Every finding on record at Clifton Healthcare Center

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to store foods in a sanitary manner and failed to maintain a clean and sanitary kitchen This had the potential to affect 135 of 137 residents who received food from the kitchen. The facility census was 137 residents.Findings include: Observation on 04/19/26 at 8:40 A.M. with Dietary Aide (DA) #853 revealed there were no paper towels available at handwashing station. Observation on 04/01/26 at 8:42 A.M. of stand-up refrigerator revealed it contained the following items: a container of sandwiches with no date, a half-gallon of milk with an expiration of date of 04/09/26, an opened jar of grape jelly with no date, a container of whipped cheese spread with an open date of 03/19/26, a cottage cheese container with use by date of 04/09/26. Interview on 04/01/26 at 8:43 A.M. with DA #853 confirmed there were no paper towels available for staff to use with handwashing, and the stand-up refrigerator contained undated and expired items. Observation on 04/19/26 8:52 A.M of walk-in refrigerator with DA #853 revealed the door would not close properly and the refrigerator contained the following items: an undated metal pan of cooked hamburgers, a large, sealed roll of undated ground beef, four gallons of milk with an expiration date of 04/09/26. Interview on 04/19/26 at 8:52 A.M. with DA #583 confirmed the door to the walk-in refrigerator did not close properly and the refrigerator contained undated and expired items. Observation on 04/19/26 at 9:03 A.M. of walk-in freezer with DA #853 revealed the freezer contained the following items: a large box of undated green peas, a pack of undated veggie burgers open to air, a large box of undated hotdogs in a plastic bag open to air, a large box of undated mixed vegetables in a plastic bag open to air, a box of undated cookie dough balls in a plastic bag open Interview on 04/19/26 at 9:03 A.M. with DA #853 confirmed the walk-in freezer contained undated and open to air items. Observation on 04/19/26 at 9:15 A.M. with DA #853 revealed the exhaust fan above oven was dirty and there were three large metal pans which were still wet from being washed stacked one on top of the other. Interview on 04/19/26 at 9:15 A.M. with DA #853 confirmed the exhaust fan above the oven was dirty and he was unsure of when it was last cleaned and was unsure of who was responsible for cleaning it. DA #853 confirmed the wet metal pans had not been dried before being stacked for storage. Observation on 04/20/26 at 2:45 P.M. with Clinical Director of Dietary Operations (CDDO) #860 P.M. revealed the walk-in refrigerator contained the following items: a container of tuna salad covered with plastic wrap which was ripped and left the tuna salad open to air, a bag of lettuce which was open to air, two containers of opened and undated shredded cheese. The walk-in freezer contained a box of frozen biscuits in an unsealed bag which was open to air, a plastic bag of hamburger patties open to air, a box of turkey patties in an unsealed bag open to air. Interview on 04/20/26 at 2:45 P.M. with CDDO #860 confirmed the undated and open-to-air items in the walk-in refrigerator Observation on 04/20/26 at 3:07 P.M. with CDDO #860 revealed there were two wet trays stacked together stored with other clean and dry pans. Interview on 04/20/26 at 3:07 P.M. with CDDO #860 confirmed the wet trays had not been dried before being stacked for storage. Observation on 04/21/26 at 11:53 A.M. of tray line revealed [NAME] #833 removed a hamburger bun from a bag with her bare hands to place on a resident tray. Interview on 04/21/26 at 11:53 A.M. with CCDO #860 confirmed [NAME] #833 had touched the hamburger bun with her bare hands and the bun should be discarded. Interview with administrator on 04/21/26 at 3:35 P.M. revealed that the only resident refrigerators in the facility on nursing units were on the first floor and the third floor. Observation of the first-floor refrigerator revealed a new empty refrigerator that had not been put into service. Observation on 04/21/26 at 3:35 P.M. of the third-floor refrigerator in the conference room used for resident food revealed there was a spill of pink liquid and crumbs and debris throughout the refrigerator. The refrigerator contained the following items: an unlabeled undated container of food, an undated container of shredded cheese, a quart of milk with an expiration date of 08/05/25, a bottle of blue cheese dressing with an expiration date of 10/20/25. Interview on 04/21/26 at 3:35 P.M. with the Administrator confirmed the third-floor refrigerator needed to be cleaned and contained unlabeled, undated, and expired items which should have been discarded. Review of the facility policy titled Food Storage: Cold Foods dated February 2026 revealed all foods would be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on medical record review and staff interview, the facility failed to document timely care conferences for residents. This affected four (Residents #79, #1, #15, and #135) of 27 residents sampled. The facility census was 137 residents: Findings include:1. Review of the medical record for Resident #135 revealed an admission date of 03/17/25 with diagnoses including vascular dementia with behavioral disturbance, anxiety, depression, and glaucoma. Review of the Minimum Data Set (MDS) assessment for Resident #135 dated 03/25/26 revealed the resident had severely impaired cognition. Review of the medical record for Resident #135 revealed the facility held care conferences for the resident on 03/18/25 and 04/17/26. Interview on 04/19/26 at 3:10 P.M. with Resident #135's representative confirmed the resident had not had any recent care conferences. Interview on 04/21/26 at 9:47 A.M. with Social Services Designee (SSD) #321 verified the facility held care conferences for Resident #135 on 03/18/25 and 04/18/26. SSD #321 stated care conferences should be held quarterly. 2. Review of medical record for Resident #79 revealed an admission date of 10/14/13 with diagnoses including Alzheimer's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and aphasia. Review of the MDS assessment for Resident #79 dated 02/14/26 revealed the resident was cognitively impaired. Review of the medical record for Resident #79 revealed the facility held care conferences for the resident on 12/24/24, 03/21/25, and 01/23/26. Interview on 04/20/26 at 3:42 P.M. with the Director of Social Services (DSS) #477 confirmed the most recent care conferences for Resident #79 were dated 12/12/24, 03/21/25, and 01/23/26. DSS #477 confirmed no other care conference documentation since 12/12/24 was available for Resident #79, and care conferences should have been held on a quarterly basis. 3. Review of medical record for Resident #1 revealed an admission date of 04/22/25 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and multiple sclerosis. Review of the MDS assessment for Resident #1 dated 02/18/26 revealed the resident was cognitively intact. Review of the medical record for Resident #1 revealed the facility held a care conference for the resident on 04/25/25. Interview on 04/21/26 10:18 A.M. with DSS #477 confirmed 04/25/25 was the only documented care conference in Resident #1's record. 4. Review of medical record for Resident #15 revealed an admission date of 01/16/25 with diagnoses including alcoholic cirrhosis of liver with ascites, type two diabetes mellitus, and hepatic encephalopathy. Review of the MDS assessment for Resident #15 dated 03/09/26 revealed the resident was cognitively intact. Review of the medical record for Resident #15 revealed the facility held a care conference for the resident on 01/25/25. Interview on 04/21/26 at 10:25 A.M. with DSS #477 confirmed the most recent care conference for Resident #15 was held on 01/25/25.

Based on medical record review, staff interview, guardian interview, and review of the facility policy, the facility failed to obtain consent from resident guardians regarding treatment. This affected (Residents #28, #64, #121, and #138) of 27 residents reviewed for consent for treatment. The facility census was 137 residents.Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of 01/27/26 with diagnoses including schizophrenia and type two diabetes. Review of the guardianship form for Resident #28 revealed Resident Guardian (RG) #999 was appointed by the court for the resident on 04/26/24. Review of a consent form for pharmacogenomics testing for Resident #28 dated 11/26/25 revealed RG #999 had not signed the form. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 01/22/26 revealed the resident had intact cognition. 2. Review of the medical record for Resident #64 revealed an admission date of 11/21/23 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type two, and vascular dementia. Review of the guardianship form for Resident #64 revealed RG #999 was appointed by the court for the resident on 05/22/24. Review of a consent form for pharmacogenomics testing for Resident #64 dated 09/25/25 revealed RG #999 had not signed the form. Review of the MDS assessment for Resident #64 dated 03/01/26 revealed the resident had intact cognition. 3. Review of the medical record for Resident #121 revealed an admission date of 03/22/24 with diagnoses including osteoarthritis, hypertension, and Alzheimer's disease Review of the guardianship form for Resident #121 revealed RG #999 was appointed by the court for the resident on 09/11/24. Review of a consent form for pharmacogenomics testing for Resident #121 dated 11/03/25 revealed RG #999 had not signed the form. Review of the MDS assessment for Resident #121 dated 03/22/25 revealed the resident had moderate cognitive impairment. 4. Review of the medical record for Resident #138 revealed an admission date of 09/30/01 with diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, and diabetes mellitus type two. Review of the guardianship form for Resident #138 revealed RG #999 was appointed by the court for the resident on 05/30/07. Review of a consent form for pharmacogenomics testing for Resident #138 dated 09/25/25 revealed RG #999 had not signed the form. Review of the MDS assessment for Resident #138 dated 02/05/26 revealed the resident had severe cognitive impairment. Interview on 04/20/26 at 2:25 P.M with RG #999 confirmed she was the court-appointed guardian for Residents #28, #64, #121, and #138. RG #999 confirmed the facility had not obtained her consent for pharmacogenomics testing for the residents. Interview on 04/21/26 at 7:47 A.M with the Administrator confirmed RG #999 was the court-appointed guardian for Residents #28, #64, #121, and #138. The Administrator confirmed the facility had not obtained the guardian's consent for pharmacogenomics testing for the residents. Review of facility policy titled Consent to Treat revealed the facility should ensure residents' legal representatives are informed of the type of care and services provided within the facility.

