Every finding on record at Cedarvale Commons Rehabilitation and Healthcare Ce

Based on staff interview, record review, and review of facility policy, the facility failed to transfer a resident as per the care plan resulting in a fall. This affected one (#54) of three residents reviewed for accidents. The facility census was 87 residents.Findings include: Review of the medical record for Resident #54's revealed an admission date of 04/13/26. Diagnoses included cerebral infarction (CVA/stroke), chronic obstructive pulmonary disease (COPD), muscle weakness (generalized), need for assistance with personal care, muscle wasting and atrophy, B-cell lymphoma, secondary malignant neoplasm of bone, and secondary malignant neoplasm of brain.Review of the admission evaluation for Resident #54 dated 04/13/26, revealed the resident was at high risk for falling.Review of the care plan for Resident #54 dated 04/14/26, revealed the resident was at risk for falls related to decreased strength and endurance, generalized weakness, history of falls, hypotension, and need for assistance with activities of daily living (ADLs). Further review of the care plan revealed the resident had an ADL self-care performance deficit related to anxiety, COPD, depression, generalized weakness, and history of falls with an intervention for two person assist during transfers. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 04/19/26, revealed the resident was cognitively intact and dependent on staff for chair/bed-to-chair transfer and sit to stand.Review of the psychiatry initial consult for Resident #54 dated 05/07/26, revealed Resident #54 had paralysis of the left side.Review of an incident note for Resident #54 dated 06/27/26 at 11:03 P.M. and authored by Licensed Practical Nurse (LPN) #105, revealed a Certified Nursing Assistant (CNA) was noted to be transferring Resident #54 from the wheelchair to the bed and while turning the resident to sit on the bed, the resident reported her leg gave out causing her to fall. The resident hit her head on the grab bar on the bed which resulted in a small abrasion to the left temple. The resident refused to go the hospital for an evaluation. Review of the fall occurrence note for Resident #54 dated 06/27/26 at 11:08 P.M. and authored by LPN #105, revealed a CNA was transferring Resident #54 by herself. Review of Nurse Practitioner (NP) note for Resident #54 dated 06/28/26 at 5:48 A.M, revealed the resident was seen related to a witnessed fall during a transfer and hit her head. The resident had history of left side paralysis secondary to a CVA/stroke. The resident was diagnosed with head strike injury with small abrasion to the left temple. The fall risk interventions were reviewed and reinforced. During an interview on 07/28/26 at 3:20 P.M., LPN #105 stated a CNA assisted Resident #54 back to her room via a wheelchair after smoking. Upon return to the resident's room, the CNA attempted to transfer Resident #54 from the wheelchair to the bed by herself. During the transfer from the wheelchair to the bed, Resident #54's leg gave out and the CNA assisted the resident to the floor. The CNA then came to get the nurse. LPN #105 confirmed Resident #54 was a two person assist for all transfers as per the resident's plan of care but was transferred with the assistance of one. LPN #105 stated the CNA did not know Resident #54 was a two person assist for transfers. During an interview on 07/29/26 at 7:25 A.M., the Director of Nursing (DON) stated physical therapy (PT) had been working on stand and pivot transfers with Resident #54 prior to the fall on 06/27/26. At the time of the fall, Resident #54 requested that the CNA allow her to stand and pivot transferred, and the resident fell.During an interview on 07/29/26 at 10:40 A.M., Physical Therapist Assistant (PTA) #204 stated PT was working on stand and pivot transfers with the assistance of one with Resident #54 prior to the fall on 06/27/26. However, Resident #54 required significant effort to stand, and pivot transfer due to the effort required to assist the resident to move her arm and leg. PTA #204 stated the CNAs had not been educated on the techniques needed to safely stand and pivot transfer Resident #54 with the assistance of one and confirmed Resident #54 should not have been transferred by a CNA using that method. During an interview on 07/29/26 at 11:09 A.M., the DON stated on the day of the fall, Resident #54 performed stand and pivot transfers with therapy with moderate to minimal assistance, and that is why Resident #54 requested to transfer with the assistance of one, and the CNA did it. The DON further stated that the facility tries to adhere to the residents' request for care and the CNA may take those requests at face value if the resident was oriented; however, the DON confirmed the practice of not following the plan of care is not acceptable. Review of policy 'Activities of Daily Living (ADLs)' undated revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking).

Based on personnel record review, staff interview, and review of facility policy and procedure, the facility failed to ensure Certified Nurse Aides (CNA) had annual performance evaluations. This had the potential to affect all facility residents. The facility census was 64. Findings include 1. Review of the employee file for CNA #120 revealed she began employment on 04/09/24 The employee file revealed no documented evidence of a completed annual performance evaluation. 2. Review of the employee file for CNA #81 revealed she began employment on 07/05/23. The employee file revealed no documented evidence of completed annual performance evaluations. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified no evaluations were in the employee files for CNA #81 and #120. Interview on 06/24/25 at 4:20 P.M. with the Administrator verified evaluations were electronic and disappeared and facility was unable to provide any evidence of them being completed. Review of facility policy titled Performance Evaluations dated September 2021 revealed the job performance of employees shall be reviewed at least annually. A copy shall be provided to the Human Resource (HR) Director and maintained in the employee file.

Based on observation, resident interview, staff interview, review of dietary production spreadsheets, review of resident meal tickets, and review of the facility's always available menu, the facility failed to ensure portion sizes were served as planned, which had the potential to affect all residents. The facility also failed to ensure items on the always available menu were available for Resident #17 and Resident #37. This affected two residents (#17 and #37) out of 64 residents observed during dining. The facility also failed to ensure the meal served matched the meal ticket. This affected two Residents (#10 and #21) of three observed for meal tickets. The facility census was 64. Findings include: 1. Observations on 06/17/25 from 11:05 A.M. to 11:35 A.M. revealed four ounce scoops were utilized for the pureed and regular broccoli. When [NAME] #125 was serving the meal and scooped the pureed and regular broccoli, she was not filling the entire scoop. Interview on 06/17/25 at 11:35 A.M., [NAME] #125 verified she was not consistently filling the entire scoop with the pureed and regular broccoli when serving. When queried as to how much broccoli was actually being served, [NAME] #125 replied, that's a good question. 2. Observations on 06/17/25 from 11:05 A.M. to 12:09 P.M. revealed three ounce scoops were utilized for the pureed and ground pork loin. Review of the Production Sheet, dated 2025, revealed the serving size for the ground pork and pureed pork was a #8 scoop (4 ounces). Interview on 06/17/25 at 12:09 P.M., Dietary Director (DD) #101 verified three ounce scoops were utilized for the pureed and ground pork and the serving size on the production sheet was four ounces. DD # 101 stated the cook was responsible for ensuring the appropriate scoop size was used. 3. Observation on 06/17/25 at 11:52 A.M. revealed an unidentified staff member opened the door to the kitchen and asked the dietary staff for a grilled cheese for Resident #17. [NAME] #135 stated there were no grilled cheese's available. The unidentified staff member then exited the kitchen without any food. Review of the undated facility document titled, Always Available at Mealtimes, revealed grilled cheese, hot dogs, peanut butter and jelly sandwiches, deli sandwiches, and salads were available. Observation on 06/17/25 at 12:50 P.M. revealed the always available menu was posted throughout the building. Interview on 06/17/25 at 12:50 P.M., Dietary Director (DD) #101 confirmed grilled cheese was on the always available menu, posted throughout the building and was not available for the lunch meal. DD #101 stated she had ran out of cheese. DD #101 stated she was going to go to a local grocery store earlier in the day, however the Administrator told her not to go. DD #101 confirmed items on the always available menu should always be available. Interview on 06/18/25 at 2:56 P.M., Resident #17 stated she did not like what she was served for lunch on 06/17/25 and stated she did not recall receiving a grilled cheese at lunch instead of the original menu items. 4. Review of Resident #37's lunch meal ticket, dated 06/17/25, revealed a note to add a grilled cheese to the meal. Review of the undated facility document titled, Always Available at Mealtimes, revealed grilled cheese, hot dogs, peanut butter and jelly sandwiches, deli sandwiches, and salads were available. Observation on 06/17/25 at approximately 12:15 P.M. revealed Resident #37's meal tray contained pork loin, a baked potato, broccoli, and a lemon bar. There was no grilled cheese provided on the lunch tray. Interview on 06/17/25 at approximately 12:15 P.M., Dietary Director (DD) #101 verified Resident #37 was not provided with a grilled cheese because the kitchen was out of cheese. Interview on 06/18/25 at 2:54 P.M., Resident #37 verified she did not receive the grilled cheese at lunch on 06/17/25 as was printed on her meal ticket. Resident #37 stated what was served on her tray did not match what was printed on her meal ticket and that happened all the time. 5. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's dietician progress notes dated 12/18/24, 01/08/25, and 01/29/25 revealed the resident did not like the quality of the food provided. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with puree texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with puree texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had significant cognitive impairment with a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. The resident was noted as independent with eating and had previous significant weight loss and was not on a weight loss program. Review of the menu ticket dated 06/16/25 revealed Resident #10 had a puree diet order and was to receive pureed honey glazed turkey, pureed sweet potatoes, pureed green beans, and pureed strawberries. Observation on 06/16/25 at 11:50 A.M. revealed Resident #10 was served a lunch tray which included mashed potatoes and gravy, with no mashed sweet potatoes provided. Resident #10 told Certified Nurse Aide (CNA) #80 she did not want her food as it looked gross and also stated, those don't look like sweet potatoes. The CNA left the tray at bedside and did not offer any alternatives. Observation and interview on 06/16/25 at 12:20 P.M. revealed Resident #10 had eaten less than 25% of the meal. CNA #80 confirmed Resident #10 had eaten less than 25% of the meal tray. The CNA also confirmed the resident was not provided the meal that was on the menu, as she was given mashed potatoes and not pureed sweet potatoes. Interview on 06/18/25 at 9:35 A.M. with Dietician #162 revealed the facility should be following the meal tickets and menu. 6. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphasia, muscle wasting, diabetes and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. Review of Resident #21's physician order dated 02/11/25 revealed a diet order for a no added salt diet with mechanical soft texture. Review of the meal ticket dated 06/16/25 revealed Resident #21 was to receive ground honey glazed turkey, soft roasted sweet potatoes, green beans, and bananas. Review of the substitution log dated June 2025 revealed no evidence of the facility being out an any items on 06/16/25. Observation and interview on 06/16/25 at 12:03 P.M. with Resident #21 and Licensed Practical Nurse (LPN) #122 revealed the LPN brought in the food tray for the lunch meal which did not include green beans. LPN #122 confirmed the meal ticket stated green beans yet no green beans were provided. Resident #21 reported that the kitchen rarely served the menu as posted and items frequently did not match the tickets. This deficiency represents non-compliance investigated under Complaint Number OH00165179.

Based on observation and staff interview, the facility failed to ensure staff wore hair nets in the kitchen as appropriate. This had the potential to affect all 64 residents in the facility. Findings include: Observation on 06/16/25 at 8:25 A.M. revealed [NAME] #135 preparing food in the kitchen. [NAME] #135 had long hair, pulled back, and was not observed to be wearing a hairnet. Observation on 06/16/25 at 8:37 A.M. revealed Dietary Aid (DA) #134 pouring juice into individual glasses. DA #134 had long hair, pulled back, and was not observed to be wearing a hairnet. Interview on 06/16/25 at 8:38 A.M., [NAME] #135 verified herself and DA #134 were not wearing hair nets. [NAME] #35 stated staff ran out of hair nets over the weekend and they were unable to get more as they were locked in the manager's office. Interview on 06/16/25 at 8:45 A.M., Dietary Director (DD) #101 verified the staff did not have access to the hair nets as they were locked up, because when she leaves them out, they go missing. DD #101 verified staff should wear hair nets upon entering the kitchen.

Based on personnel record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of annual in-services. This had the potential to affect all facility residents. The facility census was 64. Findings include: 1. Review of the employee file for Certified Nurse Aide (CNA) #120 revealed she began employment on 04/09/24. The employee file had no evidence of any continuing education. 2. Review of employee file for Certified Nurse Aide (CNA) #81 revealed she began employment on 07/05/23. The employee file had no evidence of any continuing education. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified there was no documented evidence of continuing education in the employee files for CNA #81 and CNA #120. Interview on 06/24/25 at 4:20 P.M. with the Administrator verified the continuing education was done on Relias (online education system) with the previous management company and he was unsure if the facility would have access to it. He further confirmed the facility was unable to provide any evidence of continuing education being completed.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner. This affected four residents (#17, #47, #54, and #60) of four residents reviewed for timely MDS completion. Findings include: 1. Review of the medical record of Resident #60 revealed an admission date of 02/09/24. Diagnoses included cervical spinal cord injury (C4), quadriplegia, morbid obesity, and chronic osteomyelitis of coccyx. Review of Resident #60's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for all activities of daily living. Further review of the MDS assessment revealed the assessment was completed on 06/09/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #60's MDS assessment, dated 05/17/25 was not completed until 06/09/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #60's MDS dated [DATE] should have been completed by 05/30/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. 2. Review of the medical record of Resident #54 revealed an admission date of 01/04/23. Diagnoses included hemiplegia, epilepsy, and nontraumatic intracerebral hemorrhage. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/30/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #54's MDS assessment, dated 05/14/25, was not completed until 05/30/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #54's MDS dated [DATE] should have been completed by 05/27/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. 3. Review of the medical record of Resident #47 revealed an admission date of 04/21/25. The resident discharged from the facility on 05/20/25 and did not return. Diagnoses included encounter for surgical aftercare following surgery on the digestive system and cerebral infarction. Review of Resident #47's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/12/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #47's MDS assessment, dated 04/28/25 was not completed until 05/12/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #47's MDS dated [DATE] should have been completed by 05/11/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. 4. Review of the medical record of Resident #17 revealed an admission date of 04/21/25. Diagnoses included chronic obstructive pulmonary disease and severe protein-calorie malnutrition. Review of Resident #17's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the assessment was completed on 05/13/25. Interview on 06/18/25 at 2:59 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator #96 verified Resident #17's MDS assessment, dated 04/28/25 was not completed until 05/13/25. LPN #96 stated MDS assessments should be locked within 14 days of the reference date and Resident #17's MDS dated [DATE] should have been completed by 05/11/25. LPN #96 stated she had gotten behind because she was being pulled to perform other duties. Review of the facility policy titled, MDS Completion and Submission Timeframe's, dated September 2021, revealed resident assessments would be completed and submitted based on the requirements published in the Resident Assessment Instrument Manual (RAI).

