Every finding on record at Cedarwood Plaza

Based on observations, interviews, record reviews, review of facility menus and facility policy review, the facility failed to ensure the zucchini and onions were palatable and served at a preferred temperature and failed to ensure the noodles were palatable for lunch on 10/08/25. This affected five residents (#5, #29, #41, #60, and #100) out of five residents reviewed for meal palatability but had the potential to affect an additional 94 residents the facility identified as receiving meals from the kitchen. The facility identified three residents (#21, #43, and #55) as not receiving meals from the kitchen. The facility census was 102. Findings include:1. Observation on 10/08/25 at 11:48 A.M. of Dietary [NAME] #311 taking the temperatures of meal items in the steam table revealed the parsley noodles were 161.3 degrees Fahrenheit (F), the baked chicken was 130.4 degrees F, the mushroom gravy was 157.9 degrees F, the zucchini and onions were 169.1 degrees F. Observation of the items on the steam table revealed the noodles appeared to seasoned with dried herbs, the chicken appeared to be moist, and the zucchini and onions were in a large pan with a large amount of what appeared to be water. At the time of observation, the chicken was reheated until it reached a temperature of 180 degrees F. Interviews on 10/08/25 between 12:12 P.M. and 12:17 P.M. with Dietary Consultant (DC) #650 revealed three wells of the steam table weren't working correctly, and the steamer was not operational, which had negatively affected the facility's ability to maintain a holding temperature of 135 degrees F. Observation at the time of the interview revealed the steamer was not being used, and part of the steam table didn't appear warm to the touch. Interview on 10/08/25 at 12:41 P.M. with Dietary [NAME] #311 revealed he used basil and parsley to season the herb noodles and hadn't put any seasoning or margarine on the zucchini and onions. Interview on 10/08/25 at 12:49 P.M. with DC #650 revealed the facility only had enough thermal pellet bases, used to help keep food items warm, for the residents on the third floor. He stated all residents received a heated plate and a dome lid to help with heat retention. Observations throughout the tray line revealed residents on the first and second floor had food placed on a heated plate and a dome lid was then placed over the plate. There was no observation of any thermal bases being used until meal trays were being plated for residents who resided on the third floor. On 10/08/25 at 1:09 P.M. at the start of the last food cart, the surveyor asked for a test tray. At 1:15 P.M., the kitchen ran out of noodles and mushroom gravy resulting in the tray line being stopped until more noodles and mushroom gravy could be made. Heated thermal pellets were observed sitting on residents' meal trays on the tray line while more food was being made. At 1:24 P.M. Dietary [NAME] #311 drained the cooked noodles into a colander and then dumped the noodles from the colander into a pan in the steam table without adding anything else. Dietary Consultant #650 poured new cooked mushroom gravy into a pan in the steam table and tray line started back up at 1:25 P.M. There was no observation of the heated thermal pellets, which had been left sitting on residents' meal trays on the tray line while more food items were made, being reheated. At 1:27 P.M. test tray was plated and placed onto a thermal pellet base and covered with a dome lid and then was placed into a covered food cart. The food cart then immediately left the kitchen to be delivered to the third floor. At 1:29 P.M. the food cart with the test tray arrived on the third floor, and staff immediately started to pass the meal trays. At 1:37 P.M. the last resident meal tray had been passed, and the test tray was taken out from the covered food cart by DC #650 and was placed on top of the food cart. DC #650 then took the temperature of the items on the meal tray using a facility thermometer while the surveyor tasted the meal items. The zucchini and onions were 101.5 degrees F and tasted cold and had no flavor. The herb butter noodles were 121 degrees F and tasted warm but had no flavor. There was no observation of any herbs on the noodles. The creamy mushroom chicken was 130 degrees F, tasted warm, had a good flavor, and was moist. After taking the temperature of the meal items, DC #650 tasted the zucchini and onions and stated it tastes like zucchini to me but confirmed the 101.5 degrees F was too cold. After tasting the noodles, he confirmed no margarine, or herbs had been added to the noodles made after the kitchen had run out of cooked noodles. Review of the facility recipe for zucchini and onions revealed for 104 servings, one pound and one ounce of margarine, one tablespoon and one teaspoon of margarine, and one teaspoon of pepper should be added to cooked zucchini and sauteed onions. Review of the facility recipe for herb buttered noodles revealed for 104 servings a herb mixture consisting of four tablespoons of rosemary, parsley flakes, oregano, and paprika should be added along with one pound and one ounce of margarine to the cooked egg noodles. Review of the facility policy Food Temperatures at Point of Service, revised on 01/06/25, revealed hot food items must be cooked to appropriate internal temperature, held and served at a temperature of at least 135 degrees F., and the facility should utilize methods to maintain safe temperatures such as plate warmers, insulated bases, domes, and insulated tray carts. 2. Review of the medical record for Resident #41 revealed an admission date of 02/25/25 with diagnoses including acute posthemorrhagic anemia, acute kidney failure, stage three hypertensive chronic kidney disease, stage three pressure ulcer of the sacral region, primary hypertension, urinary retention, depression, and acidosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/24/25 revealed Resident #41 had intact cognition, was independent for eating, and was not on a therapeutic diet. Further review of the MDS revealed Resident #41 had experienced a weight loss of five percent (%) or more in the last month or 10% or more in the past six months and was not on a prescribed weight loss regimen. Review of the diet order dated 09/17/25 revealed Resident #41 was on a regular diet with regular consistency and thin liquids consistency. Review of the care plan last completed 09/24/25 revealed Resident #41 had an altered nutritional status as evidenced by chronic kidney disease, dysphagia, food allergies, history of bariatric surgery, and weight loss. Interventions included providing supplements and diet per dietitian and physician recommendation, encouraging oral food and fluid intake, providing preferred beverages, and honoring food preferences. Interview on 10/08/25 at 3:00 P.M. with Resident #41 revealed meals suck and are not tasteful. The resident went on to state lunch was terrible today. 3. Review of the medical record for Resident #29 revealed an admission date of 06/22/20 with diagnoses including chronic respiratory failure with hypoxia, type two diabetes mellitus, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), hyperosmolality and hypernatremia, depression, anxiety, and gastroesophageal reflux disease (GERD). Review of the diet order dated 07/17/20 revealed Resident #29 was prescribed a controlled carbohydrate diet (CCD) with no added salt (NAS) at regular consistency and thin liquid fluid consistency. Review of the quarterly MDS 3.0 assessment completed on 07/17/25 revealed Resident #29 had intact cognition and required setup or clean-up for eating. Further review of the MDS revealed Resident #29 was on a therapeutic diet. Review of the care plan last completed 07/17/25 revealed Resident #29 had identified preferences, including choosing what to eat, making her own choices from the weekly menus, and having snacks available. The care plan further revealed Resident #29 had altered nutrition and a history of weight fluctuations. Interventions included discussion with Resident #29 to identify any cultural, ethnic, religious, or other food preferences and to accommodate for those preferences. Interview on 10/08/25 at 3:03 P.M. with Resident #29 revealed the zucchini could have used more flavor and the food was at room temperature and could have been warmer. 4. Review of the medical record for Resident #60 revealed an admission date of 05/30/24 with diagnoses including right femur fracture, malignant neoplasm of the right kidney, emphysema, type two diabetes mellitus, atrial fibrillation, chronic gastritis without bleeding, acute kidney failure, malignant neoplasm of the pancreas, and temporomandibular joint disorder. Review of the diet order dated 11/25/24 revealed Resident #60 was prescribed a regular diet with regular consistency and thin fluid consistency. Review of the quarterly MDS 3.0 assessment completed on 07/10/25 revealed Resident #60 had moderately impaired cognition and needed setup or clean-up assistance with eating. Further review of the MDS revealed Resident #60 was not on a prescribed therapeutic diet. Review of the care plan last completed 07/17/25 revealed Resident #60 had the potential for altered nutrition secondary to advanced age, cancer, diabetes mellitus, malnutrition, and decrease in oral intake. Interventions included discussion with Resident #60 to identify any cultural, ethnic, religious, or other food preferences and to accommodate for, and honor, those preferences. Interview on 10/08/25 at 3:11 P.M. with Resident #60 revealed lunch wasn't good today. Food was blah, and the food could have been warmer. This deficiency represents non-compliance investigated under Complaint Number 2618032.