Based on observation, staff interview, document review, and review of the facility policy, the facility failed to safely store chemicals on the secured unit. This had the potential to affect seven facility-identified independently mobile and cognitively impaired (Residents #16, #30, #48, #75, #79, #115, #130) who resided on the secured unit. The facility census was 137 residents. Findings include: Observation on 04/19/26 at 12:39 P.M. of the first-floor dining room in the secured unit revealed there were two cans of shaving cream in an unlocked drawer. The label on the shaving cream indicated to avoid spraying in eyes and keep out of reach of children. There was also a bottle of body wash and shampoo with a label indicating to avoid contact with eyes and keep out of reach of children. There was a spray bottle of multi-surface disinfectant in an unlocked lower cabinet with a label with the following warning statements: keep out of reach of children, hazardous to humans and domestic animals, cause moderate eye irritation, avoid contact with eyes and clothing, do not drink. Interview on 04/19/26 at 12:50 P.M. with Registered Nurse (RN) #360 confirmed the shaving cream, body wash/shampoo, and disinfectant spray should be stored in a secured location and should not be accessible to residents. Review of a Safety Data Sheet (SDS) for Ecolab Rapid Multi Surface Disinfectant Cleaner revealed it included the following hazard statements: causes severe skin burns and eye damage, harmful if inhaled, if swallowed immediately call a poison center doctor. Review of facility policy titled Care of Chemical Storage Areas dated 02/01/25 revealed staff should lock chemical storage areas or carts when not in use to prevent unauthorized access.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide nailcare for dependent residents. This affected two residents (#35 and #64) of three residents reviewed for activities of daily living (ADL) care. The facility census was 137 residents.Findings include: 1.Review of the medical record revealed for Resident #35 revealed an admission date of 07/17/24 with diagnoses including paranoid schizophrenia, vascular dementia, post-traumatic stress disorder and obsessive-compulsive disorder. Review of the care plan for Resident #35 dated 07/17/24 revealed the resident had a self-care deficit and required supervision/touching assistance for personal hygiene. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 01/26/26 revealed the resident and required staff assistance with personal hygiene. Observation on 04/20/26 at 10:21 A.M. revealed Resident #35's fingernails were long and had an unknown brown substance under the fingernails. Interview on 04/20/26 at 10:21 A.M. with Resident #35 confirmed the resident wanted staff to trim and clean her fingernails. Interview on 04/20/26 at 3:01 P.M. with Licensed Practical Nurse (LPN) #372 verified Resident #35's fingernails were long, had an unknown brown substance under the nails, and the resident needed staff to perform nailcare. 2. Review of the medical record for Resident #64 revealed an admission date of 11/21/23 with diagnoses including cerebrovascular accident, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and diabetes mellitus type two. Review of the care plan for Resident #64 dated 11/22/23 revealed the resident had a self-care deficit and was dependent on staff for assistance with personal hygiene. Review of the MDS assessment for Resident #64 dated 03/01/26 revealed the resident had intact cognition and was dependent on staff assistance with personal hygiene. Observation on 04/20/26 at 10:46 A.M. revealed Resident #64's left hand fingernails to be long and had an unknown brown substance under the nails. Resident #64's left hand and fingers were contracted, and the resident had to manually use her right hand to pry the left-hand fingers back to be able to view. Interview on 04/20/26 at 10:46 A.M. with Resident #64 confirmed the resident wanted staff to trim and clean the fingernails of her left hand. Interview on 04/20/26 at 3:04 P.M. with LPN #372 verified Resident #64's left hand fingernails were long, with an unknown brown substance under the nails, and the resident needed staff to perform nailcare. Review of the facility policy titled Routine Resident Care undated revealed licensed staff would monitor and assess resident needs. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, vascular dementia, post-traumatic stress disorder and obsessive-compulsive disorder. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment and was frequently incontinent of bowel and bladder. The resident required supervision for eating, oral and personal hygiene and bathing, moderate assistance for toileting, dressing and transfers, and set up assistance for bed mobility. Review of the plan of care for Resident #35 dated 07/17/24 revealed Resident #35 had a self-care deficit and required supervision/touching assistance for personal hygiene. Observation on 04/20/26 at 10:21 A.M. revealed Resident #35's fingernails to be long and with an unknown brown substance under the nails. Interview on 04/20/26 at 10:21 A.M. with Resident #35 revealed the resident wanted her fingernails to be cut and cleaned. Interview on 04/20/26 at 3:01 P.M. with Licensed Practical Nurse #372 verified Resident #35's fingernails were long, with an unknown brown substance under the nails, and in need of nailcare. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of cerebrovascular accident with left (non-dominant) side hemiplegia/hemiparesis, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type II, pseudobulbar affect and vascular dementia. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #64 had intact cognition and was always incontinent of bowel and bladder. The resident required supervision for eating and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Review of the plan of care for Resident #64 dated 11/22/23 revealed Resident #64 had a self-care deficit and was dependent for personal hygiene. Observation on 04/20/26 at 10:46 A.M. revealed Resident #64's left hand fingernails to be long and with an unknown brown substance under the nails. The hand and fingers were contracted, and the resident had to manually use her right hand to pry the left-hand fingers back to be able to view. The resident also stated she had a splint for her left hand that the staff never put on her. The resident said the splint was in the bottom drawer of her bedside dresser. Observation revealed the splint in the bottom drawer of the bedside dresser. Interview on 04/20/26 at 10:46 A.M. with Resident #64 revealed the resident wanted her left-hand fingernails to be cut and cleaned and her splint to be applied. Interview on 04/20/26 at 3:04 P.M. with Licensed Practical Nurse #372 verified Resident #64's left hand fingernails were long, with an unknown brown substance under the nails, and in need of nailcare. Review of the policy titled, Routine Resident Care, undated, revealed licensed staff will include the following services based upon their scope of practice, but not limited to monitoring and assessment of resident needs

Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents received care and services for management of contractures and decreased range of motion. This affected three (Residents #65, # 41 and #2) of three residents reviewed for range of motion services. The facility census was 137 residents.Findings include: 1. Review of the medical record for Resident #64 revealed an admission date of 11/21/23 with diagnoses including cerebrovascular accident, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and diabetes mellitus type two. Review of the care plan for Resident #64 dated 11/22/23 revealed the resident had a self-care deficit and was dependent on staff for assistance with personal hygiene. On 04/21/26 an intervention was added for the resident to wear left resting hand splint for six to eight hours as tolerated (may use wash cloth if hand splint is not present). Review of occupational therapy (OT) evaluation for Resident #64 dated 04/12/24 to 05/11/24 revealed goals of therapy were for the resident to complete passive range of motion to left upper extremity in all joints with fair positive tolerance to decrease the risk for contractures and assist with pain management, and for the resident to tolerate a left resting hand splint for up to three hours without pain/irritation noted to increase independence with activities of daily living (ADLs). Review of the physician's orders for Resident #64 revealed an order dated 07/23/24 for the resident to wear a left resting hand splint for six to eight hours as tolerated (may use wash cloth if hand splint is not present) every shift. Review of the Minimum Data Set (MDS) assessment for Resident #64 dated 03/01/26 revealed the resident had intact cognition and was dependent on staff assistance with personal hygiene. Review of the Treatment Administration Record (TAR) for Resident #64 dated April 2026 revealed the left hand splint was checked off as applied for 04/20/26. Observation on 04/19/26 at 9:04 A.M. revealed Resident #64 was lying in bed without a splint on her left hand, and the splint was in the resident's bedside dresser drawer. Interview on 04/19/26 at 9:04 A.M. with Resident #64 confirmed the splint for her left hand was in the bottom drawer of the resident's bedside dresser, and the resident would like the splint to be applied. Interview on 04/19/26 at 9:05 A.M. with Licensed Practical Nurse (LPN) #372 confirmed Resident #64's left hand splint was not in place. Observation on 04/20/26 at 11:13 A.M. revealed Resident #64 was up in the wheelchair without a splint on her left hand and the splint remained in the resident's bedside dresser drawer. Interview on 04/20/26 at 11:13 A.M. with Resident #64 confirmed the splint for her left hand was still not in place and remained in the resident's bedside dresser drawer. Observation on 04/20/26 at 12:32 P.M. revealed Resident #64 was in her wheelchair in the dining room, and the left resting hand brace was not in place. LPN #372 placed a rolled-up washcloth in Resident #64's left hand. Interview on 04/20/26 at 12:32 P.M. with LPN #372 confirmed Resident #64's left hand splint was not in place. LPN #372 verified the resident's TAR documented the splint as being applied. Interview on 04/21/2026 at 7:32 A.M. with Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator #425 verified Resident #64's plan of care made no mention of a left hand/wrist contracture and no identified intervention of a left resting hand splint and/or rolled up washcloth in place of the splint. LPN MDS #425 also verified Resident #64 had no contracture diagnosis, and it was the responsibility of the physician to provide the diagnosis. Interview on 04/21/26 at 10:28 A.M. with the Director of Nursing (DON) verified Resident #64 had no diagnosis of contracture in the medical record. Observation on 04/21/26 at 11:35 A.M. revealed Resident #64 was in her wheelchair in the dining room with no splint on her left hand. LPN #328 placed a rolled-up washcloth in the resident's left hand. Interview on 04/21/26 at 11:35 A.M. with LPN #328 verified Resident #64's left resting hand splint was not in place. Observation on 04/22/26 at 8:55 A.M. revealed Resident #64 was lying in bed without a splint on her left hand, and the splint was in the resident's bedside dresser drawer. Interview on 04/22/26 at 8:55 A.M. with Resident #64 confirmed the splint for her left hand was in the bottom drawer of the resident's bedside dresser Interview on 04/22/26 at 8:57 A.M. with LPN #372 verified Resident #64's left hand splint was not in place. 2. Review of the medical record for Resident #41 revealed an admission date of 10/05/21 with diagnoses including bipolar disorder, dementia, peripheral vascular disease, and contracture of right and left hand. Review of the MDS assessment for Resident #41 dated 04/05/26 revealed the resident #41 was cognitively intact and required supervision with activities of daily living. (ADLs) Interview on 04/19/26 at 10:14 A.M with Resident #41 confirmed he had limitations with both of his hands and his left hand was more affected than his right hand. Interview on 04/21/26 at 1:37 P.M. with Unit Manager (UM) #360 confirmed she was unaware of Resident #41's contractures. Interview on 04/21/26 at 4:17 P.M. with Clinical Manager (CM) #325 confirmed she managed the facility's restorative program and the resident has not received restorative services. Interview on 04/22/26 at 2:05 P.M. with Occupational Therapist (OT) #465 confirmed therapy had not treated Resident #41 for contractures. OT #465 confirmed she assessed Resident #41 on 04/22/26 and determined the resident had bilateral contractures of the upper extremities and should be treated for them. 3. Review of the medical record for Resident #2 revealed an admission date of 12/16/25 with diagnoses including chronic respiratory failure, contracture of left hand, and functional quadriplegia. Review of the MDS assessment for Resident #2 dated 03/14/26 revealed the resident had moderate cognitive impairment, was dependent on staff for assistance with ADLs, and had mobility impairments on both sides of upper and lower body. Review of the care plan for Resident #2's dated 04/16/26 revealed there were no interventions in place to prevent worsening of the resident's contracted left hand. Observation on 04/21/26 at 12:36 P.M. revealed Resident #2 was lying in bed, and the resident's left hand was visibly contracted. Resident #2 did not have any assistive devices in place to treat or manage the contracture. Interview on 04/21/26 at 12:36 P.M. with LPN #338 confirmed Resident #2's left hand was visibly contracted, and she was not aware of any interventions to treat or manage the contracture. Interview on 4/21/26 at 1:46 P.M. with Registered Nurse (RN) #374 confirmed Resident #2's left hand was visibly contracted and the facility had not implemented interventions to treat and manage the contracture and prevent it from worsening. Review of facility policy titled Plan of Care Overview undated revealed members of the care planning team would coordinate care to meet the resident's care needs.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents with orders for contact precautions. This affected two residents (Resident #77 and #131) of seven residents reviewed for infection control. The facility also failed to ensure staff practiced appropriate hand hygiene during incontinence care. This affected one resident (Resident #123) of seven residents reviewed for infection control. The facility census was 137 residents. Findings include: 1.Review of the medical record for Resident #77 revealed an admission date of 06/13/22 with diagnoses including hypertensive heart disease, chronic kidney disease, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #77 dated 04/12/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #77 revealed an order dated 04/13/26 for the resident to be on contact isolation until 04/20/26 related to an escherichia coli (e-coli) infection. Review of the care plan for Resident #77 dated 04/19/26 revealed the resident had a urinary tract infection (UTI). Interventions included the resident should be maintained on contact precautions. Observation on 04/19/26 at 12:40 P.M. revealed the door to Resident #77's room displayed a sign indicating the resident was contact precautions and staff should don a gown and gloves before entering the room. There was a storage unit outside Resident #77's door which contained gowns and gloves. Observation on 04/19/26 at 1:06 P.M. revealed Certified Nursing Assistant (CNA) #309 entered Resident #77's room and removed Resident #77's lunch tray without donning a gown and gloves prior to entering the room. Interview on 04/19/26 at 1:06 P.M. with CNA #309 verified she did not don a gown and gloves before entering Resident #77's room. CNA #309 further verified the door to Resident #77's room had a sign to indicate the resident was under contact precautions. 2. Review of the medical record for Resident #131 revealed admission date of 8/28/25 with diagnoses including spinal stenosis, major depressive disorder, and chronic kidney disease stage two. Review of the MDS assessment for Resident #131 dated 3/12/26 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the physician's orders for Resident #131 revealed an order dated 04/22/26 for contact precautions due to e an e coli infection in the urine. Observation on 4/21/26 at 8:18 A.M. revealed CNA #430 entered Resident #131's room to provide personal hygiene care and did not don a gown and gloves prior to entering the room. There was a sign on Resident #131's door indicating all care providers should don gloves and a gown before entering the room. Interview on 4/21/26 at 8:26 A.M. with CNA #430 confirmed he had not donned a gown and gloves prior to entering Resident #131's room to provide care. Interview on 04/21/26 at 10:36 A.M. with the Director of Nursing (DON) verified staff should don a gown and gloves before entering the room of a resident on contact precautions. Review of the facility policy titled Standard Precautions and Transmission-Based Precautions dated 07/22/19 revealed staff should don a gown and gloves prior to contact with a resident or the resident's environment for residents under contact precautions. 3. Review of the medical record for Resident #123 revealed an admission date of 03/08/22 with diagnoses including schizoaffective disorder, chronic viral hepatitis C, and history of methicillin resistant staphylococcus aureus infection. Review of the MDS assessment for Resident #123 dated 01/29/26 revealed the resident had intact cognition and was dependent on staff for ADL care. Observation on 04/22/26 at 9:07 A.M. of incontinence care for Resident #123 per CNA #444 revealed the aide placed clean washcloths in the bathroom sink and then washed her hands over the sink. CNA #444 placed the wet washcloths on the bedside table and donned clean gloves. CNA #444 removed the resident's soiled brief and provided incontinence care. During incontinence care CNA #444 placed additional washcloths in the sink, grabbed the bottle of soap, and turned on the faucet while still wearing the soiled gloves. CNA #444 then turned off the faucet and continued incontinence care. Interview on 04/22/26 at 9:21 A.M with CNA #444 confirmed they placed clean washcloths in Resident #123's bathroom sink and washed their hands over the sink. CNA #444 confirmed when her gloves became soiled she did not remove them and perform hand hygiene before continuing with care. Interview on 04/22/26 at 9:30 A.M with the DON confirmed staff should remove gloves and perform hand hygiene when gloves become soiled.

Based on observation, staff interview, and policy review, the facility failed to ensure residents had visual privacy in their bedroom. This affected two residents (Resident #15 and #147) of three residents reviewed for the physical environment. The facility census was 137 residents. Findings include: Observation on 04/19/26 at 10:18 A.M. revealed there no privacy curtains were in place in the double occupancy room of Residents #15 and #147. Interview on 04/19/26 at 10:20 A.M. with Medication Technician (MT) #418 verified no privacy curtains were present in the double occupancy room of Residents #15. Review of facility policy titled Resident Rights revealed residents had the right to visual privacy. This deficiency represents noncompliance investigated under Complaint Number 2606421.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on personnel record review, review of criminal background check records, staff interview and review of the facility policy, the facility failed to complete background checks upon hire for new employees. This had the potential to affect all of the residents residing in the facility. The facility census was 137 residents. Findings include:Review of the facility Bureau of Criminal Investigation (BCI) log dated 08/05/25 revealed BCI and Federal Bureau Investigation (FBI) checks had be completed for all new employees. Review of facility personnel records revealed the following staff had not had background checks completed upon hire: Housekeeper #50 hired 05/11/23, Housekeeper #52 hired 05/21/24, Certified Nursing Assistant (CNA) #22 hired 02/15/23, CNA #23 hired 09/26/23, CNA #40 hired 05/10/23, CNA #42 hired 10/23/24, CNA #46 hired 06/12/24, Med Tech (MT) #44 hired 02/21/23, Maintenance Director (MD) #28 hired 05/13/23, Dietary Aide (DA) #56 hired 08/24/23, DA #59 hired 03/09/23, DA #55 hired 06/25/24, DA #63 hired 02/06/25, Administrator hired 02/18/25. During an interview on 08/05/25 at 1:30 P.M., the Administrator verified the facility had not completed BCI and FBI checks for the following new hires: Housekeepers #50 and #52, CNAs #22, #23, #40, #42, and #46, MT #44, MD #28, DAs #56, 59, #55, #63, Administrator. During an interview on 08/06/25 at 4:54 P.M., Employee Lifecycle Manager (ELM) #65 reported it was the facility policy to complete BCI and FBI checks prior to employees being hired. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property dated 05/13/09 revealed the facility employed properly screened persons as a part of the resident care team. The facility would perform an extensive background check for potential employees, which included a BCI and FBI check. Review of the facility's corrective action plan, completed by the Administrator revealed the following actions were implemented and the deficiency was corrected on 06/02/25. On 03/26/25, the Director of Nursing (DON) completed comprehensive abuse questionnaire interviews with residents, with no additional findings. On 03/26/25, the DON performed thorough head-to-toe assessments on residents with severe cognitive impairment who could not provide meaningful information with no new injuries identified. On 03/26/25, the Administrator terminated Human Resource Manager (HRM) #70 because the employee had failed to ensure appropriate background checks for new hires. On 03/26/25, the Administrator conducted a comprehensive, facility-wide audit of staff. Employees found to be noncompliant with background check requirements were promptly removed from the schedule until their BCI checks were successfully completed. By 04/01/25, all identified employees had obtained valid BCI checks with no further findings. On 06/02/25, the Administrator provided education to the new Employee Life Cycle Manager (ELM) #65 who replaced HRM #70 regarding Ohio law requirements for background and abuse checks to ensure full compliance moving forward. To maintain ongoing compliance the Administrator or designee will monitor the completion of BCI checks for new employees on a weekly basis for the next six months. Audit results will be reviewed by the QAPI team initially for two months and subsequently on a monthly basis as needed, to ensure sustained adherence to all regulatory requirements. This deficiency represents noncompliance investigated under Complaint Number OH00164949 (IQIES Number 1351270).