Based on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure care plans were updated/revised as needed and accurate. This affected four (#4, #10, #21, and #55) of 22 residents reviewed for care planning. The facility also failed to ensure care conferences were held on a routine basis. This affected three (#10, #50 and #162) of four residents reviewed for care conferences. Findings include: 1. Review of the medical record of Resident #55 revealed an admission date of 07/30/24. Diagnoses included schizoaffective disorder, Parkinson's disease, and epilepsy. Review of Resident #55's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician orders revealed an order dated 05/15/25 for Resident #55 to be a Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) code status, indicating the resident would receive comfort care, but no resuscitation efforts in the event of cardiac or pulmonary arrest. Review of Resident #55's signed DNR form dated 04/15/25 revealed the resident was a DNR-CCA code status. Review of Resident #55's plan of care dated 12/04/24 revealed the resident was a full code status, indicating life saving measures would be completed in the event of cardiac or pulmonary arrest. Interview on 06/17/25 at 3:30 P.M., the Director of Nursing (DON) verified Resident #55's care plan did not match his code status orders. 2. Review of the medical record of Resident #4 revealed an admission date of 01/25/16. Diagnoses included epilepsy, schizophrenia, anxiety, and depression. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with all activities of daily living with the exception of bathing, which required supervision. Review of Resident #4's medical record revealed an order dated 02/12/25 for the resident to be a Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) code status, indicating the resident would receive comfort care, but no resuscitation efforts in the event of cardiac or pulmonary arrest. Review of Resident #4's signed DNR form dated 06/02/21 revealed the resident was to be a DNR-CCA. Review of Resident #4's care plan dated 01/02/25 revealed the resident was a full code status, indicating life saving measures would be completed in the event of cardiac or pulmonary arrest. Interview on 06/17/25 at 3:30 P.M., the Director of Nursing (DON) verified the plan of care did not match Resident #4's code status order. 3. Review of the medical record of Resident #50 revealed an admission date of 08/04/22. Diagnoses included chronic obstructive pulmonary disease, anxiety, depression, type two diabetes mellitus with diabetic neuropathy, malingerer, and antisocial personality disorder. Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] reveled the resident had intact cognition. Interview on 06/16/25 at 3:26 P.M., Resident #50 stated it had been a while since she had a care conference and she did not believe care conferences were being held on a quarterly basis. Review of the medical record revealed one care conference for the Resident #50 dated 12/17/24. Further review of the medical record revealed no evidence of any additional care conferences being completed during the prior year. Interview on 06/17/25 at 3:03 P.M., the Director of Nursing (DON) confirmed the last care conference for Resident #50 was held 12/17/24. The DON confirmed care conferences should be completed quarterly and Resident #50 only had one care conference in the past year. Review of the facility policy titled, Care Conference, dated 09/01/21, revealed the facility would hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care. 5. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's care conferences revealed on 02/16/25 Resident #10 and her son were present along with Director of Nursing (DON) and nurse for a care conference. The facility was unable to provide documented evidence of additional care conferences from the past 12 months. Interview on 06/18/25 at 8:56 A.M. with Social Services (SS) #89 revealed the care conference dated 02/16/25 was the only care conference for Resident #10 that they could locate. SS #89 reported it was difficult to schedule due to Resident #10's family request for Sunday meetings. SS #89 reported the facility did not hold meetings if residents or family were not in attendance. Review of the facility policy titled Care conferences dated 09/01/21 revealed the facility shall hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care. It stated meetings shall be held as needed. 6. Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphasia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's weights revealed on 03/01/24 the resident weighed 318 pounds (lbs.) upon admission, on 08/03/24 the resident weighed 269.6 lbs., on 10/04/24 the resident weighed 255.8 lbs., on 11/06/24 the resident weighed 252.0 lbs., and on 12/07/24 the resident weighed 244.0 lbs. Review of the dietitian progress notes dated 01/08/25 revealed Resident #10's weight was trending down from 275 lbs. to 239 lbs. for a 13.1 percent (%) loss in 180 days with gradual weight loss. Double protein portions were recommended although the resident voiced displeasure with the quality of the food. Intakes were variable at 25 to 100%. House shakes had also been added and ordered on 12/20/24 for lunch and dinner trays. The order was discontinued on 02/03/25 when the resident was hospitalized . The physician and nursing staff were notified of the weight loss. Review of the dietitian's progress notes dated 01/29/25 revealed Resident #10 had a weight loss of 12.9% over 180 days. Intakes were variable at 25 to 75% of meals. Weekly weights were to be added due to the need for close monitoring and follow-up. The most recent weight to this dietitian's note, was on 01/07/25 when the resident weighed 239 lbs. Review of the plan of care dated 01/29/25 revealed Resident #10 had a nutritional problem or potential nutrition problem related to significant weight loss, feeding assistance, therapeutic diet, and meal refusals with interventions including to monitor, document and report signs and symptoms of dysphagia including pocketing, choking, coughing, drooling etc., monitor signs and symptoms of malnutrition including weight loss of over three pounds in one week, over five percent in one month, over seven and a half percent in three months, and over 10 percent in six months, to provide and serve diets as ordered, and dietitian to evaluate and make recommendations as needed. There was no documentation of a nutrition care plan prior to 01/29/25 and the care plan was not updated after the resident's weight loss, pureed diet order change or her hospitalization. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with pureed texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with pureed texture. Review of Resident #10's weights revealed on 02/03/25 and 02/04/25, the resident weighed 241.3 lbs. Review of Resident #10's physician orders dated 02/04/25 through 03/04/25 revealed an order for weekly weights. Review of Resident #10's weights revealed on 03/09/25 the resident weighed 217.4 lbs. Review of Resident #10's physician orders dated 03/11/25 through 05/21/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 03/12/25 revealed Resident #10 had a weight loss of 241 lbs. to 217.4 lbs. for a weight loss of 10% over 30 days. Resident #10 did not like the pureed texture, and intakes were low at 25 to 75% of meals. Med pass (supplement) was added three times daily as well as an appetite stimulant to improve intakes. The plan was to continue weekly weights for close monitoring and follow up. Interview on 06/18/25 at 4:30 P.M. with Regional Nurse #160 confirmed the care plan had not been updated since resident was switched to a pureed diet and no new interventions had been added after significant weight loss was identified. 7. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's, dysphagia, muscle wasting, diabetes and malnutrition. Review of Resident #21's care plan dated 12/17/24 revealed the resident was at risk for falls with interventions to monitor for changes in mobility added on 12/17/24, food and fluids within reach added on 12/17/24, education on transfer and ambulation techniques added on 12/17/24, implement preventative fall interventions added on 12/17/24, resident and staff education on safety interventions added on 01/09/25, non-skid strips added on 01/23/25, non-skid footwear added on 01/23/25, remove recliner from the room and provide bed added on 02/18/25, toileting schedule added on 02/20/25, perimeter mattress/scoop mattress added on 02/25/25, medication review dated 03/04/25, maintain needed items within reach added on 03/05/25, mat to floor added on 03/05/25, room change closer to nurses station added on 03/07/25, low bed added on 03/13/25, bed against the wall added on 03/16/25, apply side rails added on 03/18/25, and increased lighting added on 03/18/25. Review of the medical record revealed Resident #21 had falls on 02/17/25, 02/20/25, 02/26/25, 02/28/25, 03/03/25, 03/05/25 in the morning and in the evening, 03/06/25, 03/13/25, 03/16/25 and 03/17/25. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a BIMS of 09. Review of fall investigation dated 02/28/25 and progress note dated 03/03/25 revealed Resident #21 had a fall trying to get out of her room during a fire drill. The new intervention was to offer resident to come to common areas during fire drills. The care plan was not updated with this intervention. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed the care plan was not revised with new interventions for Resident #21. 4. Review of the medical record for Resident #162 revealed an admission date of 11/14/24 with diagnoses that included chronic obstructive pulmonary disease (COPD), type one diabetes, and hypothyroidism. Review of Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. An interview conducted on 06/16/25 at 11:15 A.M. with Resident #162 revealed he had not been asked by facility staff to participate in an initial care conference upon admission. Review of the care conferences for Resident #162 revealed that care conferences took place on 03/19/25 and 06/09/25; however, there was no documented evidence of an initial care conference from Resident #162's admission. An interview conducted on 06/23/25 at 9:27 A.M. with the Social Worker #89 confirmed that Resident #162 did not have an initial care conference. Review of the facility policy titled Care Conference, dated 09/01/21, revealed the facility would hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care.