Based on record reviews, observation, interviews and facility policy review, the facility failed to ensure Residents #9, #35 and #36 received a two-gram sodium (low sodium) and/or cardiac diet as ordered. This affected three residents (#9, #35, and #36) out of four residents reviewed for therapeutic diets but had the potential to affect an additional six residents (#3, #7, #42, #54, #70, and #84) the facility identified as being on a two-gram sodium and/or a cardiac diet. The facility census was 102. Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 01/07/25. Pertinent diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), respiratory failure, hypertension (HTN), and hyperlipidemia. Review of the physician orders for Resident #9 revealed an order dated 03/27/25 for a low sodium, regular texture, thin consistency, two-gram sodium diet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact, required setup or cleanup assistance for eating and was on a therapeutic diet. Further review of Resident #9's medical record revealed a quarterly nutritional assessment dated [DATE] which indicated the low sodium diet was appropriate due to the diagnosis of HTN. Review of Resident #9's nutritional care plan dated 01/14/25 revealed Resident #9 had altered nutritional needs related to COPD diagnosis and difficulty breathing while eating. Interventions included administering medications as ordered and provide diet per dietitian recommendations and physician's order. 2. Review of the medical record for Resident #35 revealed an admission date of 11/01/22. Pertinent diagnoses included type two diabetes mellitus, chronic pulmonary edema, diastolic congestive heart failure (CHF), chronic kidney disease (CKD), and hyperlipemia. Review of Resident #35's nutritional care plan dated 11/09/22 revealed the resident had altered nutritional status related to being on a therapeutic diet and having type two diabetes mellitus, CKD, HTN, and hyperlipidemia diagnoses. Interventions included administering medications as ordered and providing diet per dietitian recommendations and physician's orders. Review of the physician orders for Resident #35 revealed an order dated 02/04/24 for a low sodium (two-gram), controlled carbohydrate diet (CCD), regular texture, thin consistency. Review of Resident #35's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact, required setup or cleanup assistance for eating and was on a therapeutic diet. Further review of Resident #35's medical record revealed a nutritional assessment dated [DATE] which indicated the resident was receiving a low sodium and CCD diet due to the diagnoses of CHF, CKD, and diabetes mellitus type two. 3. Review of the medical record for Resident #36 revealed an admission date of 08/14/25. Diagnoses included hypertensive heart disease with heart failure, acute on chronic systolic CHF, ischemic cardiomyopathy, and atherosclerotic heart disease. Review of Resident #36's nutritional care plan dated 08/18/25 revealed Resident #36 had altered nutritional status as evidenced by systolic heart failure/ischemic cardiomyopathy and hypertension requiring a cardiac diet and a fluid restriction. Interventions included administering medications as ordered, diet per dietitian recommendations and physician order, and fluid restriction as ordered. Review of Resident #36's physician orders revealed an order dated 08/18/25 for a cardiac diet, regular texture, thin consistency, 70-gram fat, two to three grams sodium and a 2000 milliliter (ml) fluid restriction. Review of Resident #36's admission MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, required setup or cleanup assistance for eating and was on a therapeutic diet. Further review of Resident #36's medical record revealed a significant change nutrition assessment dated [DATE] which indicated the resident was on a cardiac, regular texture, thin consistency fluids diet and meal intakes would be monitored for adequacy and tolerance. 4. Review of the facility's week four fall and winter menu for 2024 and 2025 revealed for lunch on 10/08/25 creamy mushroom chicken, herb buttered noodles, zucchini and onion, and creamy lemon pie was to be served. Review of the facility's four week fall and winter menu's spread sheet for lunch on day 25 (10/08/25) revealed residents on a cardiac diet or a two-gram (low sodium) diet were to receive one three-ounce chicken breast with sauteed mushrooms instead of one three-ounce chicken breast with mushroom gravy. Observation of the steam table on 10/08/25 prior to the start of tray line at 11:48 A.M. revealed there was no pan of sauteed mushrooms in the steam table. Observation of tray line on 10/08/25 from the beginning at 12:38 P.M. to the end at 1:27 P.M. revealed all residents, which included Residents #9, #35, and #36, had received mushroom gravy over their chicken, except for one unidentified resident who had received brown gravy over the chicken due to either a dislike or an allergy to mushroom gravy. Interview during tray line on 01/08/25 at 12:41 P.M. with Dietary [NAME] #311 confirmed everyone was receiving mushroom gravy over the chicken, unless it was a dislike or an allergy. Interview on 10/08/25 at 1:28 P.M. with Dietary Consultant #650 confirmed no sauteed mushrooms had been served to residents on a two-gram sodium (low salt) or a cardiac diet. When asked why residents who were on a two-gram sodium (low sodium) or cardiac diet had not been served sauteed mushrooms on their chicken instead of mushroom gravy, DC #650 stated I would assume it was an error. Review of the undated facility policy Accuracy and Procedure Manual revealed the meal would be checked against the therapeutic diet spread sheet to assure that foods were served as listed on the menu, and each meal tray would be checked for accuracy following the therapeutic extension. This deficiency represents non-compliance investigated under Complaint Number 2618032.

Based on observations, interviews, food temperature log review and facility policy review, the facility failed to ensure the mechanical soft chicken was held at a safe holding temperature for lunch on 10/08/25, which had the potential to affect 18 residents (#3, #4, #8, #10, #11, #15, #20, #22, #30, #42, #45, #52, #61, #63, #69, #82, #93, and #99) the facility identified as receiving a mechanical soft diet. The facility census was 102. Findings include:Review of the facility Food Temperature Log, dated 10/08/25, revealed all regular, mechanical and puree items for lunch had been cooked to safe internal temperatures with the regular texture chicken 179 degrees Fahrenheit (F), the noodles 169 degrees F, zucchini and onions 169 degrees F, mechanical soft chicken 176 degrees F, mechanical soft zucchini and onions 168 degrees F, puree chicken 174 degrees F, puree noodles 174 degrees F, and the puree zucchini and onions 169 degrees F. Observation on 10/08/25 at 11:48 A.M. of Dietary [NAME] #311 taking the food temperatures of the food items on tray line revealed the following concerns: The regular texture baked chicken was 130.4 degrees F. The mechanical chicken was 123.0 degrees F. The puree chicken was 96.6 degrees F. At the time of observation and prior to tray line starting, the puree chicken and the regular texture baked chicken were taken out of the steam table, and the puree chicken was reheated to 170.2 degrees F and the regular texture baked chicken was reheated to 178 degrees F and both were placed back into the steam table. The mechanical soft chicken remained on the steam table and had not been reheated. Interviews conducted between 12:12 P.M. and 12:17 P.M. with Dietary Consultant (DC) #650 revealed three wells of the steam table had not been working correctly for an unknown amount of time and the steamer hadn't been operational for approximately a week and half, which had negatively affected the facility's ability to hold hot food items at a safe temperature of 135 degrees F or higher. He indicated he had obtained a quote from an equipment repair company, and the reason why the steam table hadn't been fixed was because the steam table was old and there were no parts available to repair it. He indicated the steamer hadn't been repaired due to a parts issue. Observation at the time of interview confirmed the steamer was not operational and parts of the steam table were not fully operational with some wells not being able to be filled with water and some areas of the steam table not warm to the touch. At 12:32 P.M. DC #650 stated tray line was ready to go. At 12:33 P.M. the surveyor asked for a verification of the temperature of the ground chicken. Dietary [NAME] #311 took the temperature using a facility thermometer of the ground chicken and it was 109.2 degrees F. At time of observation, DC #350 stated to the dietary staff all items needed to be checked to ensure all items were being held at a safe temperature of 135 degrees F or higher and if items didn't meet the 135 degrees holding temperature, those items would need to be reheated. Various food items were reheated on the tray line, but the mechanical soft chicken was never reheated. At 12:37 P.M. all reheated food items had been returned to the tray line, and DC #650 confirmed the tray line was ready to go. At 12:38 P.M. the surveyor asked for tray line to be stopped and asked for the temperature of the mechanical soft chicken to be taken. DC #650 used a facility thermometer to take the temperature of the ground chicken, and it was 108.7 degrees F. At the time of observation, DC #650 confirmed the mechanical soft chicken was not at a safe holding temperature and then took the pan of mechanical soft chicken off the steam table to reheated it. At 12:40 P.M. DC #650 took the temperature of the reheated mechanical soft chicken, using a facility thermometer, and it had reached a safe holding temperature of 180 degrees F. The tray line then restarted. Review of the facility policy Food Temperatures at Point of Service, revised on 01/06/25, revealed hot food items needed to be held and served at a temperature of at least 135 degrees F. Temperatures should be taken periodically to assure hot foods stayed above 135 degrees F., and the tray line and service areas would avoid holding food in the danger zone (41 degrees F to 135 degrees). Review of a professional kitchen equipment supplier/repair company Repair Estimate Summary, dated 10/01/25, revealed the heating elements and thermostat needed replaced for the steam table to be functional. There was no indication noted on the Repair Estimate Summary that parts were unavailable for the repair or the facility had okayed the repair. Review of a professional kitchen equipment supplier/repair company invoice, dated 10/09/25, revealed the steamer was able to be repaired the same day as the service call by replacing the hose with a PVC pipe. There was no indication noted in the service report that parts were unavailable for the repair. Interview on 10/15/25 at 12:09 P.M. with Representative #675 from the professional kitchen equipment supplier/repair company revealed the request to repair the steamer had not been called in by the facility until 10/08/25 at 3:05 P.M. This deficiency was an incidental finding identified at the time of the complaint survey.