Based on record review, observation, staff interviews, and policy review the facility failed to ensure physician orders were timely clarified to prevent a delay in medication administration. This affected one (#37) resident of the three residents reviewed for medication administration. The facility census was 140. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), tubular interstitial nephritis, diabetes mellitus, morbid obesity, paraplegia, major depressive disorder and retention of urine. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Review of the physician order dated 09/06/24 for Resident #37 revealed the resident was ordered Bactrim double strength (DS) (Sulfamethoxazole-Trimethoprim) 800-160 milligrams (mg) (antibiotic) two times a day (8:00 A.M. and 5:00 P.M.) for infection until 09/14/24. Review of a nurse's progress note dated 09/06/24 at 736 P.M. revealed Resident #37 was ordered Bactrim DS for seven days. Review of additional nurse's notes revealed no documentation regarding the resident not receiving the Bactrim on 09/07/24 and 09/08/24. Review of the September 2024 medication administration record (MAR) for Resident #37 reveled on 09/07/24 at 8:00 A.M. and 5:00 P.M. was marked with a 5 indicating hold /see nurses notes On 09/08/24, the 8:00 A.M. dose was recorded as being administered and the 5:00 P.M. was recorded with a 5. Interview via phone on 10/23/24 at 8:19 A.M. with Pharmacy Technician #508 revealed a pharmacist entered a note where he called the facility on 09/06/24 and talked to Registered Nurse (RN) #115 informing her of Resident #37's Bactrim would not be sent to the facility due to the resident's recorded sulfacetamide allergy and the facility needed to call the provider to get clarification. RN #115 noted she would contact the provider and get clarification. Interview via phone on 10/23/24 at 10:24 A.M. with RN #115 revealed she talked with a pharmacist on 09/06/24 about Resident #37's Bactrim order and she would call the provider and get another medication due to the allergies on file. RN #115 stated she called the on-call provider; however, the provider would not order a new antibiotic. Interview via phone on 10/23/24 at 11:16 A.M. with LPN #101 revealed she did not give the two ordered doses Bactrim to Resident #37 on 09/07/24 due to not being available. LPN #101 stated the facility was awaiting delivery from the pharmacy and then forgot to follow up on the medication orders. Review of the Medication Administration (dated 2013) revealed it is the policy of this facility to provide resident centered care that's meets the psychosocial, physical, and emotional needs and concerns of the residents. This deficiency represents non-compliance investigated under Complaint Number OH00158589.

Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 137 residents in the facility. Findings Included: Review of the [NAME] PBJ staffing data report revealed the facility triggered for excessively low weekend staffing and a one star staffing rating for fiscal year quarter two of 2023. Interview with [NAME] President Analytics (VPA) #201 on 11/20/23 at 4:12 P.M. revealed the facility submitted the PBJ in the second quarter of 2023 and CMS has the wrong information. VPA #201 indicated the corporate team was working on the PBJ report and would resubmit it to CMS for the second quarter.