Based on observations, record reviews, staff interview, and review of facility policy and procedure, the facility failed to ensure fall investigations were completed thoroughly, included a root cause analysis, and appropriate fall interventions were initiated and in place. This affected four residents (#21, #25, #38, and #162) of five reviewed for falls. The facility census was 64. Findings include 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. Review of the care plan dated 12/17/24 revealed Resident #21 was at risk for falls with interventions including to monitor for changes in mobility added on 12/17/24, food and fluids within reach added on 12/17/24, education on transfer and ambulation techniques added on 12/17/24, implement preventative fall interventions added on 12/17/24, resident and staff education on safety interventions added on 01/09/25, non-skid strips added on 01/23/25, non-skid footwear added 01/23/25, remove recliner from the room and provide bed added 02/18/25, toileting schedule added on 02/20/25, perimeter mattress/scoop mattress added on 02/25/25, medication review dated 03/04/25, maintain needed items within reach added on 03/05/25, mat to floor added on 03/05/25, room change closer to nurses station added on 03/07/25, low bed added 03/13/25, bed against the wall added on 03/16/25, apply side rails added on 03/18/25, and increased lighting added on 03/18/25. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #21 had falls on 12/15/24, 02/28/25, 03/05/25, 03/06/25, 03/13/25, and 03/17/25. Review of the progress note dated 02/17/25 revealed while staff were in the room assisting Resident #21 with a bed bath, and the resident was scooting forward in her reclining chair and slid to the floor. No evidence of an investigation/report was provided. A later note on 02/17/25 revealed the new intervention included removing the recliner and having the bed return to the room. This fall was not included on the incident accident log. Review of the progress note dated 02/20/25 revealed Resident #21 had a fall with interventions to toilet every two hours. This fall was not included on the incident accident log. Review of the fall investigation dated 02/20/25 revealed Resident #21 had an unwitnessed fall at 8:15 A.M. when staff entered the room and found the resident sitting on her buttocks on the floor next to her bed. Resident #21 stated she was trying to have a bowel movement. A new intervention was created to toilet every two hours. At the time of the fall bed was found in low position and room was uncluttered. This fall was not included on the incident accident log. Review of the progress note dated 02/25/25 revealed while staff were answering a call light they found Resident #21 sitting on her buttocks. Resident #21 stated she was trying to go to the bathroom and tried to stand and walk to the commode. The resident stated she forgot she could not walk. This fall was not included on the incident accident log. Review of the progress note dated 02/26/25 revealed Resident #21 had a fall in her room after sliding out of bed. Review of the fall investigation dated 02/26/25 revealed Resident #21 had a witnessed fall at 9:00 A.M. when the resident was found beside her bed in a sitting position. Resident #21 slid out of bed onto the floor. The bed was in a low position and the resident declined to go to the common area to sit. Resident #21 stated she kept forgetting she could not walk and when trying to get out of bed, she slid to the floor. Resident #21 was noted to be alert and oriented to self and a new intervention to apply non-skid strips to the floor beside the bed was initiated. This intervention was already in place per the care plan added 01/23/25. This fall was not included on the incident accident log. Review of the progress note dated 02/28/25 revealed Resident #21 had a fall by her door. Resident #21's wrist was swollen and an x-ray was ordered. Review of the fall investigation dated 02/28/25 revealed Resident #21 had an unwitnessed fall at 4:30 P.M. when the resident was found lying across the floor in the room with the door closed due to a recent fire drill. Resident #21 was concerned the fire alarm was not a test and attempted to exit her room. Resident #21 was assisted back to bed. Her left wrist was swollen and an x-ray was ordered. No new interventions were mentioned in the report and the x-ray results came back with no findings of fracture. Review of the progress note dated 03/03/25 revealed Resident #21 had a fall after hearing the fire alarm on 02/28/25. The new intervention per note was to offer Resident to come to common areas during fire drills. Review of the progress note dated 03/03/25 revealed Resident #21 slid out of bed onto her buttocks. Resident #25 was noted with increased paranoia and confusion. Review of the fall investigation dated 03/03/25 revealed Resident #21 had an unwitnessed fall at 6:40 P.M. when the resident was found on her buttocks with no injury noted. Resident #21 had increasing periods of hallucinations and paranoia. Resident #21 stated they told me to leave or they were going to call the cops, staff reassured her safety. No new interventions were mentioned in the report. This fall was not included on the incident accident log. Review of the progress note dated 03/04/25 revealed Resident #21's new intervention was for a medication review to be completed. Review of the fall investigation dated 03/05/25 revealed Resident #21 had an unwitnessed fall at 3:00 A.M. when the resident was found on the floor after sliding off the bed. The bed was in a low position. Resident #21 stated she did not know why she was trying to get out of bed. No new interventions were mentioned in the report. This fall was not included on the incident accident log. Review of the progress notes dated 03/05/25 revealed Resident #21 had a fall after sliding from the bed. A second fall occurred where Resident #21 was found on the ground leaning up against the bathroom door. Resident #21 had a hematoma to the right eye brow. Review of the fall investigation dated 03/05/25 revealed Resident #21 had an unwitnessed fall at 4:15 P.M. when the resident was found on her buttocks leaning up against the bathroom door. Resident #21 had a noted injury (hematoma to right eyebrow). Resident #21 told staff she was trying to urinate. The bed was in a low position and the floor mat was in place. The fall investigation did not include staff interviews of the last time the resident was assisted to the toilet. No new interventions were mentioned in the report. Review of the progress note dated 03/06/25 revealed Resident #21 had a fall and was found laying next to her floor mat. Resident #21 reported she tried to get a glass of water and the water was found on the floor mat. Resident #21 had been offered a drink about 45 minutes prior. Review of the fall investigation dated 03/06/25 revealed Resident #21 had an unwitnessed fall at 5:15 P.M. when the resident was found lying on the floor besides the floor mat. Resident #21 was assisted in a tilt back wheelchair and brought to the nurses station. Resident #21 stated she was trying to get a drink of water and the water was found on the floor mat. The nurse had reported she last saw Resident #21, 45 minutes prior and offered her water. No new interventions were mentioned in the report. Review of the internal fall investigation dated 03/06/25 revealed the new immediate intervention for Resident #21's fall included placing a water pitcher within reach when in bed. Resident #21 was also moved to a room closer to the nurses station. Review of the progress note dated 03/07/25 revealed new intervention recommendations from Resident #21's fall on 03/06/25 included to ensure water was within reach and move the residents room closer to the nursing station. Review of the fall investigation dated 03/13/25 revealed Resident #21 had an unwitnessed fall at 2:00 A.M. when the resident was found crawling across the floor in the room on her elbows facing the doorway by the sink. Resident #21's bed was in the low position and the floor mat was in place. Resident #21 was noted with continued confusion and agitation, and having conversations with people who were not in the room. Resident #21 was alert to herself only. No new interventions were mentioned in the report. Review of the progress note dated 03/13/25 revealed Resident #21 was found crawling on the floor on her elbows on the floor. Review of the progress note dated 03/16/25 revealed a fall occurred and Resident #21 slid out of bed. The facility had no investigation/incident report. The fall was not included on the incident accident log. Review of the progress note dated 03/17/25 revealed Resident #21 slid out of bed. Review of the fall investigation dated 03/17/25 revealed Resident #21 had an unwitnessed fall at 3:30 P.M. when the resident was attempting to go to the bathroom and slid out of the bed to the floor due to a recent fire drill. Resident #21 was concerned the fire alarm was not a test and attempted to exit her room. Resident #21 was assisted back to bed. Her left wrist was swollen and an x-ray was ordered. No new interventions were mentioned in the report and x-ray results came back with no findings of fracture. Review of the internal fall investigation dated 03/17/25 revealed Resident #21 was toileted and educated on utilizing the call light for assistance and transfers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. The answer to question J1800 revealed the staff marked no for no prior falls. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #21's falls dated 02/17/25, 02/20/25, 02/25/25, 02/26/25, 03/03/25, 03/05/25 (first fall), and 03/16/25 were not documented on the incident accident log. They confirmed the residents falls were missing a root cause analysis and many did not have any new interventions documented. They confirmed interventions were not specific to the cause of the fall and confirmed it would not be appropriate to have a new fall intervention, be something that was already in place at the time of the fall. They were unable to provide additional information if current interventions were in place and also failed to provide evidence of additional investigation information such as staff statements about the last time the resident was toileted, after several falls were related to the need to go to the bathroom. Regional Nurse #160 acknowledged fall procedures were lacking and staff were unaware of all falls. Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications. 2. Review of the medical record for Resident #25 revealed an admission date of 12/30/16. Diagnoses included chronic obstructive pulmonary disease, diabetes, kidney disease and muscle weakness. Review of Resident #25's care plan dated 02/18/24 revealed the resident was at risk for falls with interventions of monitor for changes in mobility added 02/18/25, walker within reach added on 02/21/25, implement preventative fall interventions added on 02/21/25, resident and family education to call for assistance before transferring added on 03/18/25, education on transfers and ambulation techniques added on 03/18/25, resident education on safety interventions added on 03/18/25, clear pathways added on 04/29/25, maintain needed items in reach added on 05/05/25, and remind resident to ask for assistance added on 05/20/25. Review of the incident accident log dated 12/01/24 to 06/16/25 revealed Resident #25 had falls on 02/20/25, 03/18/25, 04/14/25, 04/19/25, 05/04/25 and 05/19/25. Review of the fall investigation dated 02/20/25 revealed Resident #25 had an unwitnessed fall at 10:00 P.M. when staff found the resident sitting on her buttocks on the floor with her back against the bed and leaning on the left side with her elbow and palm against the floor. Resident #25 stated she was attempting to stand at the end of the bed and slid down the side of the bed. No new interventions were noted in the investigation. Review of the fall investigation dated 03/18/25 revealed Resident #25 had a witnessed fall at 3:15 P.M. after the resident had ambulated to the bathroom, became dizzy, lost her balance, and landed on her buttocks. No new interventions were noted in the investigation. Review of internal fall investigation document dated 03/18/25 revealed Resident #25 was educated on the importance of utilizing the call light for assistance with ambulating if feeling dizzy. Review of the fall investigation dated 03/24/25 revealed Resident #25 had an unwitnessed fall at 7:00 P.M. when the resident was ambulating back from the bathroom and her knee gave out and resident eased herself to the floor. Resident #25 reported she was not using her walker. No new interventions were noted in the investigation and this fall was not included on the incident accident log. Review of the fall investigation dated 04/14/25 revealed Resident #25 had an unwitnessed fall at 4:55 P.M. when the resident was trying to get into her wardrobe she leaned on the bed, lost her balance, and fell on her right side. Resident #25 reported new pain to her upper right arm and an injury was documented. No new interventions were noted in the investigation. Review of the fall investigation dated 04/19/25 revealed Resident #25 had an unwitnessed fall at 7:20 A.M. when the resident slid out of bed trying to get up to go to the bathroom. Resident #25 landed on the right side and complained of right arm pain. Resident #25 was noted to have a new skin tear 3 centimeters (cm) by 3 cm on the right elbow. No new interventions were noted in the investigation. Review of internal fall investigation document dated 04/19/25 revealed Resident #25 had injury to the right upper arm, pain, and a skin tear to the right elbow. Review of the fall investigation dated 05/04/25 revealed Resident #25 had an unwitnessed fall at 7:15 P.M. when the resident slid to the floor when trying to transfer herself without assistance. No new interventions were noted in the investigation. Review of Resident #25's internal fall investigation document dated 05/04/25 revealed the resident was reminded to call for assistance. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 6:45 P.M. when the resident was found on the ground/floor with her back on the bottom bar of the overbed table. Resident #25 stated she was going to the bathroom. Abrasions were noted to the back of the resident's head. Staff reminded her to call for staff assistance before getting out of bed. Review of internal fall investigation document dated 05/19/25 revealed Resident #25 had an injury/abrasion to the back of the head. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 8:00 P.M. when the resident fell while ambulating without assistance to go to the bathroom. Resident #25's room was noted to be clear of clutter. No new interventions were noted in the investigation and this fall was not included on the incident accident log. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25's assessment for question J1800 revealed the staff marked no for no prior falls and no falls with injury were documented. Interview on 06/18/25 at 4:54 P.M. and on 06/23/25 at 9:35 A.M. to 11:30 A.M. with Director of Nursing (DON) and Regional Nurse #160 confirmed the falls dated 03/24/25 and the second fall on 05/19/25 were not documented on the incident accident log. They confirmed the fall investigations were generic and many did not have any interventions documented. They confirmed interventions were not specific to the cause of the fall. Regional Nurse #160 acknowledged that fall procedures were lacking and staff were unaware of all falls. Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications. 4. Review of record revealed that Resident #38 was admitted on [DATE]. Diagnoses included myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the facility fall document dated 04/27/25 revealed that Resident #38 slid off of his bed as he was noted to be sitting on the floor next to his bed. The physician and family were notified. Review of the progress note dated 04/27/25 revealed Licensed Practical Nurse (LPN) #79 stated she walked into Resident #38's room this morning to give him medication and the resident was noticed to be sitting on the floor in front of his bed. Resident #38 reported he was sitting on the side of the bed eating breakfast and just slid off, to the floor. The aides reported he was last seen sitting on his bed two minutes before. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had a Brief Interview of Mental Status (BIMS) of a 02 indicating the resident was severely cognitively impaired. Resident #38 was independent with eating, oral care, and personal hygiene. Resident #38 required partial to moderate assistance for toileting and substantial maximum assistance for dressing the lower body and baths. Review of the plan of care dated 05/20/25 revealed that Resident #38 was a fall risk related to decreased strength and endurance, functional problems, generalized weakness, history of falls, history of self-transfers, medications, and the need for assistance with activities of daily living. Interventions included implementing preventative fall interventions and devices and the resident was to be encouraged to sit in the wheelchair for meals. Observation on 06/16/25 at 4:50 P.M. with Resident #38 revealed he was sitting on the side of his bed eating at his bedside table. Resident #38 was sitting with regular socks on with his feet touching the floor. An unoccupied wheelchair was sitting in front of the window. Review of the facility daily schedule dated 06/17/25 and 06/18/25 revealed that Certified Nursing Assistant (CNA) #90 had worked Resident #38's hall for day shift. Observation on 06/17/25 at 5:00 P.M. Resident #38 sitting on his the side of his bed eating with the bedside table in front of him. Resident #38's feet were touching the floor and he had regular socks on his feet and no shoes. Interview on 06/23/25 at 9:15 A.M. with the Director of Nursing (DON) revealed the staff were supposed to be asking if Resident #38 would sit in his wheelchair for meals due to his fall from two months ago. The DON stated she was not aware of staff not asking Resident #38 to sit in his wheelchair during all meals in his room, but that staff should be asking Resident #38 to sit in his wheelchair for meals. The DON stated she was not notified by staff that Resident #38 was not using the wheelchair during meals. Interview on 06/23/25 at 10:29 A.M. with CNA #90 confirmed that last week she did not offer Resident 38 to sit in his wheelchair for both days, specifically on 06/17/25, when she worked at the facility. CNA #90 stated she did not know that Resident #38 was supposed to be asked to sit in a wheelchair during meals in his room. CNA #90 stated she was going to ask Resident #38 if he would sit in his wheelchair today. Review of the facility policy titled Falls dated September 2021 revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 3. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type one diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of Resident #162's initial fall risk assessment dated [DATE] revealed a score of 11, indicating moderate fall risk. Interventions included educating the resident on room orientation and call light use and ensuring the call light was within reach. Review of Resident #162's fall event dated 02/03/25 revealed the resident became dizzy and fell to his knees while returning to bed. A Certified nursing assistant (CNA) witnessed the fall but could not prevent it. Neurological checks were completed, and the walker was noted to be within reach. However, no new interventions were added, and this fall was not documented on the facility's incident and accident log. Review of Resident #162's fall event dated 05/03/25 revealed the resident was found lying in the hallway with his walker tipped over. He stated he became dizzy and saw black spots before falling. Neurological checks were completed. No injuries were noted. The only intervention added was resident education. The plan of care and interventions were not revised or expanded. Review of Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. The resident required moderate assistance with showering, transfers, and ambulation, and used a wheelchair for locomotion. Review of Resident #162's fall event dated 06/09/25 revealed the resident was found on his buttocks near the bed and reported falling after attempting to respond to someone calling his name. He stated he must have been asleep. Neurological checks were completed. No injuries were noted. There was no investigation documented whether existing interventions were in place and effective and no new interventions were implemented. Review of the plan of care dated 06/09/25 revealed Resident #162 was at risk for falls due to impaired mobility, weakness, and history of falls. Interventions included education to call for assistance before transferring, preventative fall interventions/devices, maintaining call light within reach, use of non-skid footwear, and safety education. Review of the updated fall risk assessment dated [DATE] revealed the resident remained at moderate risk for falls with a score of 40. Despite this, the care plan and existing interventions remained unchanged. Interview on 06/23/25 at 11:30 A.M. with Director of Nursing (DON) confirmed Resident #162 had a moderate fall risk and stated that education was the facility's primary fall prevention strategy. She confirmed new interventions also were not initiated for the 06/09/25 fall. Review of the facility's policy titled Falls, dated 09/2021, revealed staff were expected to identify and implement appropriate fall interventions with input from the attending Physician. If falls continued despite initial efforts, staff were to try additional or different interventions or document why the current approach remained appropriate. The policy also required staff to re-evaluate and adjust interventions as needed to prevent future falls and minimize complications.