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure proper infection control procedures were followed during care for Resident #6, including appropriate donning and doffing procedures with use of personal protective equipment (PPE), appropriate catheter care, and proper handling of soiled linen and other soiled items. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect all 16 residents (#6, #10, #19, #28, #31, #33, #43, 348, #56, #63, #68, #71, #75, #78, #98, and #102) who resided on the North unit of the second floor. The facility census was 102. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/12/24 with diagnoses including paranoid schizophrenia, arthritis due to bacteria right hip, hemiplegia or hemiparesis following cerebral infarction affecting right dominant side and left non-dominant side, paraplegia, slow transit constipation, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder. Review of the care plan initiated on 11/12/24 and last updated on 06/12/25 revealed Resident #6 had bowel incontinence. Interventions included checking Resident #6 for incontinence, removing soiled briefs, providing incontinence care, and applying a protective barrier after each incontinent episode. Further review of the care plan revealed Resident #6 was at risk for infection related to an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine), obstructive uropathy, and a neurogenic bladder. Interventions included provision of catheter care every shift and maintaining enhanced barrier precautions (EBP), including the use of a gown and gloves, for catheter care and toileting hygiene. The care plan for EBP further stated that EBP was to be maintained throughout the duration of Resident #6's stay or until reason for the precautions was resolved, such as discontinuation of the indwelling urinary catheter. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 07/16/25 revealed Resident #6 had intact cognition and was dependent on staff for bathing, dressing, grooming, and toileting hygiene. Resident #6 had an indwelling catheter and was always incontinent of bowel. Review of the physician's order dated 09/23/25 revealed Resident #6 was to have EBP, which included use of a gown and gloves for high-contact resident care, including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and device care related to having an indwelling urinary catheter. Observation on 10/07/25 from 2:45 P.M. to 3:04 P.M. of catheter care and incontinence care for Resident #6, performed by Certified Nurse Aide (CNA) #413, revealed CNA #413 wet two washcloths in sink of warm running water and laid the wet washcloths, plus one dry washcloth, directly on the uncleaned overbed table which had some of Resident #6's personal items on it. While wearing a surgical mask, a gown, and the gloves used to carry the washcloths from the sink on the room to the overbed table, CNA #413 proceeded to pull down the bedsheet, loosen and open Resident #6's brief, and explain that she was about to clean the catheter. Using the same gloves, CNA #413 was observed using one washcloth to briskly swipe back and forth under the abdominal fold, above the pubic area, then back and forth between skin folds of the left groin, then briefly on the head of the penis with two swipes, and then back and forth between the skin folds of the right groin. During this observation, CNA #413 was not observed using any method with the washcloth to ensure that a different, clean part of the cloth was used with each stroke, there were no soap suds noted during the cleansing of the perineal area, the area around the catheter insertion site was not fully cleaned from meatus outward, and no part of the catheter was secured or cleaned using the first washcloth during catheter care. The observation continued with CNA #413 laying the soiled washcloth on the outside corner of the opened brief, which remained underneath Resident #6, picking up the second wet washcloth from the overbed table, and following the same steps as with the first washcloth (briskly swiped back and forth above the suprapubic area under the abdominal fold, then back and forth between skin folds of the left groin, then briefly on the head of the penis using two swipes, and then back and forth between the skin folds of the right groin). At no time was CNA #413 observed cleaning or rinsing directly around the urinary meatus/catheter insertion site or any length of the catheter. The second washcloth was not folded in a manner to ensure a different, clean part of the cloth was used to rinse each part of the body during catheter and perineal care. The second wet washcloth was laid on the outside corner of the brief that remained under Resident #6, and the dry cloth was taken from the overbed table to pat dry the left groin area, the suprapubic area, then the shaft and left lateral ridge of the head of the penis, then the right groin. Further observation revealed CNA #413 rolled Resident #6 on the right side to remove the brief and noted it was lightly soiled. Resident #6 was rolled back onto the soiled brief, and CAN #413 walked to the door of the room, removed the right glove with the left gloved hand, stated Now I have to start over, then exited the room with the gown and left glove used to render care to Resident #6 still on, and the soiled glove from the right hand clutched in the left hand. CNA #413 returned to the room approximately one minute later with additional washcloths, while wearing the same gown used to render catheter care and search the clean linen cart down the hallway, and used the soiled gloved left hand to apply a clean glove on the right hand and wet the new washcloth. Observation of care continued while CNA #413 rolled Resident #6 onto the right side, rolled the soiled linen up in the soiled brief and laid them on the floor beside the bed, cleaned the buttocks and intergluteal cleft (the groove or fold that separates the buttocks), laid the soiled washcloths on top of the soiled brief, which was on the floor, then rolled Resident #6 onto a clean brief. Using the same soiled gloves, the clean brief was secured, the catheter tubing was positioned inside the clean brief to minimize pulling and tugging, and Resident #6 was covered with a sheet. CNA #413 was then observed picking up the soiled linen and soiled brief, carrying them to the resident's bathroom, then laying the soiled items on the floor in the doorway between the bedroom and the bathroom. Continued observation on 10/07/25 from 3:01 P.M. to 3:02 P.M. revealed CNA #413, wearing the same gown used to render catheter and incontinence care to Resident #6, exited the room, walked up and down the hall on two north, opened linen cart and moved items around before closing the flap to the linen cart, walked to the medication cart, removed two trash bags from the medication cart and returned to Resident #6's room. At this time, CNA #413 was observed performing hand hygiene, applying clean gloves, bagging the linen and trash that was on the floor in the bathroom doorway, removing the gown and placing in a trash bag, tying up the trash, then placing on new clean gloves before taking the trash to the soiled utility room and placing linen in the laundry chute. Once the soiled trash bags were properly disposed of, CNA #413 walked into the South Dining Hall, entered the kitchenette, disposed of the gloves in the garbage, then used the sink in the South Dining Hall's kitchenette to perform hand hygiene. Interview on 10/07/25 at 3:05 P.M. with CNA #413 confirmed a basin for soapy or clean water was not used for catheter and incontinence care, a barrier was not used for placing clean rags on the overbed table, the table was not cleaned prior to placing the washcloths on top for resident care use. CNA #413 further confirmed placing the soiled brief and soiled linen on the floor next to the bed of Resident #6 and again on the floor in the bathroom doorway that there should have been trash bags ready, prior to performing resident care. During the interview, CNA #413 revealed staff would normally clean well around the catheter insertion site and while securing the catheter, were supposed to wash part way up the catheter to keep the portion near the insertion site clean. CNA #413 also confirmed leaving Resident #6's room twice while wearing the same gown on used to perform care and that gowns were supposed to be removed prior to exiting the room. At the time of the interview, CNA #413 confirmed leaving Resident #6's room between catheter care and incontinence care and that only one glove was removed at that time, staff were not to be in the hall with soiled gloves, and no hand hygiene was performed before donning a clean glove. Interview on 10/09/25 at 9:55 A.M. with CNA #383 confirmed basins and clean washcloths were to be used for washing residents and that staff were never to use the same part of the washcloth for cleaning around the catheter insertion site, catheter, and other body parts during catheter and perineal care. Interview on 10/09/25 at 10:33 A.M. with CNA #390 confirmed staff were to make sure two bags were ready for linen and trash disposal prior to rendering perineal or catheter care and that soiled items were never to be placed on the floor. During the interview, CNA #390 reported PPE was to always be removed prior to exiting resident rooms. Interview on 10/09/25 at 2:40 P.M. with Registered Nurse (RN) #398 confirmed staff were to clean the urinary meatus of a male with an indwelling catheter by securing the catheter and cleaning in a circular motion from inner to outer areas, using a clean part of the washcloth with each stroke, and care should be taken to ensure cleanliness of the catheter near the insertion site. RN #398 further confirmed that staff were to use a barrier or a wash basin and not lay washcloths on an unclean overbed table before commencing care. During the interview, RN #398 stated two bags were to be readily available during care, one for soiled disposable items and one for soiled linen, and that PPE was to be removed after care, prior to leaving a resident's room. RN #398 also confirmed hand hygiene was always to be performed with glove changes. Review of the policy titled Handwashing-Hand Hygiene, last reviewed on 01/06/25, revealed hand hygiene was to be performed before and after donning and doffing gloves and after handling used linens or supplies. The policy further revealed the use of gloves did not replace hand hygiene. Review of the policy titled Enhanced Barrier Precautions, dated 01/06/25, revealed PPE was to be removed and placed in a receptacle inside the resident room after resident care activities were completed. Review of the policy titled Catheter Care (Indwelling Catheter), dated 01/06/25, revealed staff were to clean the area well at the catheter insertion site and that all debris was to be removed from around the catheter, near the insertion site. Further review of the policy revealed if the resident was soiled or had an involuntary bowel movement, the incontinence care should be provided prior to catheter care to ensure they are not contaminated with feces. Review of the policy titled Incontinence Care, last reviewed 11/30/25, revealed soiled linen was to be disposed of appropriately. This deficiency represents noncompliance investigated under Complaint Number 2618032.