Based on record review, staff interviews, and review of facility policies, the facility failed to ensure a fall was thoroughly investigated, accurately documented, and fall interventions were implemented to prevent additional falls. This affected one (#04) of the nine residents reviewed for accident hazards. The facility also failed to ensure residents were supervised while smoking, failed to ensure residents smoked safely and failed to ensure residents were assessed for smoking. This affected four (#10, #95, #04, and #187) of the nine residents reviewed for accident hazards. The facility census was 137. Findings include: 1) Review of the medical record for Resident #04 revealed he was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure, vascular dementia moderate with other behavioral disturbance, other intervertebral disc degeneration, peripheral vascular disease, unspecified protein-calorie malnutrition, personality disorder, mixed hyperlipidemia, polyosteoarthritis, paranoid schizophrenia, vitamin d deficiency, and aphasia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04 revealed the resident had significantly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require extensive assistance of two for activities of daily living (ADLs). Review of the plan of care revised on 09/21/22 revealed Resident #04 was at risk for falls related to impaired judgement and safety awareness, gait problems, impaired mobility, weakness, frequently attempted self-transfer, and resistive to fall interventions. Interventions included for the bed to be in the lowest position, the room free of accident hazards, resident to wear non-skid footwear, the call light within reach, and review the past falls and implement interventions as ordered. Review of the nurse's progress note dated 01/29/23 at 6:00 P.M. and recorded as a late entry, revealed Resident #04 was observed sitting in the hallway in front of his wheelchair in an upright position from an unwitnessed fall. The resident was assessed to have increased confusion and decreased oxygen saturation. Resident #04 stated he was picking up a soda bottle that he dropped when he fell . Resident #04 reported no pain, and the resident was assisted back in wheelchair with assistance of two staff members. Oxygen was applied to the resident and new orders were received to obtain a chest X-ray, laboratory (labs) tests and neurological (neuro) checks were started. The nurse's progress note revealed no documented evidence of any fall interventions being implemented. Review of a post fall evaluation/notification dated 01/29/23 at 6:00 P.M. for Resident #04, revealed the resident had unwitnessed fall and had no injuries or pain as result of fall. The post fall evaluation/notification revealed no documented evidence of any fall interventions being implemented. Review of the Situation Background Assessment Recommendation (SBAR) electronic interaction (eINTERACT) summary for providers dated 01/29/23 at 6:00 P.M. for Resident #04, revealed the resident had a change in condition related to falls. The SBAR revealed no documented evidence of any fall interventions being implemented. Review of a facility incident report indicated on 01/29/23 at 6:00 P.M. Resident #04 had an unwitnessed fall and was found in the hallway sitting on his buttocks in front of his wheelchair. Resident #04 stated he was trying to pick up a pop bottle. Resident #04 was assessed with no pain with range of motion assessment. The resident was placed back in his wheelchair. The resident was noted to be more confused with a decreased oxygen saturation level. The incident report revealed no documented evidence of any fall interventions being implemented. Review of the physician's progress note dated 01/30/23 at 8:18 A.M for Resident #04, revealed the resident complained of shortness of breath over weekend and a chest x-ray and labs were ordered. The resident's x-ray showed pneumonia. The physician's progress noted revealed no documentation about the resident's fall on 01/29/23. Review of the Interdisciplinary Team (IDT) progress note dated 02/01/23 at 8:50 A.M. for Resident #04 revealed the resident had a fall with no injury from leaning forward in his chair. The Root cause of the incident indicated the resident had an altered mental status and confusion. Interventions put in place were chest x-ray and labs. The IDT Team progress note revealed no documented evidence that the facility implemented any fall interventions for Resident #04. Review of the physician's progress note dated 02/01/23 at 11:31 A.M. for Resident #04 revealed the resident had a follow up for pneumonia. The physician's progress note revealed no documentation about the resident's fall on 01/29/23. Review of the nurse's progress notes from 02/01/23 through 02/09/23 revealed no documented evidence of Resident #04 falling or other related incidents related to an injury. Review of a facility incident report dated 02/09/23 and authored by Director of Nursing (DON) revealed Resident #04 had an unwitnessed fall in the resident's room on 02/09/23 at 6:15 P.M. The resident was found sitting on the floor in his room. The resident was assessed to have left hip pain when range of motion assessment was performed. Resident #04 was placed back in bed and a skin grid sheet was initiated. The follow up note entered by the DON on 02/16/23 at 3:18 P.M. revealed when STNA was performing incontinence care (on 02/10/23), the resident was screaming in pain. The nurse noted an abnormal appearance and bruising. 911 was called and a resident was sent to the hospital for evaluation. Review of the SBAR eINTERACT form dated 02/10/23 at 3:44 P.M. for Resident #04, revealed the resident had uncontrolled pain and a skin wound on right front thigh related to a fall and resident was sent to the ER. Review of the nurse's progress note dated 02/10/23 at 3:52 P.M. for Resident #04, revealed a STNA informed the nurse that Resident #04 was screaming out in pain during incontinence care. The nurse assessed Resident #04 and noted Resident #04's left hip appeared abnormal and had bruising to right lower extremity. Resident #04 reported pain level was a 10 out of 10 (scale of pain where zero is no pain and 10 is extreme pain), and emergency services were called to transport Resident #04 to the hospital for evaluation. Review of a facility incident report dated 02/10/23 at 3:25 P.M. revealed an unusual occurrence in the resident room. Resident #04 was assessed with increased pain and bruising to right inner thigh and decreased range of motion to the right lower extremity and the resident was sent to the hospital. Resident #04 was noted with fall on 01/29/23. Resident #04 was diagnosed with an acute displaced intertrochanteric fracture proximal left femur. The Incident report did not mention the resident's fall on 02/09/23 at 6:00 P.M. Review of the IDT progress note dated 02/10/23 at 5:42 P.M. and recorded as a late entry, revealed Resident #04 had bruising, pain, and decreased range of motion while receiving peri-care and refused to allow peri-care due to the pain. The nurse assessed resident legs to have bruising. The root cause of incident was noted to be a fall on 01/29/23 with injury and resident had a delayed response to feeling pain and reported pain due to medication received to suppress injury (prednisone [steroid]). Interventions revealed resident was sent to hospital for evaluation and treatment. There is no mention of the resident's fall on 02/09/23. Review of the nurse's progress note dated 02/11/23 revealed Resident #04 had a left hip fracture and would be having surgery on 02/12/23. Interview with the with the Director of Nursing (DON) on 11/29/23 at 1:18 P.M. confirmed Resident #04 had a fall on 01/29/23 and the facility implement interventions for a chest x-ray and labs to be completed. The DON also confirmed the resident had another fall on 02/09/23 when an agency nurse was on duty. The DON stated he advised the agency nurse to complete her investigation on paper because of the limited access to their risk management in the electronic health record. A follow-up interview with the DON on 11/29/23 at 3:21 P.M. confirmed there was no documentation related to Resident #04's fall on 02/09/23 in the resident electronic health record. The DON also verified the incident report completed on 02/09/23 lacked a thorough summary of the incident. The DON acknowledged the IDT follow-up on 02/10/23 failed to address the resident's fall on 02/09/23. The DON also verified there were no fall interventions placed for resident after the resident fell on [DATE] and again on 02/09/23. Review of the facility policy titled Fall Prevention and Management, revised 06/01/22, revealed the interdisciplinary team should review information for all falls at the next Daily Clinical Meeting. The team should discuss the fall, potential causes, interventions, and a deep root cause investigation should be discussed. A progress note of the discussion should be placed in the resident's chart. 2) Review of the medical record for Resident #10 revealed he was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder bipolar type, type two diabetes mellitus without complications, cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, vascular dementia moderate with other behavioral disturbance, bipolar disorder, peripheral vascular disease, major depressive disorder, generalized anxiety disorder, and delusional disorders, Review of the quarterly MDS assessment dated [DATE] for Resident #10, revealed the resident had intact cognition evidenced by a BIMS score of 13. This resident was assessed to require extensive assistance for ADLs. Review of the plan of care revised on 06/12/23 revealed Resident #10 utilized nicotine products and had a history of non-compliance with the smoking policy. Interventions included complete smoking evaluation, educating resident/resident representative on smoking policy, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #10 required supervision while smoking. Observation on 11/28/23 at 11:08 A.M. of Resident #10 revealed he was outside the facility entrance smoking with no staff present. Interview at the time of the observation with Nursing Staff Scheduler #149 confirmed Resident #10 was smoking outside the facility entrance by himself and not in the designated smoking area. Nursing Staff Scheduler #149 reported the aide that was supervising the smoke area had gone to the bathroom. Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, vascular dementia, psychotic disturbance, mood disturbance, and anxiety, hypertension, cardiomyopathy, and insomnia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #95 had severely impaired cognition evidenced by a BIMS score of 06. This resident was assessed to require supervision for ADLs. Review of the plan of care revised on 04/18/22 revealed Resident #95 utilized nicotine products and had a history of concealing smoking materials and attempting to smoke inside the facility. Interventions included complete smoking evaluation, educating resident/resident representative on the smoking policy, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #95 required supervision while smoking. Observation on 11/28/23 at 11:08 A.M. of Resident #95 revealed the resident was outside the facility smoking with no staff present. Interview at the time of the observation with Nursing Staff Scheduler #149 confirmed Resident #95 was outside smoking. Nursing Staff Scheduler #149 reported the aide that was supervising the smoke area had gone to the bathroom. Review of the medical record for Resident #04 revealed he was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure, vascular dementia moderate with other behavioral disturbance, other intervertebral disc degeneration, peripheral vascular disease, personality disorder, polyosteoarthritis, paranoid schizophrenia, and aphasia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #04 had significantly impaired cognition evidenced by a BIMS score of 06. This resident was assessed to require extensive assistance or supervision for ADLs. Review of the plan of care revised on 08/23/22 revealed Resident #04 utilized nicotine products. Interventions included complete smoking evaluation, educating resident/resident representative on smoking policy, smoke apron while smoking as ordered, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #04 required supervision and a smoking apron while smoking. Observation on 11/28/23 at 11:11 A.M. of Resident #04 revealed he was smoking without a smoking apron on and no staff present. Immediately after the observation, State tested Nursing Assistant (STNA) #19 arrived in the area and confirmed Resident #04 was smoking without utilizing a smoking apron. Review of the facility policy titled Resident Smoking, reviewed 05/30/19, revealed a smoking apron is a fire-resistant apron used to cover the torso or body and lap to aid in preventing cigarettes ashes or dropped cigarettes from igniting clothing. The policy indicated smoking would only be in designated areas and supervised smoking would be performed by a staff member. 35770 A chart review revealed Resident #187 was admitted on [DATE]. Diagnoses included mood disorder, brain cancer, insomnia, suicidal behaviors, depression, bilateral below the knee amputation, and anxiety. Review of MDS assessment dated [DATE] revealed Resident #187 had mild cognitive impairment and required limited to moderate assistance with ADLs. Review of care plan dated 11/10/23 revealed Resident #187 utilized nicotine products with an intervention dated 11/10/23 to complete a smoking evaluation. Review of medical record for Resident #187, revealed no documented evidence of a smoking assessment being completed. An interview on 11/27/23 at 4:54 P.M. with Resident #187 stated that the facility told him he would be able to smoke whenever he wanted, and after he was admitted they changed the rules and he had to wait for smoke times. An interview on 11/30/23 at 10:33 A.M. with the Director of Nursing verified Resident #187 had no smoking evaluation completed. Review of Resident Smoking Policy (dated 05/30/19) revealed assessment, observation, and designation of independent or supervised smoker will be made by the interdisciplinary team for each resident who requests to smoke in the facility with the screening in the electronic medical record system.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident's advanced directives were accurately reflected in the clinical record. This affected one (#127) of the 32 residents reviewed for advanced directives. The facility census was 137. Findings included: Review of the medical record for Resident #127 revealed the resident was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, protein-calorie malnutrition, fracture of the upper end of the right humerus, tobacco use, seizures, functional urinary incontinence, cerebral infarction, occlusion and stenosis of the left carotid artery, dysphagia following cerebral infarction, hypertension, and facial weakness following cerebral infarction. Review of the paper chart for Resident #127 revealed the resident had a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated [DATE]. Review of the electronic medical record (EMR) on [DATE] at 12:20 P.M. revealed the resident had an order for cardiopulmonary resuscitation (CPR). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #127, revealed a Brief Interview for Mental Status (BIMS) score of four indicating she had severe cognitive impairment. Review of the care plan for Resident #127 revealed the resident had a CPR code status. One of the interventions included obtaining a medical provider order for a code status. Interview with Registered Nurse Unit (RN) Manager #80 on [DATE] at 10:30 A.M. verified Resident #127's orders did not match the signed advanced directives. Review of the undated facility policy titled Advance Directive (Resident's Right to Choose) revealed any decision making regarding the resident's choice in their medical order for life-sustaining treatment and/or their advanced directive will be documented in the resident's medical record.

Based on observations, staff interview, medical record review and review of facility policy, the facility failed to ensure dependent residents were provided with effective grooming. This affected one (#86) of the four residents reviewed for the provision of activities of daily living (ADLs). The facility census was 137. Findings Included: Review of medical record for Resident #86 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), bipolar disorder, and malignant neoplasm of upper lobe left, secondary malignant neoplasm of brain. Review of the plan of care dated 07/28/23 revealed that Resident #86 had an ADLs self-care performance deficit related to signs and symptoms of involving musculoskeletal system, chronic pulmonary disease, migraines, fatigue, unsteadiness on feet, and poor motivation towards self-care. Interventions included staff to provide all assistance with showers/grooming. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #86 revealed the resident had a Brief Interview of Mental Status (BIMS) of 11 which indicated the resident was cognitively impaired. Resident #86 was dependent for showers /bathing and personal hygiene. Observation and interview with Resident #86 on 11/28/23 at 10:00 A.M. revealed the resident who was lying in bed with a facility gown on and had numerous dark facial hairs on her chin which were approximately one and a half inches in length. Resident #86 stated it had been a while since her chin hair had been addressed. Observation of Resident #86 on 11/29/23 at 1:30 P.M. with Certified Nurse Aid (CNA) #28 verified Resident #86 had chin hair and stated the resident was not bothered by it. Observation of Resident #86 on 11/30/23 at 11:00 A.M. revealed the resident was lying in her room in bed and her facial hair was still present. Interview with Resident #86 on 11/30/23 at 11:30 A.M. along with Licensed Practical Nurse (LPN) #95 who asked Resident #86 if she wanted her facial hair on her chin plucked with tweezers. Resident #86 reported she wanted her chin hair plucked out. LPN #95 stated she was not able to find any tweezers, so she would offer to shave resident's chin hair. Resident #86 stated she would like her chin hair removed. Review of facility policy undated titled Routine Resident Care revealed the facility would promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs, and honor resident lifestyle preferences while in the care of the facility.

Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected three (#95, #50 and #16) of five residents reviewed for unnecessary medications. The facility census was 137. Findings include: 1) Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypertension, cardiomyopathy, hyperlipidemia, and insomnia. Review of the plan of care initiated on 04/18/22 for Resident #95, revealed the resident had pain related to generalized body pains, osteoarthritis, and muscle weakness. Interventions included following physician orders for complaints of pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #95, revealed the resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 06. Review of the active physician orders dated 10/12/23 for Resident #95 revealed an order for Diclofenac Sodium external gel one percent to be applied to lower back topically every six hours as needed for pain. Review of the Pharmacist's Medication Regimen Review to the Physician/Prescriber dated 10/17/23 for Resident #95, revealed a recommendation to clarify the Diclofenac gel order and update the electronic health record for reflect dosage in grams. The recommendation was reviewed and approved by the physician on 10/20/23 and indicated the dosage in grams should be two grams. Interview on 11/30/23 at 4:04 P.M. with Regional Director of Clinical Operations (RDCO) #200 confirmed the physician's order for Diclofenac Sodium external gel was never updated per the pharmacist's recommendations to reflect the dosage in grams. 35770 2) Review of the clinical record revealed Resident #50 was admitted to the facility originally on 01/20/23 and was readmitted on [DATE]. Her diagnoses included, but was not limited to, hypothyroidism, thyrotoxicosis with diffuse goiter, and myxedema coma. Review of the quarterly MDS assessment dated [DATE]. She had a BIMS score of 10 indicating she had moderate cognitive impairment. Review of the Pharmacist's Medication Regimen Review recommendations dated 10/17/23 for Resident #50, revealed the resident had an elevated thyroid stimulating hormone (TSH) (laboratory blood test to show the levels of thyroid hormone in the blood) in July 2023. The Pharmacist recommended another TSH level to be completed. Review of the active November 2023 physician's orders for Resident #50's, revealed the resident was ordered Levothyroxine Sodium oral tablet 150 micrograms (mcgs) by mouth each morning for hypothyroidism before breakfast. An additional order on 10/2/23/23 revealed the resident was ordered to have TSH level completed. Review of the laboratory (lab) results for Resident #50 revealed no documented evidence that a TSH level was completed per the physician's orders on 10/23/23 and there was no documentation of the resident refusing the lab test. Interview was conducted with the Director of Nursing (DON) on 11/30/23 at 3:22 P.M., verified the TSH levels for Resident #50 was not completed and there was no evidence that the resident refused to have the lab test completed. 44069 3) Review of the medical record for Resident #16 revealed the resident was admitted on [DATE]. Diagnoses included congestive heart failure, paranoid schizophrenia, depression, mood disorder, psychotic disturbance, and delusional disorders. Review of active physician orders dated 02/03/22 for Resident #16 revealed the resident was ordered Ventolin Inhaler as needed (PRN) (rescue inhaler for respiratory issues). The Ventolin inhaler was not discontinued until 11/30/23 when a Surveyor questioned the order. Review of the September 2023 Pharmacist's Medication Regimen Review recommendations for Resident #16, revealed the resident had an active order for Ventolin Inhaler (inhaler for respiratory issues) as needed (PRN) that had not been used since it was ordered on 02/03/23 and in effort to reduce polypharmacy, the order should be reviewed and discontinued. The physician signed and approved the Pharmacist's recommendations on 09/28/23. Interview on 11/30/23 at 1:29 P.M. with the DON verified the order to discontinue Ventolin was missed and should have been discontinued in the month of September 2023. Review of the undated facility policy titled Medication Regimen Review revealed the pharmacist would report any irregularities to the attending physician, facility's medical director and director of nursing, and the reports must be acted upon in a timely manner that meets the needs of the residents.

Based on observations, medical record review, and staff interview the facility failed to serve lunch in a family style manner. This affected one (#117) of the 37 residents observed during the lunch meal service. The facility census was 137. Findings include: Review of medical record for Resident #117, revealed the resident was admitted on [DATE]. Diagnosis including schizophrenia, anxiety, hallucinations, and depression. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had no cognitive impairment and is independent with activities of daily living (ADLs). Observation of the lunch trays being served on 11/27/23 at 12:44 P.M., revealed Resident #117 was sitting at a table that was served first and everyone at the table was served except for Resident #117. The staff proceeded to serve the other three tables and then sat down to feed the residents that needed assistance and Resident #117 still had not received a tray. When surveyor questioned the staff about a tray for Resident #117, the staff provided Resident #117 with a tray. Interview on 11/27/23 at 12:53 P.M. with State tested Nursing Assistant (STNA) #43 verified that Resident #117 did not receive his tray due to not being in the dining room while tickets were being set up.

Based on record review, staff interview, and policy review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) was completed correctly to include a mental health diagnosis. This affected one (#74) of five residents reviewed for PASARR. The facility census was 137. Findings include: Review of the medical record for Resident #74 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, type two diabetes mellitus without complications, hypertensive heart and chronic kidney disease with heart failure, venous insufficiency, and anemia. Review of the history and physical dated 05/06/22 revealed Resident #74 had a diagnosis of schizophrenia. Review of the PASARR dated 05/09/22 indicated Resident #74 had no indications of serious mental illness, such as schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #74 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Interview on 11/30/23 at 11:09 A.M. with Assistant Business Office Manager (ABOM) #13 verified Resident #74 had a diagnosis of schizophrenia in the electronic health record that she was unaware of, which had not been marked on the PASARR completed on 05/09/22. Review of the facility policy titled PASARR - Pre-admission Screening and Resident Review, reviewed 08/11/20, revealed all individuals that applied for admission to a Medicaid certified nursing facility must be screened for a PASARR disability whether they have such a disability and, if so, whether they need specialized services to address their PASARR related needs.

Based on record review and staff interview the facility failed to ensure care conferences were completed. This affected two (#117 and #29) of the 27 residents reviewed for care planning. The facility census was 137. Findings include: 1) Review of the medical record for Resident #117 revealed the resident was admitted on [DATE]. Diagnoses included schizophrenia, anxiety, hallucinations, and depression. Review of the medical record from 08/26/22 through 11/30/23 for Resident #117 revealed no documented evidence of a care conference being completed. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #117. Revealed the resident had no cognitive impairments and was independent with activities of daily living (ADLs). Interview with Resident #117 on 11/27/23 at 3:18 P.M. revealed the resident had never been provided with a care conference. Interview Social Service Designee (SSD) #111 on 11/30/23 at 12:48 P.M. verified Resident #117 was admitted on [DATE] and the resident had never had a care conference. 44080 2) Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included schizoaffective disorder, type two diabetes, spinal stenosis, chronic obstructive pulmonary disease (COPD) and schizoaffective disorder. Review of the medical record for Resident #29 from 01/01/22 through 11/30/23 revealed Resident #29 had no documented evidence of any care conferences being completed. Review of the MDS assessment dated [DATE] for Resident #29 revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Review of the plan of care dated 10/23/23 revealed Resident #29 was at risk for nutritional decline related to type two diabetes, hypertension, hyperlipidemia, COPD, major depressive disorder, anxiety disorder, obesity, anemia, schizoaffective disorder; therapeutic diet; edema, history significant weight loss (planned/favorable) with weight cycling and history of wounds. Interview with Resident #29 on 11/28/23 at 12:29 P.M. revealed the resident did not have any care conferences. Interview with SSD #111 on 11/30/23 at 12:55 P.M. verified Resident #29 had no documented evidence of any care conferences being completed. Interview with the Administrator on 11/30/23 at 2:14 P.M. verified Resident #29 had no care documented care conferences in 2022 or 2023.

Based on observation, staff interview, review of the zone signs, review of the Centers for Disease Control (CDC) guidelines, and policy review, the facility failed to ensure staff wore personal protective equipment (PPE) correctly. This had the potential to affect all 140 residents who resided in the facility. The facility census was 140. Findings included: Observation and interview on 07/14/22 at 8:30 A.M. Receptionist #500 verified the facility had Covid positive individuals and was in outbreak mode, the minimum personal protective equipment (PPE) was an N95 mask and face shield for the facility staff. Observation and interview on 07/14/22 at 8:38 A.M. revealed Housekeeper #501 was only wearing one of the two straps on his N95 mask, with his mouth and nose exposed. He verified he was not wearing it properly and said it was choking him. There were residents moving freely through the hallway where Housekeeper #501 was located. Observation and interview on 07/14/22 at 8:45 A.M. the Administrator was only wearing one of the two straps on his N95 mask. The Administrator verified he was not wearing his mask properly. There were residents moving freely through the halls where Administrator was located. A follow-up interview on 07/14/22 at 9:07 A.M., the Administrator stated the first Covid positive employee and residents were identified on 07/07/22. Observation on 07/16/22 at 7:50 A.M. revealed some residents' rooms had personal protective equipment (PPE) signs on their doors for a Yellow Zone or a Red Zone. The signs read: The Yellow Zone sign indicated Transmission Based Precautions - Contact Droplet with PPE required: N95 mask or approved KN95, universal eyewear: face shield or goggles, Single gown - with each encounter GOWNS MUST BE SINGLE USE PER RESIDENT, Gloves (hand hygiene donning/doffing). The Red Zone sign indicated Transmission Based Precautions - Contact Droplet with PPE required: N95 mask or approved KN95, universal eyewear: face shield or goggles, Gown (new gown each entry in the hot zone) with each encounter GOWNS MUST BE SINGLE USE PER RESIDENT, Gloves (hand hygiene donning/doffing), DESIGNATED STAFF ONLY. Observation and interview on 07/16/22 at 7:55 A.M. Licensed Practical Nurse (LPN) #21 verified she was only wearing one strap of her N95 mask and not wearing the mask properly. Observation and interview on 07/16/22 at 7:58 A.M. State tested Nursing Aide (STNA) #300 verified she was not wearing both straps of her N95 mask and was not wearing it properly. Observation and interview on 07/16/22 at 8:00 A.M. LPN #20 verified she was not wearing her N95 mask properly because she only had on one strap. Observation and interview on 07/16/22 at 8:41 A.M. revealed Resident #03's room was in a Yellow Zone. LPN #21 verified Resident #03 was in a Yellow Zone and she was told she only had to wear her face shield and N95 mask and was not required to wear disposable gowns or gloves. Observation and interview on 07/16/22 at 8:45 A.M. revealed Resident #04 was in a Yellow Zone and LPN #21 did not wear a disposable gown or gloves. Interview on 07/21/22 at 11:28 A.M., the Director of Nursing (DON) stated the Red Zone sign was used for a resident who was positive for Covid-19 and the Yellow Zone sign was used for a possible exposure. The DON said staff must wear a gown, gloves, a mask, and face/eye protection, while providing any care for residents in the Yellow or the Red Zones. Observation and interview on 07/27/22 at 8:50 A.M. revealed Housekeeper #501 was not wearing his N95 properly, and was verified by the DON. Observation and interview on 07/27/22 at 8:55 A.M. revealed LPN #205 was not wearing her N95 properly, and was verified by the DON. Review of the policy titled Infection Prevention Program, dated 02/24/22, revealed goals of the facility infection prevention program included: Reduce the spread of infectious disease within the facility through implementation of the Standard and Transmission-based Precautions, and Identify and correct problems related to infection prevention practices. Review of the policy titled Criteria for Covid-19 Requirements and Resident Placement, dated 03/24/22, revealed the Process for isolation/Covid room for area: 4. Full PPE is required when entering a resident room which includes: N95 mask, eye protection, gown, gloves. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated 02/02/22 https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed N95 masks should be worn according to the manufacturers recommendations and straps should not be altered. Gowns and other PPE should be worn for COVID positive residents or suspected exposures. This deficiency substantiates Complaint Number OH 105.