3. a. Review of the record for Resident #59 revealed an admission date 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Review of Resident #59's physician order dated 12/09/24 revealed that Resident #59 had an order for Insulin Lispro injection solution 100 unit per milliliter subcutaneously before meals and at bedtime for diabetes. Review of the plan of care dated 04/03/25 revealed that Resident #59 had impaired metabolic status related to diabetes. Interventions included administering medication as ordered, monitoring laboratory results, monitoring vital signs, and reporting adverse side effects to the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #59 had Brief Interview for Mental Status (BIMS) of 15 that indicated she was cognitively intact. b. Review of the record for Resident #30 revealed an admission date 01/05/24. Diagnoses included type two diabetes mellitus and chronic systolic heart failure. Review of the physicians order dated 04/04/25 revealed that Resident #30 had an order for insulin Glargine-yfgn subcutaneous solution 100 units per milliliter one time a day with blood glucose check in the morning. Observation on 06/17/25 at 8:00 A.M. with Licensed Practical Nurse (LPN) #135 revealed she came out of Resident #30's room with a glucometer in her hand. LPN #135 took a Sani disinfectant wipe disinfectant (a germicidal, tuberculocidal, and viricidal disinfectant) and wrapped it around the glucometer and sat it on top of the medication cart where it stayed wrapped in the Sani wipe for six minutes. LPN #135 prepared medication for Resident #59 and after the medications were prepared, LPN #135 took the wrapped glucometer with the Sani wipe to Resident #59 room to perform a blood glucose check. LPN #135 laid a brown paper towel on top of a bedside table then placed the wrapped glucometer on top of it. LPN #135 washed her hands, then placed gloves on her hands, then unwrapped the Sani wipe from the glucometer, then picked it up to obtain Resident #59's blood glucose check. LPN #135 took the blood glucose from Resident #59's finger, then disposed of her gloves in the trash can. LPN #135 washed her hands, then wrapped the Sani wipe back around the glucometer (the same wipe that was used to disinfect the glucometer after Resident #30's blood glucose check), then exited Resident #59 room. LPN #135 laid the glucometer with the Sani wipe on top of her medication cart. Interview on 06/17/25 at 8:05 A.M. with LPN #135 verified that she did not maintain infection control by utilizing the same Sani disinfectant wipe from Resident #30's room after her blood glucose was taken and took it into Resident #59's room for her blood glucose check. Interview on 06/17/25 at 5:00 P.M. with LPN #135 stated that she also did not follow the Sani wipe directions that stated to clean, and then leave the item to dry for two minutes after the cleaning to work properly. Review of the facility document titled Safety Data Sheet dated 02/18/19 revealed that product Super Sani-Cloth Germicidal wipes directions were to use it as a disinfectant on hard, non-porous surfaces. It stated to not reuse the towelette and to pick up the wipe and place it in appropriate container for infectious waste disposal. Review of the facility document titled Super Sani-Cloth dated unknown revealed that the bactericidal, tuberculocidal and viricidal had a dwell time to dry in two minutes. 4. Review of the medical record revealed that Resident #19 had admission date 05/17/25. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, depression disorder, and dependence on wheelchair. Review of the physician order dated 12/20/24 revealed Resident #19 had an order for enhanced barrier precautions every day and night. Review of the physician order dated 12/22/24 revealed Resident #19 had a suprapubic catheter, 24 french with a 10 milliliter (ml) bulb. The orders also revealed an order for suprapubic catheter care every shift. Review of physician order dated 03/21/25 revealed that Resident #19 had wound care for right hip and left ischial with instructions to apply Dakins solution to moisten gauze, squeezing out excess moisture to lightly pack gauze inside the wound, ensuring it did not pass the edge of the wound, cover with abdominal dressing, then apply a thin layer of thick barrier paste to satellite macerated ulcerations twice a day or as needed every shift for wounds. Review of plan of care dated 04/21/25 Resident #19 had a suprapubic catheter related to having neurogenic bladder. Interventions included monitor and document intake and output as per facility policy, monitor for pain and discomfort, and report to the physician for signs and symptoms of urinary tract infection. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #19 was independent with all care though he did have a wound and a suprapubic catheter. Observation and interview on 06/16/25 at 4:51 P.M. with Certified Nurse Aid (CNA) #501 verified there was no enhanced barrier precaution sign for Resident #19's room even though the resident had an indwelling urinary catheter. Interview on 06/17/25 at 11:40 A.M. with Wound Nurse Practitioner #600 confirmed Resident #19 had a wound and it was being debrided in an outpatient clinic because it was too deep to treat at the facility. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated January 2024 revealed that enhanced barrier precautions are an infection control method used in the facility to reduce transmission of drug-resistant organisms. Review of the facility policy titled Infection Prevention and Control Program dated September 2022 revealed the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. Prevention of infection was to implement appropriate isolation precautions when necessary and educating staff and ensuring that they adhere to the proper techniques and procedures. 5. Review of the medical record revealed that Resident #38 was admitted on [DATE]. Diagnoses included myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the physician order dated 03/03/25 revealed that Resident #38 was to be on enhanced barrier precautions every shift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had a Brief Interview for Mental Status (BIMS) of 02 that indicated severely cognitively impaired. Resident #38 was independent for eating, oral care, and personal hygiene. Resident #38 required partial to moderate assistance for toileting and required substantial maximum assistance for dressing the lower body and baths. The assessment indicated the resident had an indwelling suprapubic catheter. Review of the plan of care dated 05/20/25 revealed that Resident #38 had suprapubic catheter related to obstructive uropathy. Interventions included monitor of signs and symptoms of urinary tract infection, document output, securement device to be applied to securely anchor catheter tubing, change catheter and drainage system as ordered, keep tubing free of kinks, and privacy cover to the drainage bag. Review of the physician order dated 05/22/25 revealed that Resident #38 had an order for a suprapubic catheter and an order to re-insert Foley catheter as needed for malfunction or dislodgement. Observation on 06/16/25 at 4:51 P.M. with Resident #38 revealed an enhanced barrier precaution sign was not posted outside or in the room. Interview on 06/16/25 at 4:51 P.M. with Certified Nurse Aid (CNA) #501 verified there was no enhanced barrier precaution sign for Resident #38's room even though the resident had an indwelling urinary catheter. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated January 2024 revealed that enhanced barrier precautions are an infection control method used in the facility to reduce transmission of drug-resistant organisms. Review of the facility policy titled Infection Prevention and Control Program dated September 2022 revealed the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. Prevention of infection was to implement appropriate isolation precautions when necessary and educating staff and ensuring that they adhere to the proper techniques and procedures. 6. Review of record revealed that Resident #60 had admission date 01/09/25. Diagnoses included injury at C4 level of cervical spinal cord, quadriplegia, acute and chronic respiratory failure with hypoxia, disorder of autonomic nervous system, and morbid (severe) obesity. Review of the plan of care dated 03/21/25 revealed that Resident #60 had episodes of bladder and bowel incontinence. Interventions included administering medications, assisting residents with toileting needs, monitoring rectal area for redness, irritation, and skin excoriation or breakdown, provide peri care after each incontinent episode, then apply house barrier after incontinence care. Review of plan of care dated 03/21/25 revealed that Resident #60 had impaired skin integrity as evidenced by a pressure ulcer related to the resident being confined to a bed at all times, or most of the times with intervention to assist the resident with turning and repositioning, encourage the resident to reposition, laboratory services as ordered, medication per physicians ordered, complete Braden scale as needed, if resident refuses interventions and treatments encourage compliance to minimize further skin impairment, and complete wound evaluation to monitor the progress of the resident's skin condition. Review of the physician order dated 05/04/25 revealed that Resident #60 had an order to cleanse the coccyx wound with 0.125% Dakins solution, then rinse with saline, apply zinc oxide topically to the peri wound and apply silver alginate rope to wound bed, leaving a one-inch tail and cover with abdominal daily and may change as needed if it becomes soiled or displaced. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #60 was dependent on staff for assistance with meals, oral care, incontinence care, dressing lower and upper body, personal hygiene, and bathing. Review of the skin evaluation dated 06/11/25 revealed that Resident #60's coccyx pressure wound was a stage four and measured 2.5 centimeters (cm) by 2.5 cm by 5.5 cm depth. Observation on 06/18/25 from 10:39 A.M. through 10:55 A.M. with Resident #60 who was provided incontinence care before wound care. CNA #90 provided the incontinence care. She used a washcloth to wipe away feces, but instead pushed a large amount of feces into the wound bed. LPN #94 then performed the wound treatment by using Dakins to the wound bed that was 0.0125 strength (quarter strength) then utilized four normal saline syringes to cleanse the wound bed. Then calcium alginate rope was applied with a sterile Q-Tip, then an abdominal dressing with tape was applied. Interview on 06/18/25 at 10:49 A.M. with CNA #90 confirmed that during incontinence care for Resident #60, she had wiped the feces into the wound bed when providing incontinence care. CNA #90 stated that was not normal practice and stated it could cause an infection in the wound. Interview on 06/18/25 at 10:52 A.M. with LPN #94 revealed that it looked like a problem having feces in the wound bed. LPN #94 stated it had happened before and that she would have to wash the wound out some more to cleanse the feces out of the wound bed. Review of the facility policy titled Wound Care dated September 2021 revealed part of the procedure was to wash and dry hands thoroughly, put on gloves, cleanse the wound and then apply treatments as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00165179. Based on observation, record review, interview, and review of facility policy and procedure, the facility failed to ensure implementation of the appropriate isolation status for Resident #19, #26, and #38. This affected three residents (#19, #26, and #38) out of five residents reviewed for infections. The facility failed to ensure proper hand hygiene was followed during a tube feed administration for Resident #162. This affected one resident (#162) out of one residents reviewed for tube feeding. The faciltiy failed to ensure appropriate glucometer sanitation for Resident #59. This affected one resident (#59) out of three residents observed for medication administration. And the facility failed to maintain infection control during wound care for Resident #60. This affected one resident (#60) out of one resident reviewed for pressure ulcers. The facility census was 64. Findings include: 1. Review of the medical record for Resident #26 revealed an original admission date of 01/30/25 and the most recent re-entry was on 05/28/25. Diagnoses included acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the 5-day minimum data set (MDS) 3.0 assessment dated [DATE] for Resident #26 revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of Resident #26's physician orders revealed ongoing enhanced barrier precautions (EBP) starting on 05/29/25 related to an indwelling urinary catheter and an order for contact precautions specifically for Clostridioides difficile (C. diff) from 06/16/25 to 06/17/25. Review of the laboratory results confirmed a positive test for C. diff on 06/06/25. No subsequent testing was completed to determine a resolution; however, on 06/18/25, the Assistant Director of Nursing stated that the resident had completed antibiotic treatment and had formed stool for 48 hours, so retesting was not performed. Observation on 06/16/25 at 11:45 A.M. revealed only the enhanced barrier precaution sign posted on the resident's door, but no contact precaution signage was present. Further observation and interview on 06/17/25 at 11:30 A.M. revealed multiple family members present in the resident's room without the use of any personal protective equipment (PPE). The resident's son reported that staff had not educated the family on the risks of entering the room without PPE. Interview on 06/16/25 at 11:45 A.M. with Licensed Nurse Practitioner (LPN) #93 confirmed the resident had an active C. diff infection, but contact precautions were not implemented in practice, despite new orders for contact precautions being placed on the same date. Review of the facility policy titled, Infection prevention and control program dated September 2022 revealed to prevent infection the facility will implement appropriate isolation precautions when necessary. 2. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included type one diabetes mellitus without complications, chronic obstructive pulmonary disease, muscle wasting and atrophy, and presence of a gastrostomy feeding tube. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #162 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident required moderate assistance with most transfers and lower body dressing, used a wheelchair, and was occasionally incontinent of bladder and bowel. Review of physician orders revealed Resident #162 received TwoCal 240 milliliters via gastrostomy tube five times per day as bolus feeds, with water flushes of 150 milliliters every six hours and 60 milliliters every four hours. The resident also had orders to flush the tube before and after medications, maintain the head of bed at 30 to 45 degrees during and after feedings, and monitor the site for signs of infection or complications. The care plan identified maintaining adequate nutritional and hydration status as a goal, with interventions including infection monitoring, respiratory assessment, and monitoring for gastrointestinal symptoms. Observation on 06/23/25 at 9:59 A.M. revealed Licensed Practical Nurse (LPN) #138 performed hand hygiene and donned personal protective equipment (PPE) prior to administering the resident's tube feeding. During the process, the nurse dropped an item on the floor and touched the floor while wearing gloves. The nurse did not change gloves or perform hand hygiene before proceeding with the procedure. The nurse then attempted to pull residual fluid, then flushed the tube with 30 milliliters of water, administered the full TwoCal bolus feeding via syringe, and flushed again with 30 milliliters of water. Interview on 06/23/25 at 9:59 A.M. confirmed that she had touched the ground with her gloved hands and did not remove or change gloves or wash her hands prior to completing the resident's tube feeding. Review of the facility policy titled, Infection prevention and control program dated 09/22 revealed to prevent infection the facility will educate staff and ensure that they adhere to proper techniques and procedures.

Based on record review, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the influenza and pneumococcal vaccines for four residents (#19, #26, #38, and #162) out of five residents reviewed for vaccines. The facility had a census of 64. Findings include: 1. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type 1 diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Review of the immunization records revealed Resident #162 received the pneumococcal vaccine (Prevnar 20), intramuscular suspension, 0.5 mL, administered one time for pneumonia prophylaxis on 06/24/25. There was no evidence the resident received education on the risks and benefits prior to receiving the vaccine. 2. Review of the medical record for Resident #26 revealed an admission date of 05/28/25 with diagnoses including acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the immunization records revealed Resident #26 refused both the influenza and pneumococcal vaccines on 02/03/25. There was no evidence the facility provided education on the risks and benefits prior to the resident's refusal. 3. Review of the medical record for Resident #19 revealed an admission date of 05/17/25. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, depression disorder, and dependence on wheelchair. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 indicating he was cognitively intact. Resident #19 was independent with all care. Review of the immunization records revealed Resident #19 refused the influenza vaccine on 10/15/24. There was no evidence the facility provided education on the risks and benefits prior to the refusal. 4. Review of the medical record for Resident #38 revealed an admission date of 12/11/19 with diagnoses including myotonic muscular dystrophy, aural vertigo, and ataxic gait. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. Review of the immunization records revealed Resident #38 received the influenza vaccine on 10/15/24 and the pneumococcal vaccine on 11/22/24. There was no evidence education on the risks and benefits was provided prior to administration. Interview on 06/24/25 at 11:47 A.M. with Regional Nurse #160 confirmed that the above residents (#19, #26, #38, and #162) did not receive education prior to the administration or refusal of the vaccines. Review of the facility policy titled, Influenza Vaccine - Residents revealed prior to vaccination, the resident / family will be provided information and education regarding the benefits and potential side effects of the vaccines.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure written authorization forms for the facility to manage resident funds were appropriately completed for three residents (#34, #55, and #188). Additionally, the facility failed to ensure one resident (#55) received his monthly $50 allowance. The facility census was 54. Findings include 1. Review of the medical record for Resident #55 revealed an admission date of 07/30/24. Diagnoses included epilepsy, anxiety, dementia, diabetes, psychotic disorder, and heart failure. Review of the fund authorization form dated 11/25/24 revealed it was signed by Resident #55 with no witness signature. Review of the fund statements revealed Resident #55 in 01/2025 had an income of $923 from social security and a care cost withdrawal of $938 for an overall income of negative (-) $15. In 02/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. In 03/2025, Resident #55 had an income of $946 twice from social security with no care cost withdrawal. In 04/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal liability of $3,656 to the previous ownership and a delayed care cost on 05/14/25 of $938 for an overall income of $8. In 05/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. In 06/2025, Resident #55 had an income of $946 from social security and a care cost withdrawal of $938 for an overall income of $8. Review of facility email communication with the local Jobs and Family Services (JFS) office revealed the facility informed the local JFS representative of Resident #55's social security income and care cost amount and the same day his care cost was adjusted to $896, so he received $50 each month. Review of a facility refund request dated 06/18/25 revealed a request for Resident #55 to receive a refund to the resident fund account in the amount of $233. Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #55 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. BOM #111 confirmed, according to the instructions on the form, fund authorizations required two signatures of witnesses. Interview on 06/17/25 at 6:17 P.M. with BOM #111 confirmed Resident #55's accounts had errors after transfers of funds and acknowledged the facility had no access to documentation of resident fund statements prior to 12/2024. BOM #111 revealed her understanding was a resident could take out $50 each month but denied knowledge that residents should receive their social security less $50 for care costs to the facility. BOM #111 also acknowledged the resident's account ranged from negative $15 to an overall income of $8 monthly, instead of $50 he should have received. BOM #111 revealed she reached out to the local JFS office about getting Resident #55's care cost down and when asked for evidence of this communication, an email dated 06/17/25 was provided. Interviews on 06/18/25 from 10:00 A.M. to 3:00 P.M. with BOM #111 revealed the facility had agreed to refund Resident #55 $233 of overpayment. Interview on 06/24/25 at 4:00 P.M. with the Administrator confirmed Resident #55's money was returned after surveyor intervention and communication with the local JFS office occurred was initiated by the facility after surveyor intervention. 2. Review of the medical record for Resident #34 revealed an admission date of 10/06/23. Diagnoses included Parkinson's, vascular disease, kidneys disease, and heart failure. Review of the undated fund authorization revealed an illegible signature that was allegedly signed by Resident #34. The form did not contain a witness signatures. Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #34 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. BOM #111 additionally confirmed the signature was illegible and, according to the instructions on the form, fund authorizations required two signatures of witnesses. 3. Review of the medical record for Resident #118 revealed an admission date of 02/08/24 and discharge date of 11/30/24. Diagnoses included epilepsy, alcohol abuse, vascular disease and malnutrition. Review of the fund authorization dated 04/15/24 revealed it was signed by Resident #118. The form did not contain a witness signature. Interview on 06/17/25 at 1:05 P.M. with Business Manager (BOM) #111 confirmed the fund authorization for Resident #118 was not witnessed. She revealed the facility did not witness signatures as she believed it to be a violation of privacy. Review of the facility policy titled RFMS Concepts dated 12/01/24 revealed a resident can elect to have his/her income directly deposited in the Resident Funds Management system. The designated assistant/receptionist will have the resident, representative payee, Power of Attorney, or Guardian complete the RFMS authorization form. The policy did not include language relating to witnessing of authorization forms or practices of accounting and care costs withdrawals.

Based on observations, resident interview, staff interview, and review of facility policy and procedures, the facility failed to ensure the personalized air conditioner (PTAC) in Resident #55's room was maintained in a clean manner and the facility also failed to maintain plumbing in Resident #48's bathroom to prevent leaking. This affected two residents (#48 and #55) of 30 residents in the sample. The facility census was 64. Findings include 1. Review of the medical record for Resident #55 revealed an admission date of 07/30/24. Diagnoses included epilepsy, anxiety, dementia, diabetes, psychotic disorder and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 05. Interview and observation on 06/16/25 at 10:33 A.M. with Resident #55 confirmed PTAC machine was visibly dirty and had a thick layer of dust on the vent. Resident turned on the PTAC air conditioner and a foul (trash like) smell came from the unit. Interview and observation on 06/17/25 at 3:25 P.M. with Resident #55 revealed the PTAC and vent had not been cleaned with large pieces of debris and a thick layer of dust. Interview and observation 06/17/25 at 3:31 P.M. with Maintenance Director #110 confirmed PTAC unit was dirty with large pieces of debris and a thick layer of dust. He revealed he was responsible for care and maintenance of the PTAC unit. Review of the undated facility policy titled Housekeeping/Environment Services revealed cleaning schedules shall be developed and implemented to assure each area of the facility was maintained. 2. Review of the medical record for Resident #48 revealed an admission date of 03/04/25. Diagnoses included pulmonary disease, heart disease, and visual loss. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. Interview and observation on 06/17/25 at 3:25 P.M. with Resident #48 revealed the bathroom had a leak and when you stepped on the flooring, water beads would seep through the cracks between the floorboards. Interview and observation 06/17/25 at 3:31 P.M. with Maintenance Director #110 confirmed the water beads coming up from bathroom flooring in Resident #48's room. Review of the undated facility policy titled Housekeeping/Environment Services revealed cleaning schedules shall be developed and implemented to assure each area of the facility was maintained. This deficiency represents non-compliance investigated under Complaint Number OH00165179.