Based on medical record review, interviews, hospital record review and facility policy review, the facility failed to timely address a significant weight loss for Resident #104. This affected one resident (#104) out of three residents reviewed for nutrition. The facility census was 102. Findings include:Review of the closed medical record for Resident #104 revealed an admission date of 08/22/23 and a discharge date of 09/04/25. Pertinent diagnoses included schizophrenia, severe sepsis with septic shock, adrenocortical insufficiency (a condition when adrenal glands don't make enough of the hormone cortisol with weight loss being one of the symptoms), other diseases of plasma-protein metabolism, depression, thyrotoxicosis (a condition when there is too much thyroid hormone in the body with unexplained weight loss being one of the symptoms) with diffuse goiter. Review of Resident #104's care plan initiated on 08/29/23 revealed the resident had altered nutritional status related to thyroid disorder, schizophrenia, fluid shifts, refusal of meals, weights, and supplements, and significant weight loss. Interventions included diet per dietitian recommendations and physician's orders, encourage adequate meal intake, accommodate food preferences, give supplements as ordered and alert nurse/dietitian if not consuming on a routine basis, and monitor and record resident's intake of food/fluids after each meal. Offer and appropriate meal substitutions or dietary supplement when the resident consumes less than 75% of a meal or when a resident refuses a meal. Review of Resident #104's physician orders revealed the resident had been on a regular diet, regular texture, and thin liquids diet for her entire stay at the facility. Review of Resident #104's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, rejection of behaviors were exhibited one to three days of the seven-day assessment reference period, required set-up help for eating for eating, had no weight loss with a weight of 191 pounds. Review of Resident #104's medical record revealed the resident's weight had been stable between 190 and 192 pounds between 02/13/25 and 05/08/25. On 06/23/25, the residents refused to be weighed. On 07/10/25, the resident weighed 146 pounds, which reflected a significant weight loss of 46 pounds or 23.9 percent (%) weight loss between 05/08/25, when the resident had last been weighed by the facility and had weighed 192 pounds, and 07/10/25. Review of the hospital records revealed Resident #104 was hospitalized between 05/29/25 to 06/05/25 for an altered mental status. Resident #104's initial weight at the hospital was noted to be 190.0 pounds on 05/30/25 at 2:00 A.M. A second weight of 166.2 pounds was obtained on 05/30/25 at 4:16 A.M. which reflected a 23.8 pound or 12.5 % weight loss from the first weight of 190.0 pounds. A third weight of 166.2 pounds was obtained on 05/30/25 at 4:47 P.M. which verified the 166.2 weight was the accurate weight for the resident. Continued review of Resident #104's weights in the medical record revealed the 07/10/25 weight of 146 pounds reflected a 20 pound or 12.0% significant weight loss from the hospital weight of 166.2 pounds on 05/30/25. Further review of Resident #104's medical record revealed there had been nothing noted in the record about the resident's significant weight loss between 05/08/25 and 07/10/25. Continued review of Resident #104's medical record revealed a quarterly nutritional assessment, dated 08/04/25, which noted the last weight of Resident #104 was 192 pounds on 05/08/25 and a new monthly weight was pending. (The assessment didn't address the hospital weights on 05/30/25 or the 07/10/25 facility weight). The assessment noted Resident #104 hadn't had any significant weight loss but did indicate Resident #104's meal intakes were varied with the resident averaging 50 percent of meals being consumed over the past seven days. A supplement of Ensure twice a day was recommended for added calories and protein and with diet and the recommended supplement, the resident nutritional needs would likely meet the resident's estimated nutritional needs. Review of the physician's orders for Resident #104 revealed an order dated 08/04/25 for Ensure twice a day. Continued review of Resident #104's medical record revealed the resident was not weighed again until 08/07/25 when the resident weighed 139 pounds, which reflected a seven pound or 4.7% additional weight loss from the 07/10/25 weight. Weights of 139 pounds on 08/11/25 and 138 on 08/26/25 revealed weight loss appeared to have stabilized. Further review of Resident #104's medical record revealed the resident had a seizure like activity on 08/12/25 and was sent to the hospital and was admitted for bradycardia, seizure like activity, altered mental status, and septic shock due to a urinary tract infection (UTI). The resident didn't readmit back to the facility until 08/26/25. The Ensure order was discontinued on 08/12/25 when the resident was admitted to the hospital. Review of Resident #104's five-day Medicare MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, exhibited other behavioral symptoms not directed toward others, was independent for eating, had a significant weight loss which had not been prescribed and was not on any therapeutic diet. Continued review of Resident #104's medical record revealed a readmission nutrition assessment, dated 09/01/25, which indicated the resident's most recent weight was 138 pounds on 08/26/25 which reflected a significant loss of ten percent or greater over the past six months, which was likely related to decreased meal intakes and behaviors. It was recommended that Magic cups (supplement) be added twice a day to increase caloric and protein intake to help promote weight stability, and it was noted other supplements had been refused by the resident in the past. Further review of Resident #104's physician orders revealed an order dated 09/01/25 for a nutritional treat two times a day. Continued review of Resident #104's medical record revealed a nurse practitioner note dated 09/04/25 which indicated the resident had become lethargic and nursing was reporting the resident wasn't eating well and was being sent to the hospital due to concern of sepsis. On 09/05/25 it was noted in the progress notes that the resident had been admitted to the hospital's intensive care unit for hypothermia. Interview on 10/09/25 at 11:28 A.M. with Restorative Certified Nursing Assistant (CNA) #440 revealed restorative staff were responsible for obtaining most of the weights. She stated she had weighed Resident #104 on 07/10/25 and had used a Hoyer (mechanical lift) to weigh her. She stated typically when a resident lost five or more pounds a resident would be put on weekly weights for closer monitoring. She indicated the dietitian would be the one who would indicate if a resident should be put on weekly weights. Interviews on 10/09/25 at 11:54 A.M. and 12:30 P.M. with Corporate Lead Dietitian (CLD) #651 revealed the current facility dietitian was currently out on leave of absence. He stated if a monthly weight triggered a significant weight loss of five % or more, a reweight would be obtained. If the reweight still showed a significant weight loss, the dietitian would address the weight loss in a note or an assessment and normally the resident would be put on weekly weights for closer monitoring. LCD #651 confirmed Resident #104's weight loss on 07/10/25 had not been addressed in a timely manner by the dietitian. Interview on 10/09/25 at 2:10 P.M. with the Director of Nursing (DON) revealed the dietitian reviewed all the weights and would be the one who requested a resident be put on weekly weights for closer monitoring. She acknowledged Resident #104's weight loss and stated the resident would skip meals. The DON indicated Resident #104 should have been put on weekly weights for closer monitoring. Review of facility policy Weight Monitoring, with a last review date of 01/06/25, revealed reweights would be obtained within 48 hours if there was at least a five-pound deviation from the last weight obtained. The dietitian would evaluate weights and initiate appropriate interventions as indicated and would follow up with nursing to confirm that reweights had been completed and the requested orders had been obtained. This deficiency represents non-compliance under Complaint Number 2623950.

Based on record review, observation, interview, review of infection surveillance logs and review of facility policy, the facility failed to ensure catheter care was performed per appropriate standards of practice to mitigate the potential for contamination and urinary tract infection. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect four additional residents (#2, #49, #59, and #90) who the facility identified as having indwelling urinary catheters. The facility census was 102. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/12/24 with diagnoses including paranoid schizophrenia, arthritis due to bacteria right hip, hemiplegia or hemiparesis following cerebral infarction affecting right dominant side and left non-dominant side, paraplegia, slow transit constipation, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder. Review of the physician's order dated 02/04/25 revealed Resident #6 was to have Foley catheter (a thin, flexible tube inserted into the bladder to drain urine), care every shift and as needed. Review of the care plan last updated on 06/12/25 revealed Resident #6 was at risk for infection related to an indwelling catheter, obstructive uropathy, and a neurogenic bladder. Interventions included provision of catheter care every shift and maintaining enhanced barrier precautions (EBP), including the use of a gown and gloves, for catheter care and toileting hygiene. The care plan for EBP further stated that EBP was to be maintained throughout the duration of Resident #6's stay or until reason for the precautions was resolved, such as discontinuation of the indwelling urinary catheter. Further review of the care plan revealed Resident #6 had bowel incontinence and required staff to change soiled briefs and provide incontinence care. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 07/16/25 revealed Resident #6 had intact cognition and was dependent on staff for bathing, dressing, grooming, and toileting hygiene. Resident #6 had an indwelling catheter and was always incontinent of bowel. Review of the Lab Results Report dated 09/10/25 revealed the urine specimen collected on 09/05/25 resulted in turbid light-yellow urine with mucous that was positive for leukocytes and red blood cells. Further review of the final lab report revealed growth of greater than 100,000 colony forming units (CFU) per milliliter (ml) of Morganella Morganii (an-aerobic gram-negative bacterium found in the intestines of people, the oral cavity of animals, and the environment). Review of the assessment titled UTI Decision Flow Sheet - V2 dated 09/16/25 revealed Resident #6 had an indwelling catheter, a urine specimen that showed greater than 100,000 CFU/ml of any number of organisms, and had experienced either an acute change in mental status or acute functional decline with no alternate diagnosis and leukocytosis (an increase in the number of white cells in the blood, typically occurring with infection). The assessment further revealed Resident #6 had signs of a urinary tract infection (UTI) according to McGreer's criteria (a standardized set of clinical definitions used to identify and define infections in long-term care facilities). Review of the progress note authored by the [NAME] Services Nurse Practitioner (NP) #441 on 09/25/25 at 10:25 A.M. revealed Resident #6 had a history of increased behaviors associated with bacteriuria and UTI related to chronic urinary indwelling catheter. Review of the Resident Infection Control Log for September 2025 revealed Resident #6 first began on an antibiotic for signs and symptoms of a UTI, including a change in mental status, on 09/08/25, and that the antibiotic was changed on 09/10/25, after receiving results of the urine culture and sensitivity. Observation on 10/07/25 from 2:45 P.M. to 3:04 P.M. of catheter care and bowel incontinence care for Resident #6, performed by Certified Nurse Aide (CNA) #413 revealed Resident #6 was not checked for bowel incontinence prior to the start of catheter care. Further observation revealed CNA #413 wet two washcloths in a sink of warm running water and laid the wet washcloths, plus one dry washcloth, directly on the uncleaned overbed table which had some of Resident #6's personal items on it. Once the appropriate personal protective equipment (PPE) was donned and Resident #6's brief was loosened and opened on the front, CNA #413 took one of the wet washcloths off the overbed table and briskly washed back and forth under the abdominal fold, just above the pubic area, then back and forth between skin folds of the left groin, then briefly on the head of the penis with two swipes, and then back and forth between the skin folds of the right groin. During this observation, CNA #413 did not use any method with the washcloth to ensure that a different, clean part of the cloth was used with each stroke, there were no soap suds noted during the cleansing of the perineal area, the area around the catheter insertion site was not fully cleaned from meatus outward, and no part of the catheter was secured or cleaned using the first washcloth during catheter care. Continued observation revealed CNA #413 picked up the second wet washcloth from the overbed table and followed the same steps as with the first washcloth (briskly swiped back and forth above the suprapubic area under the abdominal fold, then wiped back and forth between skin folds of the left groin, then wiped briefly on the head of the penis using two swipes along the edges, and then wiped back and forth between the skin folds of the right groin). The second washcloth was not folded in a manner to ensure a different, clean part of the cloth was used to rinse each part of the body during catheter and perineal care. At no time was CNA #413 observed cleaning or rinsing directly around the urinary meatus/catheter insertion site or any portion of the catheter. CNA #413 then took the dry washcloth from the overbed table to pat dry the left groin area, the suprapubic area, then the shaft and left lateral ridge of the head of the penis, and then the right groin area, in that order. Resident #6 was assisted to the right side to place a clean brief once catheter care was completed but was then noted to have had a small smear of stool between the buttocks and brownish discoloration along the backside of the brief. Incontinence care was performed by CNA #413 after leaving and re-entering the room with the same gown and gloved left hand (used for catheter care) and a new glove that was applied by the soiled left hand with no hand hygiene. Once incontinence care was completed, CNA #413 used the same soiled gloved hands to position the catheter tubing inside the brief to prevent accidental tugging and then fastened the dry brief. Interview on 10/07/25 at 3:05 P.M. with CNA #413 confirmed a basin for soapy or clean water was not used for catheter care, a barrier was not used for placing clean rags on the overbed table prior to using for catheter care, and the table was not cleaned prior to placing the washcloths on top. During the interview, CNA #413 revealed staff would normally clean around the catheter insertion site and while securing the catheter, were supposed to wash part way up the catheter to keep the portion near the insertion site clean. At the time of the interview, CNA #413 confirmed leaving Resident #6's room between catheter care and incontinence care, only one glove was changed, and no hand hygiene was performed before donning a clean glove. Interview on 10/09/25 at 9:55 A.M. with CNA #383 confirmed that basins and clean washcloths were to be used for catheter care and that staff were never to use the same part of the washcloth for cleaning around the catheter insertion site, catheter, or other body parts during catheter and perineal care. Interview on 10/09/25 at 2:40 P.M. with Registered Nurse (RN) #398 confirmed staff were to clean the urinary meatus of a male with an indwelling catheter by securing the catheter and cleaning in a circular motion from inner to outer areas, using a clean part of the washcloth with each stroke, and care should be taken to ensure cleanliness of the catheter near the insertion site. RN #398 further confirmed that staff were to use a barrier or a wash basin and not lay washcloths on an unclean overbed table before commencing care. RN #398 also confirmed hand hygiene was always to be performed between glove changes. Review of the policy titled Handwashing-Hand Hygiene, last reviewed on 01/06/25, revealed hand hygiene was to be performed before and after donning and doffing gloves and after handling used linens or supplies. The policy further revealed the use of gloves did not replace hand hygiene. Review of the policy titled Catheter Care (Indwelling Catheter), dated 01/06/25, revealed staff were to clean the area well at the catheter insertion site and that all debris was to be removed from around the catheter, near the insertion site. Further review of the policy revealed if the resident was soiled or had an involuntary bowel movement, the incontinence care should be provided prior to catheter care to ensure the area was not contaminated with feces. This deficiency represents noncompliance investigated under Complaint Number 2623950.

