. the Director of Nursing (DON) was interviewed. She stated it was her expectation the nurses kept the insulin under lock and key when not being supervised by the nurse. The Storage of Medications Policy, dated 05/10 was reviewed. The policy stated the facility should ensure that all medications and biologicals are securely stored in a locked cabinet, cart or locked medication room that is inaccessible by residents and visitors.