Based on record review, staff interview, and review of facility policy and procedures, the facility failed to ensure as needed (PRN) psychotropic medication and antianxiety medication were not ordered for longer than 14 days without a stop date or reassessment for appropriateness. This affected one resident (#21) of five reviewed for unnecessary medication. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's physician order dated 04/02/25 to 06/24/25 revealed an order for Haloperidol (antipsychotic medication) injection solution 5 milligrams per milliliter (mg/ml) with instructions to give 10 mg once every 24 hours as needed (PRN) for severe agitation. Review of Resident #21's Medication Administration Record (MAR) dated April 2025, May 2025 or June 2025 found Resident #21 did not receive any doses of this medication. Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. Interview on 06/24/25 at 10:15 A.M. with Director of Nursing (DON) confirmed Resident #21 had an order for a Haldol injection as needed dated 04/02/25 that was currently active. The DON confirmed the medication had no stop date and also was unable to provide evidence of any reassessment for the medication to continue past 14 days. 2. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. a. Review of Resident #21's physician orders revealed an active order initiated on 03/07/25 for Lorazepam (antianxiety medication) 0.5 milliliters (ml) by mouth with instructions to give every four hours as needed (PRN) for anxiety. Review of Resident #21's Medication Administration Record (MAR) dated March 2025 revealed the resident received the medication once on 03/08/25, 03/11/25, 03/12/25, 03/18/25, 03/20/25, 03/21/25, and 03/24/25, and twice on 03/13/25. Review of Resident #21's MAR dated April 2025 and May 2025 revealed the resident did not receive any doses. Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. b. Review of Resident #21's physician orders revealed an overlapping order dated 03/08/25 to 03/12/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's MAR dated March 2025 revealed the resident received the medication once on 03/08/25, 03/10/25 and 03/12/25, and three times on 03/09/25. c. Review of Resident #21's physician orders revealed an overlapping order dated 03/12/25 to 03/12/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed for anxiety and give one tablet by mouth six times a day. Review of Resident #21's Medication Administration Record (MAR) dated 03/12/25 revealed the resident did not receive any doses. d. Review of Resident #21's physician orders revealed overlapping orders dated 03/12/25 to 03/13/25 for Lorazepam 0.5 mg by mouth with instructions to give every four hours as needed (PRN) for anxiety. Review of Resident #21's Medication Administration Record (MAR) for 03/12/25 to 03/13/25 revealed the resident received PRN doses intermittently. e. Review of Resident #21's physician orders revealed an overlapping order dated 03/13/25 to 04/23/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tab every four hours as needed (PRN). Review of Resident #21's Medication Administration Record (MAR) revealed in March 2025 the resident received all scheduled doses as ordered and received the PRN the medication dose once on 03/13/25. In April 2025 the resident received all scheduled doses as ordered and did not receive any PRN doses. Review of Resident #21's pharmacy recommendation dated 03/17/25 revealed the resident was receiving the PRN psychoactive medication, Lorazepam 0.5 mg every four hours as needed. The form had the information circled with a note to clarify with pharmacy. The provider wrote they disagreed with the recommendation and documented the reason as hospice. The provider did not sign or date when they reviewed the pharmacy recommendation. Further review of Resident #21's medical record revealed no documented evidence of a clinical rationale for the medication and dose to extend beyond the 14 days, and to include the duration of the PRN order. The record also was absent for an evaluation pertaining to the appropriateness of the medication. f. Review of Resident #21's physician order dated 04/24/25 to 04/24/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours for restlessness anxiety and agitation. Review of Resident #21's Medication Administration Record (MAR) dated 04/24/25 revealed the resident did not receive any doses. Interview on 06/24/25 at 10:15 A.M. with Director of Nursing (DON) confirmed Resident #21 had an order for Lorazepam PRN with overlapping dates and duplicate orders from March to April 2025. The DON also confirmed that some of the orders did not have a stop date and others were active over 14 days without a stop date and without any reassessment to continue past 14 days. Review of the facility policy titled Psychotropic's, dated September 2021 revealed the facility shall use psychotropic's appropriately and comply with state and federal regulations for psychopharmacological medications.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two Residents (#21 and #25) of 30 residents reviewed in the sample. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. a. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #21 had falls on 12/15/24, 02/28/25, 03/05/25, 03/06/25, 03/13/25, and 03/17/25. Review of Resident #21's progress note dated 02/28/25 revealed the resident had a fall by her room door when trying to leave during a fire drill. The resident's wrist was visibly swollen and an X-ray was ordered. Review of the fall investigation dated 02/28/25 revealed Resident #21 had a fall with injury and a swollen wrist. The X-ray returned with no findings of a fracture. Review of the progress notes dated 03/05/25 revealed Resident #21 had a fall and was found on the ground leaning up against the bathroom door. Resident #21 had a hematoma to the right eye brow. Review of the fall investigation dated 03/05/25 revealed Resident #21 had a fall with injury, a hematoma to the right eye brow. b. Review of physician orders dated 03/07/25 to 06/24/25 revealed Resident #21 was ordered Lorazepam 0.5 milliliters (ml) by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's physician orders revealed an overlapping order dated 03/13/25 to 04/23/25 for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tab every four hours as needed. Review of Resident #21's Medication Administration Record (MAR) revealed the resident was receiving the medication every four hours and as needed. Review of physician order dated 04/24/25 for Lorazepam 0.5 mg with instructions to give one tab every four hours for restlessness anxiety and agitation. c. Review of dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. It stated the resident had no broken teeth and no mouth pain or discomfort. The MDS also revealed resident was prescribed antipsychotic medication, but question N0450 was documented as no antipsychotic's were not received. The MDS stated for question J1800 had the resident had any falls since admission, entry of reentry of since prior assessment whichever was more recent was marked no indicating the resident had no prior falls. It also did not include any falls with injuries. Interview on 06/16/25 at 11:56 A.M. with Resident #21 revealed she had several broken teeth that needed pulled and had not heard any update on getting extractions scheduled. Interview on 06/24/25 at 11:05 A.M. with Regional Nurse #160 confirmed Resident #21's MDS assessment was marked incorrectly for dental problems and for the use of antipsychotic's. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with the Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #21 had dental problems not accurately marked on the MDS assessment, psychotropic medications ordered and/or administered that were not accurately marked on the MDS, and falls/falls with injury were not marked accurately on the MDS. 2. Review of the medical record for Resident #25 revealed an admission date of 12/30/16. Diagnoses included chronic obstructive pulmonary disease, diabetes, kidney disease and muscle weakness. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #25 had falls on 02/20/25, 03/18/25, 04/14/25, 04/19/25, 05/04/25 and 05/19/25. Review of the fall investigation dated 04/19/25 revealed Resident #25 had an unwitnessed fall at 7:20 A.M. when the resident slid out of bed trying to get up to go to the bathroom. Resident #25 landed on the right side and complained of right arm pain. Resident #25 was noted to have a new skin tear measuring 3 centimeters (cm) by 3 cm on the right elbow. Review of the internal fall investigation document dated 04/19/25 revealed Resident #25 had an injury to the right upper arm (pain) and a skin tear to the right elbow. Review of the fall investigation dated 05/19/25 revealed Resident #25 had an unwitnessed fall at 6:45 P.M. when the resident was found on the ground floor with her back on the bottom bar of the overbed table. Resident #25 stated she was going to the bathroom. Abrasions were noted to the back of the resident's head. Review of the internal fall investigation document dated 05/19/25 revealed Resident #25 had an injury, an abrasion to the back of the head. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had assessment that stated for question J1800 had the resident had any falls since admission, entry of reentry of since prior assessment whichever was more recent was marked no indicating the resident had no prior falls and no falls with injury were documented. Resident had not had an updated MDS assessment since the second fall with injury occurred. Interview on 06/18/25 at 4:54 P.M. and 06/23/25 at 9:35 A.M. to 11:30 A.M. with the Director of Nursing (DON) and Regional Nurse #160 confirmed Resident #25 had falls and falls with injury and they were not marked accurately on the MDS assessment.

Based on record review and staff interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) was updated after a change in the mental health diagnosis for one resident. This affected one resident (#21) out of four reviewed for PASARR. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes and malnutrition. A diagnosis of unspecified psychosis was added to the medical record on 07/02/22 and schizophrenia was added to the medical record as a diagnosis on 07/19/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's most recent PASARR dated 10/24/23 revealed panic/anxiety disorder and another mental disorder were documented (delusional disorder and post-traumatic stress disorder). There was no documented evidence of a new PASARR to reflect the change in mental disorder diagnosis (schizophrenia) after the diagnosis was given. Interview on 06/17/25 at 5:46 P.M. with Social Services (SS) #89 confirmed the facility did not complete an updated PASARR after a change in mental disorder diagnosis. SS #89 confirmed the facility had no process in place to ensure PASARR's were updated when a resident had a change in mental disorder diagnosis.

Based on medical record review, staff interview, and review of facility policy and procedure, the facility failed to ensure care plans were developed as appropriate. This affected one resident (#21) of 22 residents reviewed for care planning. The facility census was 64. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphagia, muscle wasting, diabetes, and malnutrition. Review of the social services documentation revealed Resident #21 was approved for Medicaid on 07/17/24. Review of Resident #21's dental consent dated 07/31/24 revealed the resident signed a consent to receive dental services. Review of the dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. The note further stated Medicaid resident-resources were sent to the facility and the appointment should be scheduled with a Medicaid provider, location determined by the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. It stated the resident had no broken teeth and no mouth pain or discomfort. Review of the plan of care on 06/23/25 revealed Resident #21 did not have any care plan related to dental needs. Interview on 06/16/25 at 11:56 A.M. with Resident #21 revealed she had several broken teeth that needed pulled and she had not heard any update on getting extractions scheduled. Interview on 06/17/25 at 5:46 P.M. with Social Services #89 revealed Resident #21 was seen by the dentist 04/16/25, but confirmed a follow up was not scheduled and she was unaware of any recommendations for needs for a follow up. Interview on 06/23/25 from 10:00 A.M. to 2:30 P.M. with Regional Nurse #160 confirmed the facility had no documented evidence of a care plan for dental needs for Resident #21, including having pain and broken teeth and needing significant extractions. Review of facility policy titled Care Plans, Comprehensive Person Centered, dated September 2021 revealed a care plan that included measurable objectives and timetables to meet resident needs shall be developed and implemented for each resident. The interdisciplinary team shall develop a care plan for each resident.

Based on record review, resident interview, staff interview, and review of policy and procedure, the facility failed to ensure a resident received showers/bed baths as scheduled. This affected one (Resident #24) out of two residents reviewed for activities of daily living (ADLs). The facility census was 64. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/26/23 and diagnoses including cerebral palsy (unspecified), generalized muscle weakness, unsteadiness on feet, and major depressive disorder (recurrent, mild). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Additionally, the resident required maximum assistance with bathing. Review of the care plan for Resident #24 revealed a self-care deficit related to factors including chronic fatigue, generalized weakness, impaired mobility, poor balance, poor coordination, and shortness of breath, which necessitated staff assistance with personal hygiene, including bathing. The care plan included goals to maintain the resident's current level of function while ensuring timely and adequate support with activities of daily living. Interventions specifically called for assistance with personal hygiene and bathing as needed, encouragement for the resident to use the call light to request help, and ensuring staff promptly responded to these needs. Review of the shower records for Resident #24 revealed multiple instances where showers were not provided as scheduled, with gaps exceeding seven days. Specifically, there was an 18-day gap between showers from 03/07/25 to 03/25/25, an 11-day gap from 03/28/25 to 04/08/25, another 11-day gap from 04/18/25 to 04/29/25, and an 8-day gap between 05/23/25 and 05/31/25, during which no showers were recorded. After 06/07/25, no further showers were documented. There was no documented evidence that the resident refused showers during these periods. Interview on 06/16/25 at 12:15 P.M. with Resident #24 revealed she would at times go more than a week without a bath and reported that facility staff would document a refusal even when she had not refused. She also stated she preferred bed baths over taking showers. Interview on 06/17/25 at 11:52 A.M. with Certified Nursing Assistant (CNA) #115 revealed that if residents refused showers, staff would ask the resident three times and then have them sign the shower sheet. She added that if the resident still refused, staff would ask again the next day. CNA #115 noted that Resident #24 received bed baths on Tuesdays and Fridays and typically did not refuse her bed baths. Interview on 06/17/25 at 11:56 A.M. with the Director of Nursing (DON), revealed that refusals for showers were only documented on the shower sheets and not in the progress notes. She also confirmed Resident #24 had multiple gaps in bathing. Interview on 06/18/25 at 9:44 A.M. with Resident #24 revealed that she had not been to the hospital recently and had remained in the facility the entire time. She reported refusing showers only a couple of times and that when she refused, she signed a refusal form. Review of the facility policy titled Activities of Daily Living (ADLs) revealed appropriate care and services were to be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.