Based observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include:Observation of the kitchen area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:02 A.M. revealed the following that was verified at the time of discovery.Observation of the walk-in cooler revealed a spiral ham with no date, an onion chopped in half and stored in plastic wrap with no date, a large plastic container of diced turkey with no date, a metal container with butter that had no label or date, a metal container of bacon bits with no label or date, and a large plastic container of fat from the preparation of a beef roast with no label or date. Observation of the walk-in freezer revealed a box of beef slabs which was opened and the slabs of beef were sitting on the cardboard box and not in a plastic bag or any sort of container. The exposed beef slabs showed signs of significant freezer burn. Further observation of the walk-in freezer revealed a plastic bag of cookie dough bites were in a plastic bag that were open to air. Continued observation of the kitchen revealed multiple light fixtures through out the area that had various amounts of dust, debris, and dead bugs in them. Observation of the six burner cook top had a thick layer of black food buildup around each of the burners and underneath the burner. The microwave used to heat up and defrost residents food was extremely dirty with brown residue all over it.Interview with DA #750 confirmed all of the above findings at the time of discovery on 08/20/25.Review of the undated policy titled, Food Preparation and Storage, revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. This deficiency represents non-compliance investigated under Complaint Number 2569014.

Based observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include: Observation of the outside dumpster area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:45 A.M. revealed to the left of the dumpster area, outside of the physical dumpster, were significant amounts of debris, including plastic gloves, used plastic silverware, paper plates (many with noticeable food residue), brown bags, and various other pieces of plastic laying around. In front of the dumpster, approximately fifteen feet away, was a cardboard box on the ground and the box appeared to have been run over multiple times by vehicles. To the right of the dumpster was the facility's grease barrel, used to store excess oil and grease from the kitchen, and it was observed to be open to the air with a stock pot of water placed on top of it.Interview with DA #750 on 08/30/25 confirmed the above findings of the outside dumpster area at the time of discovery.This deficiency represents an incidental finding discovered while investigating Complaint Number 2569014.

Based on observation, record review, and interviews, the facility failed to ensure the correct serving sizes and all menu items were provided per the menu. This affected four residents (#28, #43, #55, and #99) but had the potential to affect all residents, except two residents (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Interviews on 07/01/25 between 9:44 A.M. and 1:18 P.M. with Residents #28, #55, and #99 revealed they received small portions at mealtimes, but also stated they never knew what was on the menu prior to receiving meals. Review of the menu revealed lunch for 07/01/25 was deli meat and cheese sandwich, creamy coleslaw, and four ounces (oz) of cinnamon apple slices. Residents on a pureed diet were to get pureed soft, cooked vegetables servings size was #12 scoop (green handle which provides a 2.7 oz portion) and pureed cinnamon apple slice serving size was a #10 scoop (three oz). Residents on a mechanical soft diet were to receive ground deli meat and cheese using a #8 scoop (four oz). Observations on 07/01/25 between 12:20 P.M. and 12:45 P.M. of the lunch tray line revealed a large pan of sliced deli meat sitting on the steam table (not in an ice bath), next to it was a large pan of lettuce, and a large pan of sliced tomatoes. [NAME] #555 tore open a loaf of white bread while wearing gloved hands, grabbed slices of bread, grabbed two slices of deli meat, folded it over onto the bread and proceeded to grab lettuce and tomato slices and place onto one slice of bread and then place the second slice of bread on top all while using the same gloved hands. Further observation revealed [NAME] #555 made a pureed plate serving mixed vegetables using a purple handled scoop #40 (providing 0.75 oz. serving). Observation of the mechanical soft diet being plated revealed [NAME] #555 plated ground turkey using a green handled scoop #12 (providing a 2.7 oz. portion) and placed the ground meat between two slices of bread. Observation at the end of the tray line revealed two additional pans. In one pan were several two oz. plastic containers of applesauce, and in the second pan next to it were several two oz. plastic containers of cottage cheese and pineapples tidbits. Interview on 07/01/25 between 12:20 P.M. and 12:45 P.M. with Dietary Manager (DM) #648 they had to swap out the coleslaw and provide chips instead, and also had to provide cottage cheese with fruit and applesauce cups instead of apple slices. DM #648 verified there was no cheese for the deli sandwiches and that the plastic containers were two ounce servings instead of the four ounce servings for the fruit. DM #648 also verified the scoop serving for the pureed veggies and mechanical meat were not correct as well and residents were served smaller portions than what was listed on the menu. Observation on 07/01/25 at 1:04 P.M. of Resident #43's lunch revealed two sandwiches, bag of chips, and a two ounce serving of pineapples. Interview at the time of observation with Resident #43 revealed portion sizes for the fruit cups and cottage cheese were usually in the two ounce containers. Resident #43 stated they don't get or see a menu to know what they will receive for meals. Observation on 07/01/25 at 1:23 P.M. of Resident #55 and #99's lunches revealed both had sandwiches and potato chips but did not receive any fruit cups on their trays. Interview on 07/01/25 with Certified Nursing Assistant (CNA) #408 verified Residents #55 and #99 did not receive dessert or fruit cup on their lunch trays. Observation on 07/01/25 at 1:30 P.M. of Resident #28's lunch revealed a burger, chips, juice, but no fruit cup observed. Interview at the time of observation with CNA #408 verified Resident #28 had no fruit on his lunch tray. This deficiency represents non-compliance investigated under Complaint Number OH00166944.

Based on observation, interview, and record review, the facility failed to dry silverware and serve food in a sanitary manner. This had the potential to affect all residents except two (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Observations on 07/01/25 at 12:19 PM observed Dietary Aide (DA) #409 using a dish cloth to dry the silverware that was in a tray sitting on the end of the steam table. DA #409 proceeded to place the silverware after drying them in a silverware holder. DA #409 verified the observation and stated she didn't know they weren't supposed to dry them that way. Observations on 07/01/25 at 12:20 P.M. of the lunch tray line revealed a large pan of sliced deli meat sitting on the steam table (not in an ice bath), next to it was a large pan of lettuce, and a large pan of sliced tomatoes. [NAME] #555 tore open a loaf of white bread while wearing gloved hands, grabbed slices of bread, grabbed two slices of deli meat, folded it over onto the bread and proceeded to grab lettuce and tomato slices and place onto one slice of bread and then place the second slice of bread on top all while using the same gloved hands throughout the meal service. Interview at the time of observation with Dietary Manager (DM) #648 verified the observation and stated his expectation was for [NAME] #555 to use serving utensils. Review of the resident diet order list revealed two residents (#36 and #51) who had physician orders to receive nothing by mouth. Review of the undated facility policy, Food Preparation and Storage, revealed all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food.

Based on observation and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 111 residents receiving meals from the kitchen excluding Resident #36 and #51 who the facility identified as eating nothing by mouth. The facility census was 113. Findings include: An observation was conducted on 02/25/25 from 12:35 P.M. to 1:33 P.M. with Dietary Manager (DM) #503 of the facility kitchen. In the main freezer there was bread stored in a clear plastic bag with no label or dates, and an open bag of French fries in a clear plastic bag with no label or date on it. Observation of the dry food storage area revealed an open, two-pound bag of powdered sugar that was wrapped in ripped plastic wrap without a date or label and the powdered sugar was spilling out of the bag when it was picked up to check for a label and date. Pumpernickel bread and sausage buns were observed with no dates or labels on the bread items. A 55 ounce bag of tortilla shells were observed on the bread shelf with a use by date of 12/13/24. An unlabeled plastic container with a green lid had a brown substance in the plastic container stored in the dry storage room that was not labeled or dated. Live gnats were observed hovering by the bread in the dry food storage areas. Next to the dish machine live gnats were observed flying around the dish machine. Four wet oven trays were observed sitting on the pot and pan rack along with dried and clean pots and pans. There was a heavy build-up of black grime on the floor under the dish machine and a heavy build-up of dried food particles and black grime were observed on the bottom of the walls where the walls met the floor throughout the kitchen. In addition, two tray carts used to transport resident food had a large amount of dried white substance resembling dried milk on each cart indicating the carts had not been kept clean and sanitary. An interview was conducted on 02/25/25 at 1:33 P.M. with DM #503 who confirmed the above findings at the time of the observations. This deficiency represents non-compliance investigated under Complaint Number OH00162967