Based on medical record review, staff interview and policy review, the facility failed to ensure neurological assessments were completed after unwitnessed falls. This affected two residents (#14 and #11) of three residents reviewed for falls. The facility census was 140. Findings include: 1. Review of the medical record for Resident #11 revealed admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed he required supervision for bed mobility, eating and limited assistance for toilet use and transfers. He had impaired cognition. A care plan relative to behaviors revealed Resident #11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administration of medication as ordered, monitor behavioral episodes and approach in a calm manner. Review of the 06/20/22 8:23 A.M. progress note for Resident #11 revealed he had slipped and fell after trying to toilet himself and was found on the floor. He denied injury, vitals were within normal limits, and he was educated on the use of the call light for transfers/toilet use and the need for appropriate footwear. Interview on 07/27/22 at 12:51 P.M. with Licensed Practical Nurse (LPN) #25 revealed she cared for Resident #11 on 06/20/22 and was informed during her medication pass around 9:30 A.M. he had fallen in the bathroom. LPN #25 stated Resident #11 said he hit his head on the shower chair when he fell . She said Resident #11 had soiled himself, so she assisted in cleaning him, assessed him, did neurological checks, and assisted him back to bed. She shared he was hallucinating and stated there were mice all over his room, which there were not. LPN #25 stated she called to inform the physician of the fall and the hallucinations. LPN #25 continued neurological checks until the physician returned the call with an order to send him to the hospital to be evaluated around 11:00 A.M. LPN #25 shared she was unfamiliar with the electronic neurological assessment (neuro assessment) and instead wrote down her assessments, which she later gave to RN #30 to put into the electronic charting system. LPN #25 verified Resident #11 had only fallen one time on 06/20/22 and at no time did he refuse a neurological assessment. Review of the electronic charting for Resident #11 revealed neurological checks were attempted on 06/20/22 at 10:00 A.M. and he refused. The next documented time was 10:30 A.M., where he again refused. The next document was 06/20/22 at 11:00 A.M. and the Resident was noted to be out of the facility and refused assessment as well. Review of the policy titled Fall and Prevention Management, dated 05/21/22 revealed if the resident had an unwitnessed fall, complete neurological checks per policy. Review of the policy titled Neurological Checks (Neuro-checks), last revised 06/21/18 revealed neuro checks will be done for a fall with an unknown head injury every 15 minutes times four, every 60 minutes times four, every four hours times four and daily times four. 2. Review of the medical record for Resident #14 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident remained in the facility. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had impaired cognition and required extensive one person assistance for bed mobility, transfers, toilet use and eating. A care plan relative to at risk for falls related to history of traumatic brain injury, [CONDITION(S)] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 06/29/22 revealed Resident #14 had an unwitnessed fall and was found on her knees on side of the bed. Resident #14 stated she was trying to transfer herself from the chair to the bed and balance became unsteady. An assessment revealed no injuries or visible bruising, and no complaints of pain or discomfort. Resident #14 was picked up off ground by two staff and placed in the chair. Review of the electronic charting for Resident #14 revealed no documented neurological assessments. Interview on 07/25/22 at 12:17 P.M. with the Director of Nursing verified there were no neurological checks documented for Resident #14. Review of the policy titled Fall and Prevention Management, dated 05/21/22 revealed if the resident had an unwitnessed fall, complete neurological checks per policy. Review of the policy titled Neurological Checks (Neuro-checks), last revised 06/21/18 revealed neuro checks will be done for a fall with an unknown head injury every 15 minutes times four, every 60 minutes times four, every four hours times four and daily times four. This deficiency substantiates Complaint Number OH 691.