Based on observations, medical record review, staff interview, family interviews, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of nutritional problems and malnutrition, maintained acceptable parameters of nutritional status, and failed to follow nutritional interventions, complete weekly weights as ordered, provide appropriate assistance with meals, and provide appropriate oversight and monitoring to address significant and severe weight loss for Resident #10. This affected one (#10) of five residents (#10, #21, #26, #34, and #35) reviewed for nutrition. The facility identified a total of eight residents (#10, #11, #21, #27, #33, #35, #46 and #58) as being at nutritional risk. The facility census was 64. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphagia, atrial fibrillation, diabetes, muscle weakness, metabolic encephalopathy, and muscle wasting atrophy. Review of Resident #10's medical record revealed no documented evidence of an admission nutritional assessment or admission risk assessment. Review of Resident #10's weights revealed on 03/01/24 the resident weighed 318 pounds (lbs.) upon admission, on 08/03/24 the resident weighed 269.6 lbs., on 10/04/24 the resident weighed 255.8 lbs., on 11/06/24 the resident weighed 252.0 lbs., and on 12/07/24 the resident weighed 244.0 lbs. Review of Resident #10's dietitian progress notes dated 12/18/24 revealed the resident's weight was trending down from 273 lbs. to 244 lbs. for a 10.6% weight loss in 180 days with 25 to 100% of intakes. Ice cream and pudding supplements were in place and weight loss was beneficial due to the residents' high Body Mass Index (BMI). The physician and nursing staff were notified of the weight loss. Review of Resident #10's physician order dated 12/20/24 revealed a diet order for regular diet at regular consistency with double protein portions. Review of Resident #10's physician orders revealed an order dated 12/23/24 for the resident to be assisted with meals due to pocketing food. Review of Resident #10's weights revealed on 01/07/25 the resident weighed 239 lbs. Review of the dietitian progress notes dated 01/08/25 revealed Resident #10's weight was trending down from 275 lbs. to 239 lbs. for a 13.1% loss in 180 days with gradual weight loss. Double protein portions were recommended although the resident voiced displeasure with the quality of the food. Intakes were variable at 25 to 100%. House shakes had also been added and ordered on 12/20/24 for lunch and dinner trays. The order was discontinued on 02/03/25 when the resident was hospitalized . The physician and nursing staff were notified of the weight loss. Review of progress note dated 01/28/25 revealed upon assessment, Resident #10 had increased confusion and frequent involuntary movements. Vital signs included blood pressure 143/90 millimeters of mercury (mmHg) [normal ranges around 120/80 mmHg], respirations 19 breaths per minute (normal ranges from around 12 to 18) and pulse 87 beats per minute (bpm) [normal ranges from around 60 to 100]. The resident was maintaining oxygen saturation levels at 94 % on 3 liters of oxygen. After informing the nurse practitioner of findings, an order was received to send Resident #10 to the hospital for evaluation. Review of the dietitian's progress notes dated 01/29/25 revealed Resident #10 had a weight loss of 12.9% over 180 days. Intakes were variable at 25 to 75% of meals. Weekly weights were to be added due to the need for close monitoring and follow-up. The most recent weight to this dietitian's note, was on 01/07/25 when the resident weighed 239 lbs. Review of the plan of care dated 01/29/25 revealed Resident #10 had a nutritional problem or potential nutrition problem related to significant weight loss, feeding assistance, therapeutic diet, and meal refusals with interventions including to monitor, document and report signs and symptoms of dysphagia including pocketing, choking, coughing, drooling etc., monitor signs and symptoms of malnutrition including weight loss of over three pounds in one week, over five percent in one month, over seven and a half percent in three months, and over 10 percent in six months, to provide and serve diets as ordered, and dietitian to evaluate and make recommendations as needed. There was no documentation of a nutrition care plan prior to 01/29/25 and the care plan was not updated after the resident's weight loss, pureed diet order change or her hospitalization. Review of Resident #10's hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The summary also revealed the resident was evaluated for altered mental status, dysphagia, and aspiration. The hospital discharge diet recommendations were for a carb-controlled diet with pureed texture and thin liquids. Review of physician orders dated 02/03/25 revealed Resident #10 had a diet order for a carb-controlled diet with pureed texture. Review of Resident #10's weights revealed on 02/03/25 and 02/04/25, the resident weighed 241.3 lbs. Review of Resident #10's physician orders dated 02/04/25 through 03/04/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 02/12/25 revealed Resident #10's weight loss was trending down from 270 lbs. to 241.3 lbs. with a weight loss of 10.7% over 180 days. Resident #10 had returned from the hospital with a diet downgrade to pureed texture. Intakes were poor at less than 25 to 75% of meals consumed. It noted that Resident #10 needed assistance for feeding at times and weekly weights were to be continued for close monitoring and follow-up. There was no documented evidence in the medical record of the resident having a weight of exactly 270 lbs. per this dietitian's note. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had significant cognitive impairment with a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. The resident was noted as independent with eating and had previous significant weight loss and was not on a weight loss program. Review of the physician note dated 03/03/25 revealed Resident #10 continued to require full assistance with activities of daily living including supervision during meals due to pocketing. She had chronic weight loss with a current weight of 239 lbs. It noted that Resident #10 had a history of poor oral intake due to food dissatisfaction but agreed to house shakes. Review of Resident #10's weights revealed on 03/09/25 the resident weighed 217.4 lbs. Review of Resident #10's physician orders dated 03/11/25 through 05/21/25 revealed an order for weekly weights. Review of the dietitian's progress notes dated 03/12/25 revealed Resident #10 had a weight loss of 241 lbs. to 217.4 lbs. for a weight loss of 10% over 30 days. Resident #10 did not like the pureed texture, and intakes were low at 25 to 75% of meals. Med pass (supplement) was added three times daily as well as an appetite stimulant to improve intakes. The plan was to continue weekly weights for close monitoring and follow up. Review of Resident #10's progress notes dated 03/12/25 revealed the physician was notified of the resident's significant weight loss. A new order was received for Mirtazapine (an appetite stimulant). Review of Resident #10's physician orders revealed on 03/12/25 the resident was ordered Med Plus 2.0 three times daily for a supplement and Mirtazapine due to increased weight loss. Review of Resident #10's Medication Administration Record (MAR) from March 2025 through June 2025 revealed the supplements and appetite stimulant were completed and offered as ordered. The Med Plus supplement was frequently refused or very little was consumed. Review of Resident #10's weights revealed on 03/18/25 the resident weighed 216.6 lbs. and on 04/06/25 the resident weighed 217.8 lbs. Review of the dietitian's progress notes dated 04/09/25 revealed Resident #10 had a weight loss of 14.8% over 180 days. Resident #10 required assistance at times with meals. The plan was to continue weekly weights for close monitoring and follow up. Review of the dietitian's progress notes dated 04/29/25 revealed Resident #10 had a weight loss of 14.9% over 180 days. Resident #10 required assistance at times with meals. The plan was to continue weekly weights for close monitoring and follow up. The most recent weight to this dietitian's note, was on 04/06/25 when the resident weighed 217.8 lbs. Review of Resident #10's weights revealed on 05/04/25 the resident weighed 216.6 lbs. Review of the quarterly Minimum Data Set (MDS) assessment, with a target date of 05/16/25, revealed Resident #10 had significant cognitive impairment with a BIMS of 04. The activities of daily living section of the assessment, dated 05/29/25 within the MDS, noted that Resident #10 was independent for eating. Review of facility tasks from 05/01/25 to 05/31/25 revealed Resident #10 was independent with eating seven meals out of 93. The remaining days the resident required supervision assistance for 42 meals, limited assistance for five meals, extensive assistance for three meals, and total dependence for three meals. Thirty-three meals were either not documented or marked as refused and NA for not applicable. Review of facility tasks from 06/01/25 to 06/15/25 revealed Resident #10 was independent with eating two meals out of 45. The remaining days the resident required supervision assistance for 26 meals, limited assistance for zero meals, extensive assistance for one meal, and total dependence for three meals. Thirteen meals were either not documented or marked as refused and NA for not applicable. Review of the dietitian's progress notes dated 05/21/25 revealed Resident #10's weekly weights were discontinued due to stabilization of weights over 90 days. Review of Resident #10's Treatment Administration Record (TAR) from February 2025 to May 2025 revealed Licensed Practical Nurse (LPN) #138 had signed off the weekly weight for all of the residents ordered weekly weights, but there was no documentation on the TAR for what the weights actually were. Review of Resident #10's medical record related to the weekly weights order for February 2025 through May 2025 revealed weekly weights were not completed as ordered. The resident had monthly weights completed with only two additional weights completed on 03/09/25 and 03/18/25. Review of Resident #10's weights revealed on 06/04/25 the resident weighed 212.4 lbs. Review of the dietitian's progress notes dated 06/04/25 revealed Resident #10 triggered for significant weight loss for a weight loss of 13.1% over 180 days. It noted that her intake improved from 25 to 100% and the resident required assistance at times with meals. Review of a speech therapy note dated 06/07/25 revealed an assessment occurred of Resident #10 eating a cookie. She required excessive time for chewing and moderate pocketing and food left in the cheek. Resident #10 was unable to fully clear food and was given maximum verbal cues. Review of speech therapy notes dated 06/11/25 revealed Resident #10 was trialed on a more liberalized (mechanical) diet and had a choking episode during the trial. Review of the menu ticket dated 06/16/25 revealed Resident #10 had a pureed diet order and was to receive pureed honey glazed turkey, pureed sweet potatoes, pureed green beans, and pureed strawberries. A note at the bottom stated vanilla house shake and ice cream with lunch and dinner trays only [indicating the shake and ice cream were to be given in addition to the meal]. Observation on 06/16/25 at 11:50 A.M. revealed Resident #10 was served a lunch tray. Resident #10 was not assisted to a sitting position in her bed and was not supervised or assisted while eating. Resident #10 told Certified Nurse Aide (CNA) #80 she did not want her food as it looked gross. CNA left the tray at the bedside and did not offer any alternatives. Observation and interview on 06/16/25 at 12:20 P.M. revealed Resident #10 had eaten less than 25% of the meal. CNA #80 confirmed Resident #10 had eaten less than 25% of the meal tray and confirmed no assistance was provided. Review of facility tasks for meal assistance revealed on 06/16/25 it indicated Resident #10 received supervision assistance for the lunch meal. Interview on 06/16/25 at 3:19 P.M. with Resident #10's family revealed the resident had not been eating the pureed food and confirmed she had lost weight. He was concerned and wanted her moved back to a mechanical soft diet so she wouldn't refuse her meals as often. He also reported concerns about quality of life versus quantity of life, especially if she was just starving herself due to not liking the food. Observation on 06/17/25 at 12:08 P.M. revealed Resident #10 had a lunch tray at bedside. Resident #10 was not assisted to a sitting position in her bed and was not supervised or assisted while eating. Review of facility tasks for meal assistance revealed on 06/17/25 it stated Resident #10 required total dependance upon staff assistance for the lunch meal. Interview on 06/17/25 at 12:13 P.M. with CNA #118 revealed they picked up Resident #10's food tray and the resident had eaten about 10% of her food. CNA #118 confirmed she did not offer an alternative and did not assist the resident with eating. CNA #118 was unable to answer if Resident #10 required assistance with eating and was unable to answer when asked how staff should find out/determine if a resident required assistance with eating. CNA #118 was shown the orders in Resident #10's record and she then confirmed Resident #10 had an order to assist with eating due to pocketing food and confirmed staff should be observing and offering assistance per the physician order. Interview on 06/17/25 at 12:13 P.M. with the Director of Nursing (DON) confirmed Resident #10 had an order to assist with meals due to pocketing and was unable to state what the order meant for the resident or what her expectations were related to staff responding to or following the order. She further stated she would need to review the facility policy regarding what the order meant. Interview on 06/17/25 at 1:51 P.M. with Regional Nurse #160 confirmed Resident #10 had an order for assistance with meals due to pocketing and the facility had no policy specific to and could not explain what the order of assistance due to pocketing meant. Interview on 06/18/25 at 9:35 A.M. with Dietitian #162 revealed Resident #10 had been steadily losing weight since her admission in March 2024. She confirmed Resident #10 was obese and some weight loss was not concerning to her, but she did not want the resident to have significant drops in weight or be listed as excessive weight loss. Dietitian #162 confirmed the resident was hospitalized for an aspiration event and returned on a pureed diet. Resident #10 was accepting of the shakes and ice cream and ate very little of her meals. Dietitian #162 confirmed she recommended weekly weights to try and catch any big drops or changes in her weights and staff informed her they were assisting residents [including Resident #10] with eating. Dietitian #162 confirmed facility staff were not completing weekly weights as recommended and it was a struggle to get staff to obtain weights. She stated she spoke to the floor staff and management staff about getting the weights completed. She also reported corporate staff told her to discontinue weekly weights so they would not get a citation for not obtaining weights. She stated she would expect staff to offer assistance with eating when required and alternatives should have been offered if residents declined the meal or ate very little of it. Interview on 06/18/25 at 10:29 A.M. with Speech Therapist (ST) #155 revealed Resident #10 had not passed the food trial for the mechanical soft food texture due to coughing during the trial. She revealed Resident #10 did pocket pureed food, especially pureed eggs, but that she continued to recommend pureed texture and continued to work with the resident. She acknowledged while many days Resident #10 could feed herself, pocketing food was not safe and monitoring/assisting during meals was appropriate. Interview on 06/18/25 at 11:00 A.M. with the DON confirmed weekly weights were not obtained as ordered for Resident #10 and she also confirmed the resident was not being assisted during meals as ordered/required. Interviews on 06/16/25 around 11:00 A.M. and on 06/18/25 around 4:00 P.M. with Regional Nurse #160 revealed the facility had been purchased by a new entity with a change over in December 2024. Regional Nurse #160 stated the previous company had walked in and took many boxes of records without current staff's knowledge of exactly what was taken. He also revealed the previous company had Matrix electronic charting system and now this new company had Point Click Care (PCC) charting system, and not everything had been transferred over to PCC. He revealed they only had access to a limited version of the old Matrix charting system, leading to missing medical record documentation including information pertaining to Resident #10's nutrition. Interview on 06/26/25 at 10:54 A.M. with LPN #138 revealed that weekly weights and other vital signs were to be completed over the weekends, so when she worked on Tuesday's she would just sign off it got completed. LPN #138 verified she did not obtain any weights for Resident #10 but signed them off. She reported all weights would be documented in the weights and vital signs section of the medical record. Review of the facility policy titled, Weights, dated 09/01/21 revealed weights must be obtained routinely in order to monitor parameters of nutrition over time. Weekly weight should be obtained by the same day each week when possible. The dietitian or physician may order specific nutritional interventions as indicated. Review of the facility policy titled Assistance with meals dated September 2021 revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff shall serve resident trays and help residents who require assistance with eating. Review of the undated facility policy titled Activities of Daily Living revealed residents shall be provided with care, treatment and services to maintain or improve abilities. The types of assistance included: Independent, where the resident shall complete the activity with no help or staff oversight at any time in the last seven days; Supervision, where the resident required oversite, encouragement or cueing to complete the activity three or more times in the previous seven days; Limited assistance, where the resident was highly involved in the activity and received physical help in guided maneuvering of limbs(s) or other non-weight bearing assistance three or more times in the previous seven days; Extensive assistance, where the resident preformed part of the activity over the past seven days or staff provided weight bearing support; And total dependance, where staff performed an activity with no participation by resident for any aspect of the ADL activity during the entire seven day look back. This deficiency represents non-compliance investigated under Complaint Number OH00165179.