Based on observation, interview and review of facility policy, the facility did not ensure palatable food was served to all residents receiving meals from the kitchen. This affected six residents (#24, #28, #29, #32, #43 and #87) of six residents reviewed for food service. The facility census was 113. Findings include: An observation was conducted on 02/25/25 at 12:35 P.M. to 1:33 P.M. of the kitchen food production, kitchen environment and lunch tray line meal service. The lunch consisted of chicken cutlet, spinach, chocolate chip cake and substitutes available were hamburger or ham slices, mixed vegetables, potato salad and ice cream. All hot foods on tray line reached acceptable temperature above 165 degrees Fahrenheit ( F) prior to the start of meal service. A second set of temperatures were not taken to monitor the temperatures of the food on tray line throughout the observation. A test tray was requested as the last resident's food was plated and ham slice, potato salad and mixed vegetables were placed for the test tray. The food cart left the kitchen at 1:33 P.M. with the test tray and arrived to the unit at 1:40 P.M. When the test tray reached the floor at 1:40 P.M. the test tray was placed in the dining room where food temperatures were taken by Dietary Manager (DM) #503 using a calibrated facility thermometer. The temperature of the ham slice was 106 degrees F and was barely warm to taste. The cold potato salad was 75 degrees F and was not cold. The mixed vegetables were 136 degrees F and tasted warm. DM #503 verified the food temperatures at the time of the test tray. An interview was conducted on 02/25/25 at 1:46 P.M. with Resident #28 who revealed he did not like the food, and the hot food was not hot. An interview was conducted on 02/25/25 at 1:48 P.M. with Resident #87 who stated the food is horrible. An interview was conducted on 02/25/25 at 1:51 P.M. with Resident #32 who revealed hot foods were served cold. An interview was conducted on 02/25/25 at 1:52 P.M. with Resident #24 who revealed the food did not taste good. An interview was conducted on 02/25/25 at 4:48 P.M. with Resident #29 who revealed they ordered food out because the food is not good. An interview was conducted on 02/25/25 at 5:07 P.M. with Resident #43 who stated the hot food is always cold. Review of the facility policy titled Food Temperatures at Point of Service, dated 01/06/25 revealed hot food items must be cooked, held and served at appropriate temperature. Food temperatures were taken often to monitor safe food holding temperature at or below 41 degrees F for cold foods, and at or above 135 degrees F for hot foods. This deficiency represents non-compliance investigated under Complaint Number OH00162967

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provided timely incontinence care to the residents. This affected two (Residents #10 and #74) of three residents reviewed for incontinence care. The facility census was 110. Findings include: 1. Record review for Resident #10 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Resident #10 had impairment on one side of the upper and lower extremities, was frequently incontinent of urine and always incontinent of bowel. Resident #10 required substantial/maximal assistance with toileting hygiene, personal hygiene, and was dependent on staff for transfers. Review of the care plan dated 12/23/24 revealed Resident #10 had bowel incontinence due to impaired mobility and physical limitations. Resident #10 also had bladder frequent incontinence due to impaired mobility and physical limitations. Interventions included to check resident, if she was continent, offer to assist with toileting. If she was incontinent, remove wet or soiled clothing, briefs; provide incontinent care; apply protective barrier after each incontinent episode; and maintain resident dignity during incontinent care. Observation and interview on 01/06/25 at 12:53 P.M. revealed Resident #10 was sitting up in her chair. Resident #10 stated she had been incontinent and asked the Certified Nursing Assistant (CNA) to change her since 10:00 A.M. Interview on 01/06/25 at 12:57 P.M. with CNA #335 confirmed she was Resident #10's CNA. CNA #335 stated she needed two people to transfer Resident #10 to her bed to change her so she would do it at 2:00 P.M. Interview on 01/06/24 at 2:22 P.M. with CNA #335 stated she was not ready yet to change Resident #10, she needed to wait for another staff member to assist her with the transfer. CNA #335 stated Resident #10 was a mechanical lift and required two persons to transfer her. The night shift placed her in the chair, unsure what time but it was before 7:00 A.M., and Resident #10 has not been laid back down or checked and changed since night shift got her up. CNA #335 stated she did not have enough hands to do it all. Observation on 01/06/25 at 2:30 P.M. revealed Licensed Practical Nurse (LPN) #312 assisted CNA #335 to transfer Resident #10 to her bed. Observation during incontinence care revealed Resident #10's brief was completely saturated front and back with urine and stool. 2. Record review for Resident #74 revealed an admitted [DATE]. Diagnoses included spondylosis with myelopathy cervical region, overflow incontinence and muscle weakness. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #74 was cognitively intact. Resident #74 required supervision or touch assistants with toileting hygiene and transfers. Resident #74 was occasionally incontinent of bowel and bladder. Review of the care plan revealed Resident #74 had bladder incontinence related to impaired mobility. Interventions included to check the resident if he/she was incontinent, remove wet or soiled clothing, briefs; provide incontinence care; and apply protective barrier after each incontinent episode. Observation and interview on 01/06/25 at 1:03 P.M. revealed Resident #74 was sitting up in his chair next to his bed. Observation revealed the sheets on top of Resident #74's bed were saturated from one side of the bed to the other with a large dried yellow ring on the edges. The room had a strong odor of urine. Resident #74 stated he was up on his chair since 8:45 A.M. Resident #74 stated he had not been changed yet and asked for assistance to get changed a few hours ago. Resident #74 stated he often had to wait to get changed and he was wet now. Interview on 01/06/25 at 1:10 P.M. with CNA #402 stated each of her residents were checked and changed two times a shift, in the morning and at the end of her shift. CNA #402 stated the shift began at 7:00 A.M. until 3:00 P.M. Observation and interview on 01/06/25 at 1:19 P.M. with CNA #403 confirmed Resident #74's sheets were saturated with urine and the room had a strong urine odor. CNA #403 stated Resident #74 used a urinal, he was incontinent sometimes but if he needed help he would ask, otherwise she did not need to check on him for incontinent care needs. CNA #403 stated she changed other incontinent residents twice a shift, in the morning and at the end of her shift. CNA #403 confirmed she worked from 7:00 A.M. until 3:00 P.M. Interview on 01/06/25 at 1:38 P.M. with CNA #461 stated she could not take residents to the bathroom or provide incontinence care during meal time which included passing the meal trays, feeding residents and picking up the trays. Interview on 01/06/24 at 3:20 P.M. with Regional Director #476 revealed residents were checked and changed on an individualized bases but at least every two hours, some residents may require it more often and as needed. Review of the facility policy titled ADL Care (Activity of Daily Living) dated 11/30/23 included the purpose was to meet the resident's physical and mental needs. Assist resident with toilet activities and provide incontinence care as needed. This deficiency represents non-compliance investigated under Complaint Number OH00161188.

Based on observation, interview, record review and facility policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who had orders for Enhanced Barrier Precautions (EBP). This affected one Resident (Resident #51) of three residents reviewed for infection control, and had the potential to affect an additional 23 residents (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55 and #56) living on the South unit. The facility identified 24 residents in EBP (Residents #4, #10, #11, #14, #20, #27, #30, #31, #33, #41, #47, #48, #50, #51, #52, #54, #58, #75, #81, #86, #87, #88, #97, and #103). The facility census was 106. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, infection and inflammatory reaction due to indwelling urethral catheter, and a personal history of other infectious and parasitic disease sepsis due to staph Aureus. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of Resident #51's physician orders dated June 2024 revealed she was in Enhanced Barrier Precautions (EBP) and staff were to use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (trach, central line, tube feeding, and catheter) every shift for reducing the chance of spreading infection. Further review of Resident #51's physicians orders revealed she had a foley catheter, tube feedings, and wound care. Observation on 06/27/24 at 11:45 A.M. of Resident #51 revealed she was to be in Enhanced Barrier Precautions related to her heel wound, and lines and tubes such as foley catheter and tube feeding. Observation on 06/27/24 at 11:47 A.M. of wound care for Resident #51 by Registered Nurse (RN) #705 revealed she cleansed the left heal with saline soaked gauze, painted with betadine then applied Adaptic, then applied a clean dry dressing and reapplied the residents heel boots. Hand hygiene was completed appropriately with no concerns identified related to the wound care. While RN #705 performed wound care she was not wearing the proper Personal Protective Equipment (PPE) as required including a gown. Interview on 06/27/24 at 12:00 P.M. with RN #705 the facility Wound Care Nurse and Infection Preventionist revealed she confirmed Resident #51 whom she just completed wound care on was in Enhanced Barrier Precautions (EBP) and should have worn a gown to complete the residents wound care and did not. She stated she got caught up in the moment and forgot to put on her gown. She confirmed all appropriate signage was posted. Review of the facility policy titled Enhanced Barrier Precautions, last reviewed 11/30/23 revealed under the procedure section, number two Gowns and gloves are to be used for high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Under number three it stated examples of high-contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing lines, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tubes, tracheostomy/ventilator, wound care including any skin opening requiring a dressing. This deficiency was an incidental finding of non-compliance during the investigation of Complaint Number OH00154399.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of a police report and review of facility policy, the facility failed to provide a safe environment free from a potential accident hazard when State tested Nursing Assistant (STNA) #563 was found to have an unsecured loaded firearm in the facility. This resulted in Immediate Jeopardy and potential for serious life-threatening harm when STNA #563 left a loaded firearm, with additional rounds of ammunition, wrapped in a fleece vest and in a clear plastic bag, unsecured on a cart on the 3 North Hallway where residents resided and had access to the bag. Resident #64 subsequently took the bag containing the loaded firearm to her room, without staff knowledge, found the firearm, and placed it under the mattress of her bed. This affected one (#64) resident and had the potential to affect all 108 residents residing in the facility. The facility census was 108. On 05/13/24 at 2:25 P.M., the Director of Nursing (DON) and Regional Registered Nurse (RRN) #707 were notified Immediate Jeopardy began on 05/03/24 at approximately 1:00 P.M. when STNA #563 notified Unit Manager (UM) #628 his coat and loaded firearm were missing from the 3 North Hallway. STNA #563 left the loaded firearm, unsecured, in a plastic bag on a cart in the hallway and discovered it was missing at approximately 1:00 P.M. Resident #64 saw the unattended bag on the cart, believed it was hers, and took the bag to her room. Resident #64 found the loaded firearm and placed it under her mattress. The facility was unable to locate the firearm during searches of the facility. On 05/03/24 at approximately 3:33 P.M., Resident #64 told STNA #592 she found the firearm and the local police department, who had been contacted regarding the incident by the facility, took possession of the weapon and additional rounds of ammunition. The Immediate Jeopardy was removed on 05/04/24 and the deficiency continued at a Severity Level II (no harm with the potential for more than minimal harm that is not immediate jeopardy) until the deficiency was corrected on 05/06/24, when the facility implemented the following corrective actions: On 05/03/2024 at approximately 1:00 P.M., STNA #563 informed Unit Manager (UM) #628 his coat and firearm were missing from the 3 North Hallway. UM #628 immediately notified the DON of the missing firearm. On 05/03/24 at approximately 1:05 P.M., the DON notified the Administrator of the missing firearm. On 05/03/24 at approximately 1:07 P.M., the Administrator notified the local police department (LPD) of the missing firearm. On 05/03/24 at approximately 1:10 P.M., the DON assigned managers to search the first, second, and third floors of the facility for the missing firearm. On 05/03/24 at approximately 1:40 P.M., the Local Police Department (LPD) arrived at the facility. The Administrator and UM #628, along with the responding officer, reviewed camera surveillance to determine if the missing firearm could be seen being removed from the last known location. The cameras did not assist in identifying who may have removed the bag carrying the missing firearm. On 05/03/24 at approximately 2:00 P.M., the DON and Administrator assigned new areas for managers to search for the missing firearm, including dietary, the basement, and the exterior of the facility. On 05/03/24 at approximately 2:15 P.M., the DON and Maintenance Supervisor (MS) #618 searched the garbage for the missing firearm. On 05/03/24 at approximately 2:20 P.M., a second officer from the LPD arrived and obtained a statement from STNA #563 regarding the missing firearm. On 05/03/24 at 3:33 P.M., STNA #592 located the missing firearm in Resident #64's room. The LPD took immediate possession of the firearm. On 05/03/24, STNA #563 was suspended pending the investigation into the firearm he brought into the facility. On 05/03/24, at approximately 4:00 P.M., an Ad Hoc QAPI was held with the Administrator, DON, Business Office Manager (BOM) #537, Cook #639, Receptionists #535 and #583, Corporate Admission (CA) #701, Dietary Tech (DT) #702, Assistant Business Office Manager (ABOM) #565 and Admissions Director (AD) #703 to review the facility policy on Firearms and Other Weapons. The facility prohibits employees, residents, visitors, vendors, or others from possessing firearms or other weapons while in/on facility premises. On 05/03/24, the DON notified Medical Director (MD) #704 of the incident involving the firearm. On 05/03/24, Chief Clinical Officer (CCO) #705 re-educated the DON on the facility's policy on firearms and other weapons. On 05/03/24, the DON and CCO #705 educated all staff, including five activities staff, two admissions staff, two business office staff, one central supply staff, 25 dietary staff, seven hospitality aides, 12 housekeepers, two laundry staff, 27 Licensed Practical Nurses (LPN), one maintenance staff, three medication technicians, three social workers, two therapists, three receptionists, 10 Registered Nurses (RN) and 37 STNAs related to the facility firearm policy. Education was provided in person for staff at the facility and over the phone for those off duty. On 05/03/24, UM #628 completed a skin assessment for Resident #64. No new areas of concern were identified. On 05/03/24, the DON or designee completed an assessment of all residents. Residents were safe and at baseline. No psychosocial concerns were identified. On 05/03/24, the Administrator placed new, more prominent signage at the entrances prohibiting firearms in the facility. On 05/03/24, Maintenance Staff (MS) #618 changed door codes due to the suspension of STNA #563. Beginning 05/04/24, the DON or designee implemented a system to audit five random staff four times weekly for four weeks then three random staff weekly for eight weeks to ensure knowledge of the facility's firearms policy. Findings would be reviewed in weekly QAPI meetings to ensure compliance with the policy. On 05/06/24 at approximately 11:00 A.M., Regional Director of Operations (RDO) #706 notified STNA #563 of termination of employment due to not following the facility policy on firearms. Interviews on 05/13/24 from 2:37 P.M. through 05/14/24 at 8:58 A.M. of Resident #64, #18, and #42 revealed each denied any knowledge of firearms or other weapons in the facility, outside of the incident involving STNA #563's firearm. Interviews on 05/13/24 from 3:06 P.M. through 05/14/24 at 9:49 A.M. of STNAs #542, #543, and #644 and LPN #628 revealed each were able to articulate the facility policy related to firearms and other weapons. Each denied knowledge of any weapons in the facility, outside of the incident on 05/03/24. Observation on 05/14/24 at 8:58 A.M. verified prominent signage prohibiting firearms in the facility were placed at the entrances. Review of staff education sign-in sheets verified all staff were educated on the facility's firearms and other weapons policy on 05/03/24. Findings include: Review of Resident #64's medical record revealed an admitted [DATE]. Resident #64 had diagnoses including depression, anemia and uncomplicated alcohol dependence. Review of the Minimum Data Set (MDS) assessment, dated 04/11/24, revealed Resident #64 had mild or no cognitive impairment and daily occurrences of feeling down or depressed. Review of a psychiatry note, dated 05/09/24, revealed Resident #64 was alert and oriented to person and place, but had poor memory, insight, and judgement. Review of a social worker progress note, dated 04/10/24, revealed Resident #64 had periods of forgetfulness. Interview with the DON on 05/13/24 at 9:52 A.M. revealed STNA #563 brought a gun to the facility on [DATE]. The gun was located in a bag, which was taken mistakenly by Resident #64 who thought the bag was hers. Resident #64 subsequently found the gun and gave it to STNA #592, and the police took immediate possession of the firearm. During the interview, the DON revealed guns were not permitted in the facility. Interview with STNA #563 on 05/13/24 at 12:01 P.M. verified he brought a loaded nine-millimeter [NAME] pistol to work at 11:00 P.M. on 05/02/24. The STNA indicated he had the gun for personal protection due to working nights and taking the bus (to and from work). STNA #563 stated he stored the firearm with his personal belongings in a bag at his workstation on the third floor. STNA #563 stated he last saw the bag at 12:40 P.M. on 05/03/24 after coming back from lunch. At approximately 1:00 P.M., STNA #563 noticed the bag was missing and he was unable to locate it. STNA #563 stated he notified an unknown nurse of his missing belongings, including the gun. STNA #563 stated he was removed from the search then told to leave the building after giving a statement to the police. STNA #563 stated it was common for him to bring the pistol wherever he went, though he stated he never took it out of the bag while at the facility. STNA #563 confirmed the facility terminated him following the incident. Interview with Resident #64 on 05/13/24 at 2:37 P.M. confirmed she found a bag at the aide's workstation (a desk and chair in the hallway) on 05/03/24 at approximately 1:00 P.M., and believed it was hers. Resident #64 brought the bag into her room and found a jacket with a pistol in the pocket. She stated she then hid the gun under the mattress of her bed until she found STNA #592 and told her about it. STNA #592 told Resident #64 the facility had been looking for the gun. The police were brought to her room and removed the firearm. Interview with UM #628 on 05/13/24 at 3:06 P.M. revealed STNA #563 informed her his coat was missing on 05/03/24 and staff began looking for it. When they could not find the coat, STNA #563 came to UM #628's office, shut the door, and said his gun was with the coat. UM #628 notified the DON. The managers broke into pairs and began searching the building for the firearm. Resident #64 told an aide the gun was in her room roughly two hours after the event began. Interview with STNA #592 on 05/14/24 at 3:11 P.M. revealed she worked second shift (3:00 P.M. to 11:00 P.M.) on 05/03/24. Shortly after she entered the building, Resident #64 informed her she took a bag to her room thinking it had her own belongings in it and found a gun inside. STNA #592 notified the police, who took control of the weapon. Record review of STNA #563's personnel file revealed he was hired 03/18/24 and his orientation paperwork included acknowledgement of receipt of various policies, including deadly weapons. Further review revealed STNA #563 had no disciplinary action until his suspension on 05/03/24 and subsequent termination on 05/06/24 for violating the facility's firearms and other weapons policy. Review of the local police report, identified as Incident Number 24-01711 and dated 05/03/24, revealed police responded to the facility on [DATE] at 2:00 P.M. for a report of a missing firearm. STNA #563 reported his [NAME] pistol was concealed inside a fleece vest pocket along with two additional magazines, which was stored inside a clear garbage bag and left on a nursing cart outside of room [ROOM NUMBER]. STNA #563 told the police he brought his gun to work because he worked nights and had to ride the bus. Staff located the weapon at 3:45 P.M. under a mattress in room [ROOM NUMBER]. The gun was found with a bullet in the chamber, an inserted magazine containing nine bullets, and with two extra magazines of ten bullets each. Police interview with Resident #64 revealed she initially believed the bag was hers and took it into her room, where she found the gun. She did not feel comfortable turning it over to any staff member except STNA #592 and so waited until this staff began her shift to report it. The police took custody of the firearm. Review of the facility policy titled Firearms and Other Weapons, dated April 2007, revealed the facility prohibited any individual from possessing firearms or other weapons on the premises. Individuals bringing a weapon into the facility must leave it with the administrative office or a security officer before entering resident care areas. Violations of the policy could result in various steps including immediate termination of employment.