Based on record review, observation, interview, and facility policy review, the facility failed to provide oxygen to one resident (#58) out of two reviewed for respiratory care. The facility census was 64. Findings Include: Review of the medical record for Resident #58 revealed an admission date 04/28/25. Diagnoses included chronic systolic heart failure, paroxysmal atrial fibrillation, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #58 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #58 was dependent on turning, personal hygiene, toileting, dressing upper and lower body. Review of the plan of care dated 06/10/25 revealed that Resident #58 had impaired respiratory status related to anxiety, congestive heart failure, history of smoking, obesity, pulmonary edema, and respiratory failure. Interventions included activity level as tolerated, administer medication as ordered, monitor for increased anxiety associated with shortness of breath, monitor for signs and symptoms of increased shortness of breath, monitor for lung sounds, provide oxygen as ordered, and monitor lung sounds for wheezing or crackles as needed. Review of Resident #58's medical record from 05/01/25 through 06/16/25 revealed no documented evidence of a physician order to administer oxygen by nasal cannula. Observation on 06/16/25 at 11:25 A.M. revealed Resident #58 was trying to get out of bed and had both feet and legs coming off of the bed. The resident had oxygen on via nasal cannula and the oxygen concentrator was set at five liters per minute. Resident #58 was alert with confusion. Interview on 06/16/25 at 11:29 A.M. with Licensed Practical Nurse (LPN) #122 verified that Resident #58 had oxygen on at five liters via nasal cannula. LPN #122 verified that there was no active order for oxygen in Resident #58's medical chart. Review of the facility policy titled Oxygen Administration dated September 2021 revealed that oxygen therapy was the administration of oxygen at concentration greater than room air with the intent of treating or preventing the symptoms and manifestations of hypoxia. Initial need was determined by documenting hypoxia or having a physician's order.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure pharmacy reviews were followed up on in a timely manner and documentation of the pharmacy recommendations were maintained for one resident (#21) out of five reviewed for pharmacy recommendations. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. a. Review of monthly pharmacy reviews dated 08/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 09/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 10/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 11/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 04/2025 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Further review of the medical record for Resident #21 revealed no documented evidence of the pharmacy recommendation forms for 08/2024, 09/2024, 10/2024, 11/2024, and 04/2025. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the facility was missing pharmacy recommendations for 08/2024, 09/2024, 10/2024, 11/2024 and 04/2025. b. Review of Resident #21's pharmacy recommendation dated 12/30/24 revealed the resident was ordered Gabapentin 200 three times daily and the medication had life threatening respiratory risk and recommended a risk verse benefit analysis to be completed or taper the medication. The medical provider signed on 01/05/25 and check marked the need for a risk versus benefit analysis. Review of Resident #21's medical record found no evidence of documentation of the risk versus benefit analysis and what risks and benefits were identified for Resident #21. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the facility did not have a documented risk versus benefit analysis for Resident #21. c. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated please evaluate risk versus benefit of the following medication in a hospital patient. Listed medications included vitamin D, B-12, Iron, multivitamin, and potassium. The provider signed and marked agree with a note to discontinue all five supplements. The provider did not date the form. Review of facility orders for June 2025 revealed a continued order initially ordered on 02/25/25 for potassium oral tablet with instructions give 20 milliequivalents (mEq) once daily. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing confirmed the form was not dated by the provider and also acknowledged the potassium medication was still an active medication and was never discontinued per the Pharmacist and Physician decision. d. Review of Resident #21's physician order dated 02/01/25 to 04/25/25 revealed orders for Bupropion HCl extended release (SR) oral tablet 12 hour 150 mg with instructions to give one tablet daily. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated Wellbutrin SR (12 hour) 150 milligrams (mg) once daily was to be twice daily and it asks if the medication should be the XL (24 hr) medication instead. The provider marked other and stated updated in Point Click Care (PCC) (the electronic charting system). The provider signed and dated the form on 04/01/25. Review of Resident #21's physician order dated 04/26/25 revealed and order for Wellbutrin XL oral tablet extended release 24 hour with instructions to give 150 mg one tablet daily. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing (DON) confirmed the medication was changed according to pharmacy recommendation on 04/26/25. The DON acknowledged a delay from a recommendation given 03/17/25 that was addressed by the provider on 04/01/25, but the order was not changed until 04/25/25. e. Review of Resident #21's physician orders dated 03/07/25 revealed an order for Lorazepam 0.5 ml by mouth with instructions to give every four hours as needed for anxiety. Review of Resident #21's physician order dated 03/13/25 through 04/23/25 revealed orders for Lorazepam 0.5 mg with instructions to give one tablet every four hours and give one tablet every four hours as needed. Review of Resident #21's pharmacy recommendation dated 03/17/25 stated the resident was receiving the following as needed (PRN) psychoactive medication Lorazepam 0.5 milligrams (mg) every four hours as needed. The form had the information circled with a note to clarify with pharmacy. The provider wrote disagree and documented the reason as hospice. The provider did not sign or date when they reviewed the pharmacy recommendations. Interview on 06/24/25 at 10:15 A.M. with the Director of Nursing (DON) reported she was unaware of what clarification occurred with the pharmacy, but stated the doctor wrote disagree and hospice. The DON acknowledged all PRN psychotropic medications should be limited to 14 days and have a stop date and reevaluation for appropriateness. The DON also confirmed no provider signed or dated the form. Review of facility policy titled Medication Regimen Review, dated September 2021 revealed a consultant pharmacist shall review medications at least monthly and evaluate for drug or food interactions, accuracy, timing, dosage, and form, and be aware for adverse side effects. The Pharmacist will provide a written report of irregularities. Documentation shall be maintained as part of the residents medical record.

Based on observations, staff interviews, interview with the Legionella Consultant, record reviews, review of the Certificate of Death, review of the water sample report, review of the facility's water management policy, review of the facility's Legionella water management program, and review of the facility's Legionella written plan, the facility failed to adhere to their policy and water management program to prevent the spread of Legionella. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when one resident (Resident #100) was found lethargic, with a reddened rash, cool skin, unable to answer or follow commands, and was going in and out of consciousness. Resident #100 was sent to the emergency room for evaluation. On [DATE], Resident #100 tested positive for legionella at the hospital, and expired on [DATE]. This affected one (Resident #100) of three residents reviewed for exposure to Legionella and placed all other residents residing in the facility at risk for potential negative health outcomes as the facility was not implementing their water management program to detect and prevent the spread of Legionella. The facility census was 51. On [DATE] at 4:16 P.M., the Administrator, Director of Nursing (DON), and Corporate Nurse #300 were notified that Immediate Jeopardy began on [DATE] when Resident #100 was found lethargic, with a reddened rash, cool skin, unable to answer or follow commands, and was going in and out of consciousness before being transported to the hospital. The resident was subsequently diagnosed with Legionella on [DATE] and expired on [DATE]. Additionally, the facility was not implementing their water management program in accordance with their Water Management Policy by not obtaining quarterly water testing to detect and prevent the spread of Legionella and not maintaining their holding tank at the required temperature of 140 degrees Fahrenheit or above. The Immediate Jeopardy was removed on [DATE] at 2:45 P.M. when the facility implemented the following corrective actions: · On [DATE] at 10:30 A.M., Assistant Director of Nursing (ADON) #75 received a phone call from the [NAME] County Health Department that Resident #100 had tested positive for Legionella. · On [DATE] at 10:42 A.M., ADON #75 notified the DON of potential Legionella in the water system. · On [DATE] at 10:46 A.M., ADON #75 notified the Medical Director of potential Legionella in the water system. · On [DATE] at 10:56 A.M., ADON #75 notified the Administrator of potential Legionella in the water system. · On [DATE] at 11:00 A.M., ADON #75 notified all department managers of potential Legionella in the water system. · On [DATE] at 11:15 A.M., the facility suspended mobile drink carts, all communal activities involving food and drink, and suspended all resident showers. · On [DATE] at 11:30 A.M., ADON #75 met with all floor staff and department heads currently working in the facility to provide an update on potential Legionella in the water system and discussed the immediate action plan which included to enact the emergency water plan, suspend any use of water for consumption, including the ice machine and juice machine, and showers suspended until further notice. · On [DATE] at 12:00 P.M., Plant Operations Director #150 was notified of the need for the emergency water plan to be enacted. The residents were notified not to drink water through room taps by ADON #75. · On [DATE] at 12:35 P.M., the facility received instruction from the Medical Director on monitoring guidelines and current orders for resident testing. · On [DATE] at 12:45 P.M., ADON #75 and all Licensed Nursing Staff screened all in-house residents for signs and symptoms of Legionella. Two residents (Resident #08 and #20) were identified as potentially having symptoms and urine tests were obtained with results being negative for Legionella [MEDICATION(S)]. · On [DATE] at 1:00 P.M., ADON #75 instructed licensed nursing staff and State tested Nursing Assistants (STNA's) that showers were suspended until further notice. ADON #75 notified kitchen staff to cease utilizing the juice dispenser and ice maker. ADON #75 notified nursing staff and STNA's that the ice makers on the units were to be taken out of use until further notice. · On [DATE] at 1:40 P.M., ADON #75 notified Regional Support of potential Legionella in the water system. · On [DATE] at 2:00 P.M., ADON #75 in-serviced all nursing staff on temporary measures implemented which included tap water was not to be used for consumption, shower rooms are put out of service, ice machines and juice machines are out of service, and to monitor residents for any signs and symptoms of respiratory changes. · On [DATE] at 6:00 P.M., a Teams Meeting was held with the Regional Nurse Consultant, Reginal Vice President, and Regional Plant Operations to update on measures taken and receive any further guidance. · On [DATE] at 7:30 P.M., ADON #75 obtained free chlorine test kits and results showed acceptable amounts in the cold water with 0.6 ppm FC. ADON #75 updated Plant Operations Director #150 with the results. · On [DATE], the City of Washington Court House came to the facility and tested the water system. · On [DATE], the facility received the results from the City of Washington Court House with no negative findings in the water. · On [DATE], the Administrator received a call and a follow-up e-mail from the Ohio Department of Health, Bureau of Environmental Health and [CONDITION(S)] Protection with recommendations made for the facility which included to obtain a Legionella Consultant. · On [DATE], the facility hired Legionella Consultant #500. · On [DATE], the facility ordered shower filters. · On [DATE], the facility obtained a quote from a plumbing company to completely fix their boiler system. During the quote inspection, it was identified that there were temperature issues in the holding tank dropping below the required 140 degrees. · On [DATE], shower filters arrived and installation began by Plant Operations Director #150 and facility showers continued. · On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, DON, Administrator, and ADON #75. · On [DATE], Legionella Consultant #500 swabbed water sources in the facility to gather samples. There were a total of 20 samples obtained. · On [DATE], water samples were delivered to the Centers for Disease Control (CDC) testing facility. · On [DATE], water filters were installed in all resident rooms and community water sources by Plant Operations Director #150. · On [DATE], Plant Operations Director #150 called the plumbing company to follow up on the status of the boiler repairs. The plumbing company notified Plant Operations Director #150 that the new boiler system arrived damaged in shipping and a new system was reordered. · On [DATE], the water sample report was received by the facility with positive results for Legionella in the water system. · On [DATE], Plant Operations Director #150 called the plumbing company to follow-up on the status of the new boiler and was told the company was still awaiting shipment. · On [DATE], Regional Plant Operations Director discussed plans with Legionella Consultant #500 of the plan to replace the boiler system before sanitizing piping, follow the chemical disinfectant with a heat disinfectant and then have Plant Operations Director #150 run the water where the samples indicated Legionella bacteria in the test report, then water will be tested after disinfecting by Legionella Consultant #500 and then again 12 days later. · On [DATE], Plant Operations Director #150 called the plumbing company to follow-up on the status of the new boiler and was told the company was still awaiting shipment. · On [DATE], Plant Operations Director #150 called the plumbing company to follow-up on the status of the new boiler and was told the company was still awaiting shipment. · On [DATE], all residents in-house were re-screened by DON/Designee for signs and symptoms of Legionella with no findings. · On [DATE], re-education started with all staff on the facility's Legionella policy, as well as the signs and symptoms of Legionella by the DON/Designee. · On [DATE], Plant Operations Director #150 was re-educated on the facility water management and Legionella policies and procedures by the Administrator. · On [DATE] at 2:45 P.M., the DON/Designee finished re-education with all staff on the facility's Legionella policy, as well as the signs and symptoms of Legionella. · Beginning on [DATE], the DON/Designee will screen five residents for Legionella three times a week for four weeks, then monthly for two months. In addition, the facility Plant Operations Director #150 will test the water for free chlorine and pH levels weekly for four weeks, monthly for two months, then quarterly thereafter. Results of the screens will be reviewed with QAPI committee monthly for three months with further recommendations as warranted. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan to ensure on-going compliance. Findings include: Resident #100 was admitted on [DATE], discharged on [DATE], readmitted on [DATE], and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed this resident had intact cognition and was assessed to require extensive assistance for bed mobility, transfer, dressing, eating, toileting, and personal hygiene. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #100 was seen for increased confusion. It was noted he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care indicated the following laboratory tests (basic metabolic panel, complete blood count, and urinalysis) were to be ordered and nursing staff were to monitor chronic and acute conditions with no acute condition changes noted on this date. Review of the nursing note dated [DATE] at 5:55 P.M. revealed the resident was awakened by staff earlier this morning for a visit with his daughter. The daughter reported she was concerned about the resident being confused with a rash on his hand. He was assessed, vitals were taken, and he was found to be alert and oriented times three. The resident reported that he felt fine and denied discomfort. The nurse practitioner was notified and gave an order to apply [MEDICATION(S)] cream to rash and monitor. The note indicated as of 5:00 P.M. on this date there was a light rash and puffiness with improvement noted. Review of the nursing note dated [DATE] at 11:11 P.M. revealed the resident was noted to be lethargic with a reddened rash, ashy skin, cool to touch, pedal pulse was absent on left foot, and was coming in and out of consciousness. He was unable to answer or follow simple commands. The nurse practitioner and Director of Nursing were notified, and an order was obtained to send the resident to the emergency room . Review of the Certificate of Death dated [DATE] revealed Resident #100 expired on [DATE] of multisystem organ failure due to severe [CONDITION(S)] and Legionella Pneumonia. Interview on [DATE] at 11:54 A.M. with Plan Operations Director #150 revealed there had been ongoing issues with the boiler system, including a leak. He stated new boilers were ordered but were damaged in shipping and had to be reordered. Interview on [DATE] at 12:36 P.M. with the Administrator, DON, Plant Operations Director #150, and ADON #75 revealed the ADON received a call on [DATE] from the local public health department informing them Resident #100 had tested positive for legionella. The ADON reported he informed the DON, medical director, and Administrator. A meeting was held with department heads, the emergency water plan was implemented, and staff education was provided to nurses and STNAs. It was revealed during the interview that the city came out per the facility ' s request to test the water with no concerns identified. Interview on [DATE] at 5:28 P.M. with the Administrator confirmed the facility does not have documentation regarding the water quality samples being measured at least quarterly. Interview on [DATE] at 9:56 A.M. with ADON #75 revealed the facility was contacted by an individual from the Bureau of Environmental Health with the Ohio Department of Health. The ADON reported the facility was given a recommendation to hire a consultant. Interview on [DATE] at 10:20 A.M. with the Administrator revealed he was not the facility ' s Administrator when a conference call was held between the facility and Environmental Health. He reported a legionella consultant was hired and the water was tested for legionella. He stated the consultant was not concerned by the results. The Administrator reported the consultant said there would be tolerable amounts of Legionella in the system. Review of the water sample report provided during the interview and dated [DATE] revealed there were several water samples that tested positive for legionella, including a sample from the room where Resident #100 resided in. Interview on [DATE] at 10:45 A.M. with Legionella Consultant #500 revealed the facility had failures in their boilers and the water temperature was too cool. He stated the water samples came back with high results of legionella. Interview on [DATE] at 11:01 A.M. with Plant Operations Director #150 revealed filters were installed on [DATE] on all water sources. Observation on [DATE] at 2:03 P.M. revealed there was not a filter on the sink in the bistro area where an employee was observed passing out ice cream floats. Interview on [DATE] at 2:07 P.M. with Plant Director #150 confirmed there was not a filter on the sink. He immediately went and installed a filter after the interview. Interview on [DATE] at 12:14 P.M. and 12:42 P.M. via phone with Corporate Nurse #300 revealed he was aware of legionella issues and stated the water sample report was received on [DATE]. Interview on [DATE] at 12:24 P.M. with Legionella Consultant #500 revealed the facility ' s water system was unable to maintain consistent temperatures and that the temperatures were not where they needed to be for pathogen control as 140 degrees Fahrenheit will kill Legionella. Legionella Consultant #500 also expressed he recommended quarterly sampling to the facility. Interview on [DATE] at 12:59 P.M. with Plant Operations Director #150 revealed the holding tank had been showing a temperature of 137 to 138 degrees Fahrenheit and confirmed the temperature should be above 140 degrees Fahrenheit. He stated repairs were being done and it was during the repairs that there were other parts malfunctioning, which led to the decision to replace the boilers. Observation on [DATE] at 2:40 P.M. of the mechanical room where the boilers are located revealed buckets were on top of one of the boilers to catch water and there were wet linens on the floor due to leaks in the system. Observation on [DATE] at 9:26 A.M. revealed the temperature probe located on top of the holding tank for hot water read 133 degrees Fahrenheit. Interview on [DATE] at 9:30 A.M. with Plant Operations Director #150 confirmed the water temperature was 133 degrees Fahrenheit. He stated there is no documentation of logging the temperature for the holding tank. Review of the records provided by the facility regarding their water management program revealed there was no documentation to support quarterly water testing had been completed or the temperature for the holding tank had been maintained at 140 degrees Fahrenheit or above. Review of the facility policy titled Facility Water Management Policy, last revised on [DATE], revealed the facility will have a water management program in place to prevent, detect and control water-borne contaminants and ensure domestic water is safe for consumption and use. Further review of the policy revealed water temperatures in water heaters and holding tanks need to meet or exceed 140 degrees Fahrenheit, and water quality samples will be measured a minimum of quarterly using organization approved test kit. Review of the facility policy titled Legionella Water Management Program, last revised [DATE], revealed the purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire ' s disease. Further review of the policy revealed the program includes the identification of situations that can lead to Legionella growth, such as water temperature fluctuations as well as specific measures used to control the introduction and/or spread of Legionella like temperature. Review of the undated LEGIONELLA WRITTEN PLAN, revealed cold water is heated to 140 degrees Fahrenheit by a split boiler system, stored in a 200-gallon storage tank, and hot water is distributed to all resident fixtures through the 200-gallon storage tank. The water is tempered (mixed with cold water) by thermostatic mixing valves. This deficiency substantiates Master Complaint Number OH 714 and Complaint Number OH 693.