Based on observation, staff interview, and policy review, the facility failed to ensure food items were stored and prepared in a safe and sanitary manner. This had the potential to affect all 101 residents residing in the facility. The facility census was 101. Findings Include: A tour of the facility kitchen was completed on 03/06/24 between 8:15 A.M. and 8:33 A.M. with Dietary Manager #200. Observation of the walk-in cooler revealed a box containing approximately six raw carrots and noted the carrots to be significantly brown in color with significant areas of rot on them, a large box of green peppers with soft exterior skins and numerous other peppers were discolored with various areas of brown and black rot, and a bag of fresh heads of lettuce with significant areas of rot and brown spots on the lettuce. Observation of the walk-in freezer revealed a bag of chicken breast was significantly freezer burned and a frozen chuck roast was noted on the floor. Observation of the food preparation areas revealed there were approximately five burners on the kitchen stove that were incased in burned/dried food, grime, and other unknown debris. Further observation of the food preparation areas revealed the plumbing pipe above the food preparation area was coated in dust, unused oven racks were stored on top of the convection oven with the top of the convection oven noted with large amounts of dirt, dust, grime, and dried foods on it, and there was an open trash can with no covering placed between the griddle and stovetop while the breakfast meal was being prepared. Interview with Dietary Manager #200 verified the findings in the kitchen during the kitchen tour on 03/06/24 at the time of discovery. Review of the undated policy titled, Food Storage, revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. This deficiency represents an incidental finding discovered during the investigation for Master Complaint Number OH00151714 and Complaint Number OH00151480.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and facility policy review the facility failed to ensure proper physical assistance was provided to prevent a fall. This affected one resident (#107) of three residents reviewed for falls. Findings include: Review of the medical record for Former Resident #107 revealed an admitted [DATE]. Diagnoses included epilepsy, hemiplegia, and hemiparesis following cerebral infarction, acquired absence of left leg above knee, and acquired absence of right leg below knee. The resident was discharged to the hospital on 01/19/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had intact cognition. The resident had the behavior of rejection of care. Functional Abilities: used a wheelchair, no impairment upper extremities, impairment on one side lower extremities. Review of the plan of care dated 10/20/22 revealed Resident #107 was at risk for falls. Interventions included: Assist with all transfers, etc., Bed in lowest position while in bed, call light accessible when in room. Grab bars to both sides of bed to assist with turning and repositioning was added 12/15/23 as an intervention. Review of physician orders for January 2024 identified orders for occupational therapy evaluation and treatment, one time only for one day, on 12/20/23. Grab bars to BOTH sides of bed to assist with turning and repositioning, transfers, and to promote safety due to weakness, dated 12/15/23. Review of the nurse's note dated 12/15/23 at 7:09 A.M. revealed at approximately 5:00 A.M. Resident #107 fell from the bed when aide was providing care. An assessment was completed. Vital signs were completed blood pressure was 127/81, pulse 64, oxygen saturation was 94% on room air, temperature was 97.8 degrees Fahrenheit (F), range of motion (ROM) was within normal limits, resident moved all extremities without pain, no visible injury was observed. The resident's bed moved when locked, a bed rail was not on the side where the resident fell . Maintenance was notified about the bed. The Wong-Baker FACES pain scale indicated zero, no pain. Interventions: keep items within reach, nonskid footwear, half siderail for bed mobility, maintenance to check the bed. Review of the fall review on 12/15/23 revealed a fall risk assessment was completed with a score of 12, indicated the resident was a high fall risk. At approximately 5:00 A.M. Resident #107 fell from the bed when an aide was providing care. An assessment was completed. Vital signs were completed blood pressure was 127/81, pulse 64, oxygen saturation was 94% on room air, temperature was 97.8 degrees F, ROM was within normal limits, resident moved all extremities without pain, no visible injury was observed. The resident's bed moved when locked, a bed rail was not on the side where the resident fell . Maintenance was notified about the bed. The Wong-Baker FACES pain scale indicated zero, no pain. Interventions: keep items within reach, nonskid footwear, half siderail for bed mobility, maintenance to check the bed. Symptoms prior to fall: none noted. Interventions: keep items within reach, nonskid footwear, half siderail for bed mobility, maintenance to check the bed. The resident's family and physician were notified of the fall. Review of the Interdisciplinary Team (IDT) note on 12/15/23 at 10:18 A.M. revealed the IDT team met to review the fall on 12/15/23. While being assisted with toiletings needs, Resident #107 rolled out of bed onto floor. Resident #107 denied hitting his head. Risk factors included but were not limited to epilepsy, anxiety and bilateral below knee amputation (BKA). Immediate intervention: the resident was assisted back into bed with three-person assistance, evaluated by nurse, physician notified, and neurological checks were initiated. Locks on bed wheels were found not to be working properly. New intervention: a new bed and grab bars to both sides of bed. All parties were notified. Review of the Physician's Monthly Progress Note on 12/26/23 at 4:04 P.M. revealed Resident #107 was a new resident for the nurse practitioner (NP) at the facility. The musculoskeletal exam revealed no tenderness, normal ROM, and right lower leg edema (above the amputation). Interview on 02/08/24 at 10:42 A.M. the Director of Nursing (DON) and Administrator revealed that during care the aide turned Resident #107 toward the wall, the bed moved away from the wall, and he rolled off. The resident was immediately assessed. Staff got him back to bed. That was when they noticed the lock was broken on the bed. The facility got him a new bed and had grab bars put on both sides. During that time the resident never complained of pain or said anything that indicated he wasn't feeling okay. The resident never complained of pain after that, or we would have had x-rays done. We did a re-education with the state tested nurse aide (STNA) about making sure the bed was locked before doing care and about how the need to turn a resident toward yourself, not away. Interviews on 02/08/24 from 12:19 P.M. through 12:48 P.M. with Licensed Practical Nurse (LPN) #302, LPN #303, LPN #304, and STNA #304 revealed all had been trained in fall prevention and in what to do after a resident fell . All residents were assessed by a nurse after a fall. None of the staff interviewed had heard Resident #107 complain of any pain in the days after his fall. The deficient practice was corrected on 12/16/23 when the facility implemented the following corrective actions: On 12/15/23 at 10:18 A.M. the IDT met to review Resident #107's fall. The interventions included a new bed and grab bars to both sides of bed. On 12/15/24 at 7:09 A.M. the nurse assessed Resident #107 after the fall. The assessment at the time did not reveal any injuries. On 12/15/23 Resident #107's plan of care (POC) and Kardex were reviewed and updated. On 12/15/23 the physician ordered grab bars to both sides of bed to assist with turning and repositioning, transfers and to promote safety due to weakness. Bed Safety Inspection Audits were held 12/15/23, 12/19/23, 12/26/23, 01/02/24, 01/09/24, 01/16/24, and 01/23/24. On 12/16/23 a re-education was done with STNA#305 about making sure the bed was locked before doing care and about the need to turn a resident toward yourself, not away. This deficiency represents non-compliance investigated under Complaint Number OH00150400.

Based on observations, interview, and facility policy review the facility failed to ensure that the kitchen was clean and sanitary. This had the potential to affect 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101. Findings include: During the initial tour of the kitchen on 09/25/23 from 8:15 A.M. to 8:35 A.M. revealed that the slicer had dried beef on it, the mixer had dried food splatter on the back splash, tomato soup and ham salad was not labeled or dated in the walk-in refrigerator, and pizza crust was not wrapped properly, labeled, or dated in the walk-in freezer. Observation on 09/27/23 at 7:40 A.M. revealed Cook #801 was not wearing a beard net. Dietary Manager (DM) #802 verified that Cook #801 was not wearing a beard net and got one for Cook #801. During tray line observation on 09/27/23 at 9:49 A.M. revealed Cook #801 used his gloved hand to take the biscuits out of the pan and cut them in half for the sausage gravy then proceeded to serve hard boiled eggs on the plates after touching utensils and plates. DM #802 verified at the time of the observation. Review of the undated facility policy titled Food Infection Control Policy revealed hand washing when changing gloves, cleaning of equipment and surfaces areas as well as items should be labeled and dated when removed from original packaging.

Based on observation, interview, and taste test the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected five residents (#8, #26, #42, #55, and #94) who were prescribed pureed diets of 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101. Findings include: Observation on 09/27/23 at 11:28 A.M. with Cook #880 revealed pureed yellow squash that was not proper consistency. Cook #880 put some pureed squash in a portion control cup for taste test, then put the pan in the oven to keep warm and took the robot coupe to the dish machine for cleaning. Taste test revealed that the pureed squash had chunks of squash in it and was not pureed properly. Dietary Manager (DM) #802 was asked to taste pureed squash. DM #802 tasted the pureed squash and stated that it had to be pureed more. Observation on 09/27/23 at 11:37 A.M. Cook #880 proceeded to puree roast beef and then portioned two souffle cups with purred beef. Taste test revealed that pureed roast beef was not of proper consistency. DM #802 verified the pureed beef was not puree smoothly and stated that it had to be pureed more. Review of the pureed herbed rubbed roast beef recipe revealed that prepared beef should be put into the processor with hot broth and blend to a smooth consistency. Review of the pureed squash medley recipe revealed that prepared squash medley should be put into the processor and blended to a smooth consistency.

Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for Resident #23 and Resident #29. This affected two residents (#23 and #29) of 101 residents reviewed for call light placement. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with a readmitted [DATE] with diagnoses including aphasia, bipolar disorder, rhabdomyolysis, chronic obstructive pulmonary disease, and unspecified convulsions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and required extensive assistance of one staff for mobility, total dependence with two staff for transfers, and extensive assistance with two staff for toilet use. Observation of Resident #23 on 09/25/23 at 10:08 A.M. revealed Resident #23 was lying in bed and his call light was lying on the floor. The call light was noted to be out of reach of Resident #23. Review of the care plans dated 02/24/22 revealed Resident #23 was at risk for falls related to diagnoses. Interventions included but were not limited to call light within reach. Interview with State tested Nursing Assistant (STNA) #855 on 09/25/23 at 10:09 A.M. verified the call light was out of reach, and Resident #23 would be able to use the call light if it was within reach. 36650 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnosis including diabetes, hypertensive heart disease, and asthma. Review of the annual MDS dated [DATE] revealed Resident #29 was cognitively impaired. Observation on 09/25/23 at 9:50 A.M. of Resident #29 revealed the resident lying in bed with the touch pad call light hanging from the left side of his bed, out of reach. Resident #29 stated he wanted water and was unable to reach his call light to ask staff for water. Interview on 09/25/23 at 9:50 A.M. with Licensed Practical Nurses (LPN) #820 verified Resident #29's touch pad call light was not within reach, and Resident #29 was wanting water. This deficiency represents non-compliance investigated under Master Complaint Number OH00146530.