Based on observation, staff interview, medical record review, review of the manufacturer's guidelines for the use of side rails and low air loss mattresses, review of the U.S. Food and Drug Administration's (FDA) bed rail entrapment guidelines and review of the facility policy regarding restraints and side rail measuring, the facility failed to ensure the resident environment remained free of accident hazards for two residents utilizing half side rails with a low air loss mattress. This resulted in Immediate Jeopardy for two (#32 and #25) of eleven residents identified by the facility as hospice patients with hospice-provided beds. The total facility census was 66. On 11/13/13 at 10:00 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 09/30/13 when Resident #32 was admitted to the facility with a hospice bed with side rails. On 11/12/13 at 10:02 A.M., the side rails were observed hanging loosely from the bed frame, resulting in a six inch gap between the low air loss mattress and the side rail. Upon further observations at 11:00 A.M., Resident #25 was also noted to have a five and a half inch gap between the low air loss mattress and the side rail. This bed with side rails had been utilized beginning 10/01/13. The potential for harm or death from entrapment for both Resident #32 and Resident #25 is more than likely to occur with the large gaps between the mattress and top half side rails. The Immediate Jeopardy was removed on 11/12/13 at 4:30 P.M. when the side rails in Resident #32's room were removed from the bed frame and Resident #25 was placed into a Broda chair and a new bed without side rails was provided. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 11/15/13 at 9:00 A.M. when the facility implemented the following corrective actions: ? On 11/12/13 at 12:07 P.M., the side rails in Resident #32's room were removed from the bed frame by the hospice nurse and at 3:30 P.M. the side rails were removed from the resident's room. ? On 11/12/13 at 4:30 P.M., Resident #25 was removed from the bed with side rails and placed into a Broda chair. A new bed without side rails was received and put in place at 6:15 P.M. ? On 11/12/13 at 6:15 P.M., the facility implemented a new "Bed Audit Safety Check" policy and Side Rail Measurement Form, which states that beds coming into the facility will not have side rails, and if so, the DON must approve. Upon bed arrival, the nurse must review the bed for side rails and the maintenance man will fill out a Side Rail Measurement Form within 24 hours of admission for safety. ? On 11/13/13 at 10:15 A.M., the facility initiated staff in-servicing regarding side rails, assessing new beds brought into the facility and the new policy for all staff members. The policy will be as noted above, including reporting any changes in condition in residents with side rails or any noted loose side rails to the nurse. ? On 11/13/13 at 11:00 A.M., the facility completed the side rail measurement form for Residents #76, #39, #77, #16, #61, #5, #40 #26, and #48, identified by the facility as having beds with side rails. ? On 11/15/13 at 9:00 A.M., the facility had completed all staff in-servicing regarding the side rails. ? On 11/15/13 at 3:00 P.M., Licensed Practical Nurse (LPN) #6, State tested Nurse Aide (STNA) #72, Registered Nurse (RN) #11, and Maintenance Director #23 were interviewed regarding the in-servicing they received and verbalized knowledge of the new policy and what to do if they receive a new bed from an outside source with side rails, as well as the potential hazards of side rail use. Findings include: 1. Review of the medical record for Resident #32, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/11/13, revealed the resident was identified with moderate cognitive impairment, requires the assistance of two people for bed mobility and use of a low air loss mattress. The MDS did not indicate bed rails were in use. Review of the care plans revealed no care plan related to side rail use. Review of the physician's orders revealed no order for any type of side rails. Review of the Restraint/Enabler Decision Tree form, dated 09/30/13, revealed Resident #32 had half side rails that allowed for resident mobility but did not assist in the improvement of the resident's functional status. On 11/12/13 at 10:02 A.M., observation of Resident #32's room revealed both of the side rails on the bed to be loose, with the left side rail leaning to the point of touching the bedside table on the left side. The bed was not placed with one side against a wall. The gap between the low air loss mattress and the left side rail measured six inches. On 11/12/13 at 10:07 A.M., interview with LPN #53 confirmed the gap between the mattress and the side rail in Resident #32's bed. LPN #53 revealed the hospice company had provided the bed to Resident #32 upon admission to the facility and that Resident #32 had been in the bed with the same side rails since that time. LPN #53, the nurse assigned to Resident #32's hallway at the time, did not know how to tighten or release and lower the side rails on the bed. LPN #53 stated Resident #32 uses the side rails to assist with bed mobility and is able to move minimally in bed. On 11/12/13 at 10:10 A.M., an interview with the DON confirmed the gap between the low air loss mattress and the side rails on Resident #32's bed. She stated she had no knowledge of the gap prior to that moment and when asked, she did not know how to tighten or release the side rails to lower them. The DON stated there was no formal process in place to assess the beds brought in from the hospice companies for side rail safety. On 11/12/13 at 10:35 A.M., Resident #32 was observed by three surveyors in her bed with loose bilateral half side rails. On 11/12/13 at 11:55 A.M., an interview with RN #94 and RN #95, both from the hospice company, revealed Resident #32 was admitted with the bed and side rails. RN #95 stated the company that provides the bed does facility staff training when they deliver the bed, if the facility staff present request it. She could not confirm that facility staff were ever trained on how to use Resident #32's side rails, which operated differently from the side rails on the facility's beds. On 11/13/13 at 11:17 A.M., an interview with Physician's Assistant #97 revealed Resident #32 is mobile in bed and does use the side rails for mobility. She confirmed that residents with side rails should have both a physician's order and a care plan related to side rails in place. 2. Review of the medical record for Resident #25 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed severe cognitive impairment, total dependence on bed mobility and the use of a low air loss mattress. The MDS did not indicate use of side rails. Review of the care plans revealed no care plan related to side rail use. Review of the physician's orders revealed no order for any type of side rails. Review of the resident assessments revealed no Restraint/Enabler Decision Tree form was completed prior to the survey. Review of the care plan cover revealed no indication Resident #25 had side rails but did indicate Resident #25 needed a low bed, floor mats and wedges to both sides of her bed for safety purposes. It also documented the resident was unaware of safety needs due to impaired decision making and she was on a fall risk protocol. Review of the Fall Risk Assessment, dated 07/21/13, revealed Resident #25 was at risk for falls. The fall risk care plan, last reviewed 10/29/13, revealed the resident was at risk for falls characterized by multiple risk factors. The care plan interventions included a bolstered mattress and a low bed due to unawareness of safety needs. Side rail use was not included in the care plan. Review of the Hospice Certification and Plan of Treatment, dated 09/25/13, revealed that Resident #25 was in end-stage Alzheimer's Disease and could be combative at times. Review of the instruction manual for the Invacare low air loss mattress on Resident #25's bed revealed that "Patient entrapment with bed side rails may cause injury or death. Mattress MUST fit the bed frame and side rails snugly to prevent patient entrapment". On 11/12/13 at 11:05 A.M., observation of Resident #25's bed during a check of all beds in the facility with side rails, revealed a gap of five and a half inches between the low air loss mattress and the bilateral half side rails. The low air loss scooped mattress did not properly fit the bed frame and also had a seven inch gap between the top of the mattress and the headboard. The bed was not against a wall on the side and had a bedside table to the right. On 11/12/13 at 11:10 A.M., the Assistant Director of Nursing (ADON) confirmed the measurement of the gap between the low air loss mattress and the side rails in Resident #25's bed. She confirmed the bed was provided by the resident ' s hospice company and she was unsure if the bed had been assessed for side rail safety when it was brought into the facility. On 11/12/13 at 11:20 A.M., interview with LPN #53 revealed that there was no way to tighten Resident #25's side rails. She stated Resident #25 needs to be positioned and leans to the side requiring the staff to place pillows on her side to help her maintain an upright position. LPN #53 revealed the side rails were in place for safety purposes, to prevent falls. On 11/12/13 at 3:40 P.M., interview with the DON and Administrator revealed Resident #25 received the bed with side rails on 10/01/13. The DON stated the resident is not cognitively aware enough to use a call light and if she was to become lodged in the side rails, she did not have the physical capability of getting herself out. The Administrator stated the resident required the use of wedged bolsters while in bed to prevent her from moving toward the side of the bed. On 11/13/13 at 8:15 A.M., observation of Resident #25 revealed her in bed with the top of the bed raised approximately 60 degrees. The resident was leaning to the left side with her head toward the side of the bed. On 11/13/13 at 9:50 A.M., Resident #25 was in her Broda chair, leaning to the left with multiple pillows in place to her left side to prop her up. On 11/13/13 at 10:20 A.M., Resident #25 was observed in bed with the head of the bed flat and she was leaning to the left with her head on the edge of the mattress. On 11/13/13 at 11:17 A.M., interview with Physician's Assistant #97 revealed Resident #25 was not physically capable of getting herself out of the side rails if she became entrapped. She stated Resident #25 does lean to the left and requires pillows or bolsters to prop herself up. She confirmed there should be an order for [REDACTED]. On 11/13/13 at 11:31 A.M., observation of Resident #25 in her Broda chair revealed she was leaning to the left, propped up with pillows, moving both arms regularly with no purpose and squirming in the chair. This was verified by LPN #21 at 11:42 A.M. who stated Resident #25 is able to move her upper extremities and does squirm or scoot in the chair and bed which is why the staff use pillows or bolsters to prevent her from falling. On 11/13/13 at 12:17 P.M., interview with RN #96, from Resident #25's hospice company, revealed Resident #25 can move her arms although she is stiff. RN #96 stated the resident can scoot around in the bed which is why the facility placed side bolsters and wedges on her bed to prevent falls. On 11/18/13 at 1:17 P.M., an interview with STNA #8 during resident care revealed that wedges were placed in the bed to help keep Resident #25 in the bed and prevent her from falling. She also revealed that the bed is always kept lowered with mats to the floor in case the resident rolls out of bed. STNA #8 explained that the resident can be combative with care, including screaming and grabbing at the staff. Review of the facility policy entitled "Restraints: Side Rail Measuring", dated 12/21/09, revealed that all types of side rails will be evaluated for gaps upon physician order, when changes are made to the mattress or bed and quarterly. Resident #32 and Resident #25's beds were not assessed upon admission or changes to their beds. Review of the U.S. Food and Drug Administration's (FDA) Bed Rail Entrapment Guidelines, dated 03/10/06 revealed that the population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless or who have uncontrolled body movement. The FDA uses a head breadth dimension of 4 ? inches as the basis for its dimensional recommendations for side rails. They recommend 2 and 3/8 inches as an appropriate dimension for neck diameter. There are seven potential entrapment zones, with zone three being between the rail and mattress. Zone three is the space between the inside surface of the rail and the mattress compressed by the weight of the patient's head. This space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The FDA therefore recommends a gap of no more than 4 ? inches in this zone to prevent entrapment.

Based on record review, staff interview and review of the feeding pump manufacturer's guidelines, the facility failed to prevent unplanned significant weight loss in one resident receiving nutrition via tube feed. This affected one Resident (#29) of three reviewed for nutrition. This resulted in harm for Resident #29 when she lost 11.2 % of weight in 180 days. The facility census was 66. Findings include: Review of the clinical record for Resident #29, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was in a persistent vegetative state with no discernable consciousness. Review of the alteration in nutrition care plan, last updated April 2013, revealed interventions including weights as ordered, tube feed as ordered, check residuals as ordered, flush as ordered and monitor for intolerance. Review of the weights for Resident #29 revealed an admission weight of 163.5 pounds, a height of 66 inches, and a body mass index (BMI) of 26.3. The weight on 08/07/13 was 163 pounds. The weight on 10/09/13 revealed a weight of 135 pounds, which was a 11.2% weight loss over 180 days. The most current weight on 11/13/13 was 137 pounds and a BMI of 22.1. Review of the dietary assessment notes on 10/09/13 revealed a significant weight loss of 8.5% in 30 days and 11.2% in 180 days. The recommendation was to increase the rate of the feed by 5 milliliters (mL) per hour to increase the calories. Weights were being monitored weekly. Review of the physician progress notes [REDACTED]. In the note dated 10/11/13, he revealed the resident's weight went from 158 on 08/07/13 to 135 on 10/09/13, which was a 14.6% weight loss in 60 days, which is considered a severe weight loss. He noted weight loss had stabilized and a change in feed was noted. Review of the physician orders [REDACTED]. Review of both the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the laboratory tests for Resident #29 revealed no testing for labs indicating nutritional status had been drawn since April 2013. This was verified by the Assistant Director of Nursing on 11/18/13. Review of the Kangaroo Feeding Pump Manual revealed that the flushes run at 1960 mL per hour, which when it runs 250 mL every four hours, means the feeding is turned off for over 63 minutes each day. Multiple observations from 11/13/13 to 11/15/13 of Resident #29's feeding pump revealed total volumes administered of 2050 to 6000 mL's, with a rate of 55 mL per hour of [MEDICATION NAME] 1.5 and a flush volume of 250 mL every four hours. On 11/14/13 at 12:09 P.M., an interview with Registered Nurse (RN) #11 during gastric tube medication administration revealed that the total volume to infuse for the feeding on the pump is set to the nurse's discretion and the volume infused is not checked or cleared on a set basis. On 11/15/13 at 11:47 A.M., an interview with Registered Dietician (RD) #101 revealed that Resident #29 did have a significant weight loss. She revealed she does not take into account the time the feeding is on hold for the flushes every four hours. She stated that staff weighs the resident weekly and does not call her with any weight changes, that she just checks when she visits weekly. On 11/15/13 at 2:13 P.M., an interview with Physician Assistant #97 revealed that the weight gain that appears in October for Resident #29 was due to [MEDICAL CONDITION] and when diuretics were given, the weight decreased right back down. The weight gain was not a true weight gain during October. On 11/15/13 at 3:28 P.M., an interview with RN #11 revealed the nursing staff does not document intake of feedings or flushes. She revealed they assume intake is the same as the hourly rate and that the staff does not check or clear the volume infused each shift. On 11/18/13 at 9:39 A.M., an interview with RD #101 reveled that she considered a significant weight loss anything over 5% in 30 days or 10% in 180 days. She confirmed that with Resident #29's severe weight loss she recommended an increase of 5 mL per hour in the resident's feeding, which is an additional 180 calories per day, and that no other supplementation or interventions were added. She further confirmed that she had not taken into consideration the amount of time the feeding tube is on hold for the water flushes. She revealed that she does not check if intakes are documented for this resident, but that they should be charted by nursing staff.