Based on medical record review, observations, interviews with facility staff, contracted wound team, law enforcement (LE), review of justice system procedures, review of facility policies and review of the National Pressure Injury Advisory Panel (NPIAP) recommendations, the facility failed to ensure residents who were being restrained, received appropriate monitoring and treatment to prevent the development of pressure ulcers and /or impaired skin integrity. This resulted in actual harm when Resident #100 was admitted to facility on 11/05/21 with no skin impairments and was discharged to the hospital on 01/19/22 with unstageable ( dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like) pressure ulcer to right hip, deep tissue injuries (DTIs) (purple or maroon localized area of discolored intact skin) on sacrum, left heel, right ankle, right heel, right fifth toe, and let hip; stage two (II) ( partial thickness tissue loss) pressure ulcer to left ankle, and unstageable pressure ulcer on right lateral foot. This affected one Resident (#100) of the three residents reviewed for pressure ulcers. The facility census was 138. Findings included: Review of the medical record for the Resident #100, revealed an admitted [DATE], was discharged with return anticipated (DRA) on 01/19/22, readmitted on [DATE] and discharged via justice system and sent to hospital on 02/17/22. Medical record indicated Resident #100 was admitted to facility as a justice involved resident /inmate of a public institution/local jail. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment completed on 11/12/21 revealed Resident #100 had severely impaired cognition, had numerous physical behaviors, rejected care daily, did not wander, was two-person physical extensive assist with activities of daily livings (ADLs) and was frequently incontinent of bowel and bladder. Section-M (skin) indicated resident had no skin issues but as risk for pressure ulcers/injuries. Section P (physical restraints) indicated no restraints were assessed as being used. Continued review of MDS dated [DATE] revealed a significant change completed and Section-M indicated resident was readmitted to the facility with numerous skin impairments. Review of 11/11/21 care plan for Resident #100 revealed resident was risk for altered skin integrity and pressure ulcer development related to cognitive impairment, incontinence and declined mobility. Interventions included complete skin checks as ordered and as needed. Care plan indicated resident had psychosocial wellbeing related to dementia, impaired judgment, impaired cognition, mood impairment and resident was admitted to facility as an incarcerated person through the [NAME] County Justice Center (HCJC) /local jail. Interventions were silent for any monitoring and treatment/prevention interventions for resident being restrained per HCJC custodial procedures. Review of undated on-boarding clinical evaluation (admission document) for Resident #100 was silent for any indication resident was to be monitored and any treatment/prevention interventions put in place for a resident being restrained to check for any skin issues or checks and placement of the restraints. Review of nurse's progress notes for Resident #100's from 11/05/21 through 02/17/22 revealed no documented monitoring and treatment/prevention interventions in place for resident being restrained. Physician orders for Resident #100 dated 11/05/21 revealed resident was ordered barrier cream to buttocks and peri areas every shift (day and night) and as needed (PRN) after incontinence episodes and resident was on a standard pressure relieving mattress. Review of physician orders for Resident #100 from 11/05/21 through 02/17/22 revealed no documented orders for resident to be in restraints, no orders for being monitored and no documented treatment/prevention orders or intervention being in place for resident being restrained. Additional review of physician orders for Resident #100 from 11/05/21 through 02/17/22 revealed resident was not ordered to be monitored and physician orders were silent for any prevention intervention measures in place for resident being in restraints. Review of orders revealed no pressure relieving devices ordered and no orders for pressure treatment/prevention for residents being restrained. Review of December 2021 treatment administration records (TAR)s revealed resident received barrier cream to buttocks as ordered. January TAR revealed no documented evidence resident received barrier cream on buttocks on 01/07/22 dayshift, 01/14/21 dayshift, and 01/16/22 dayshift. TAR was silent for any monitoring and treatment/prevention interventions for resident being restrained. Review of weekly skin assessments for Resident #100 dated 11/12/21 through 01/14/22 were silent for any skin areas and for any monitoring and treatment/prevention intervention measures in place for resident being in restraints. Review of psychiatry (psych) progress notes for Resident #100 dated 11/15/21 indicated resident was observed in two-point restraints (right hand and left leg were handcuffed to bed). Psych notes dated 12/21/21 indicated resident was evaluated with right arm and left leg in restraints. Review of wound Nurse Practitioner (NP) #101 notes dated 01/11/22 revealed resident was assessed for comprehensive skin and wound evaluation and there were no wounds during the skin examination. Review of wound NP #101 notes dated 01/27/22 indicated resident was assessed on 01/11/22 and resident was noted with a metal handcuff on residents left ankle. NP notes were silent for any ordered monitoring and treatment/prevention interventions for resident being restrained. Review of physical restraint assessment form for Resident #100 revealed one quarterly assessment dated [DATE]. Notes indicated resident had unsafe mobility, postural instability, agitated behavior and continue the restraint due to being in police custody. Notes indicated the restraint stabilized the resident. Review of restraint assessments from 11/05/21 through 02/17/22 revealed no other documented restraint assessments, monitoring and treatment/prevention interventions. Interview with Local LE #100 on 02/18/22 at 3:35 P.M. indicated the Sheriff's Office departmental policy/procedure was for all inmates/residents to always be restrained. LE #100 stated residents/inmates were shackled (cuffed) via one leg and [NAME] was attached to the bed. LE #100 indicated each inmate/resident was guarded 24 hours a day for custodial but played no part in the medical care. LE #100 stated he guarded Resident #100 on numerous occasions and indicated resident was in restraints per department procedure. Interview with Regional Clinical Director (RCD) #102 and Director of Nursing (DON) on 02/18/22 at 3:30 P.M. indicated the facility had a contract with the HCJC to care for their inmates with severe medical conditions. RCD #102 indicated the facility did not have a general contract with the HCJC, but each resident admitted from the HCJC had an individual contract. RCD #102 indicated Resident #100 was originally admitted on [DATE] from the HCJC as resident/inmate and had 24-hour police custody per procedure. RCD #102 indicated resident was cognitively impaired and had numerous behaviors, refused to eat, refused to take medications, and was sent to hospital on 01/19/22 for illness. RCD #102 indicated resident returned to the facility on [DATE] with numerous skin issues. RCD #102 indicated the facility was a restraint free facility and did not restrain any residents including the justice system residents, so they did not need to monitor anyone for restraints. RCD #102 stated she was not aware of the HCJC policy/procedure and was not aware if LE restrained/cuffed residents/inmates. DON verified he had witnessed Resident #100 being shackled to the bed at times. DON indicated resident had an advanced disease process and believed that many of his skin issues were from chronic malnutrition, refusing to eat, refusing care and near end-of-life process. DON verified Resident #100 had no documented monitoring and treatment/prevention interventions in place for resident being restrained/cuffed. Interview with Staff #31 on 02/18/22 at 3:45 P.M. indicated Resident #100 was admitted to the facility in police custody and through a contract with HCJC. Staff #31 indicated resident needed therapy/rehabilitation due to chronic medical and cognition issues and the HCJC was not able to provide care for him. Staff #31 stated Resident #100 was sent to hospital on 01/19/22 and returned with several sores throughout his body. Staff #31 indicated she observed cuffs on resident when he was originally admitted but not after being returned from hospital on 01/25/22. Staff #31 verified the facility had no documented monitoring and treatment/prevention interventions in place for Resident #100 being restrained. Staff #31 stated HCJC picked resident up on 02/17/22 and took him to university hospital. Review of facility NP #103 notes for Resident #100 dated 01/18/22 indicated she was contacted by nurse who stated resident seemed pale and was not feeling well and symptoms started on 01/17/22. Notes indicated resident did not respond to verbal questions and resident complained of chills and fever. Resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Plans include a COVID-19 test, Stat chest x-ray, stat blood work, start [MEDICATION(S)] (Antibiotic) for possible community acquired pneumonia and a close follow up. Notes were silent for any skin assessments being completed. Interview with contracted wound Nurse Practitioner (NP) #102 on 02/22/22 at 4:45 P.M. indicated she made a visit with Resident #100 on 01/11/22 as part of a facility skin sweep and resident was noted with a [NAME] /restraint attached to left ankle and attached to the bed. NP #102 indicated resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During subsequent interview on 02/23/22 at 4:06 P.M. revealed resident was on regular pressure relieving mattress and not a low loss air mattress, no pressure boots in place or any other pressure relieving devices in place. NP #102 also indicated she was not aware if facility was monitoring or had any treatment/prevention interventions in place for resident being restrained. NP #102 indicated she did not order any pressure reliving devices for him since he was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with facility NP #103 on 02/24/22 at 9:10 A.M. indicated she assessed Resident #100 on 01/18/22 and did a focused assessment on his respiratory system and did not assess his skin. NP #103 indicated the guards left the [NAME] on during her assessment and did not notice if there were any skin issues due to focusing on respiratory system. NP #103 indicated resident was non-responsive to her assessment which she was told was his baseline. NP #103 stated she was not certain the if the facility had a specific policy that addressed residents being restrained with handcuffs, but her expectations would be if residents were restrained with handcuffs/shackles, then resident should be closely monitored and have treatment/prevention interventions in place, and someone should be responsible for checking the restraints. NP #103 stated she assessed resident upon returning on 01/25/22 and noticed he had bilateral wrist redness from the handcuffs which appeared to be too tight but did not document or say anything about it. Review of hospital notes dated 01/19/22 at 7:46 P.M. indicated resident was admitted in the emergency room . Notes indicated resident was admitted with acute [CONDITION(S)], [CONDITION(S)] (in the setting of dehydration), COVID-19 infection, severe [CONDITION(S)], severe malnutrition, and wounds on right posterior hip, left foot, right foot, and buttocks. Hospital notes indicated wound care NP evaluated Resident #100 on admission to hospital and resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 01/27/20 [NAME] County Sheriff's Office Policy and Procedure Jail Services revealed guidelines for Deputies that are assigned to provide security at a hospital, nursing home or any off-site medical facility. Document indicated Deputies were responsible for custody and control of any inmate receiving care at offsite medical facilities for extended treatment. Document indicated deputies were not to take any inmate outside of the secure perimeter of the HCJC without inmate being handcuffed and leg irons applied. Document indicated deputies shall ensure that the inmate is always shackled while in their room and one ankle shall be always shackled to the bed frame. Review of 10/05/21 facility policy titled Skin Care and Wound Management Overview revealed the facility would identify and implement interventions to prevent and treat potential skin integrity issues. Policy indicated the wound management program included identification of residents at risk for development of pressure ulcers and implementation of prevention strategies to decrease the potential for developing pressure ulcers. Policy indicated the facility procedures included the facility would identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 06/15/18 facility policy titled Physical Restraint and Management revealed a physical restraint was a mechanical device, equipment or material that was attached to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his / her body. Such examples included application of leg or arm restraints which a resident cannot remove. In the event of a physical restraint being used the facility was to provide ongoing re-evaluation. Policy indicated the facility was responsible for the process to meet the minimum requirements of the regulation including appropriate assessment, care planning by the Intradisciplinary Team (IDT) and documentation the use of the physical restraint. Physical risks included decline in physical activity, and skin breakdown. Review of the facility policy was silent for addressing the justice system residents in the facility and monitoring skin during restraint use. Review of NPIAPwebsite(https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) revealed pressure ulcers have been defined by the National Pressure Ulcer Advisory Panel (NPUAP) as localized damage /injury to the skin and underlying tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure. References indicated a stage two pressure injury was partial thickness skin loss with exposed dermis. Unstageable pressure injury obscured the full-thickness skin and tissue loss and full thickness skin and tissue loss in which extent of tissue damage with ulcer could not be confirmed because of being obscured by slough or eschar (black area on skin) and if slough or eschar was removed, a Stage 3 or Stage 4 pressure would be revealed. Deep Tissue Pressure injury persistent non-blanchable deep red, maroon or purple discoloration intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealed a dark wound bed or blood-filled blister and this injury resulted from intense and/or prolonged pressure at the bone-muscle interface. This deficiency substantiates Complaint Number OH 254.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of the facility Self-Reported Incident (SRI), review of county clerk of courts documents, review of a facility investigation, and review of facility policy, the facility failed to ensure a resident was free from physical abuse. This resulted in actual physical harm when Resident #113 was physically abused by Resident #138 and subsequently required an emergency transfer to the hospital, an inpatient hospital stay, and surgical repair of a right [MEDICAL CONDITION]. This affected one (#113) of four residents reviewed for abuse. The facility census was 136. Findings include: Review of the medical record for Resident #113 revealed an admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the face sheet for Resident #113 revealed the resident was [AGE] years of age. Review of the Minimum Data Set (MDS) assessment for Resident #113 dated 02/07/20 revealed the resident was cognitively impaired, was coded for delusional behaviors, and required supervision and set up help with Activities of Daily Living (ADL's). Review of a nurse progress note for Resident #113 dated 03/08/20 at 9:57 P.M. revealed the resident was pushed by his roommate (Resident #138) against the wall. The nurses progress notes documented Resident #113 sustained a skin tear and bleeding on his right elbow, a bruise to his right knee and swelling to his right hip. Further review of the notes revealed the resident complained of pain to his right hip of nine on a scale of one to 10 with 10 being the worst pain. Further review of the notes revealed emergency medical personnel and the police were called and the resident was taken to the emergency room . Review of the hospital admitting physician note for Resident #113 dated 03/08/20 revealed the reason for the residents' visit to the Emergency Department (ED) was listed as assault victim/fall/hip injury. Further review of the admitting physician's note revealed Resident #113 reported he was assaulted by another resident at his nursing facility and suffered a fall which resulted in sudden onset of pain to his right hip. Review of the nurse progress note for Resident #113 dated 03/09/20 revealed the resident was admitted to the hospital with [REDACTED]. Review of hospital discharge summary for Resident #113 dated 03/14/20 revealed the resident had surgical repair of his right hip and discharge instructions included aftercare guidelines for Post-Traumatic Stress Disorder ([MEDICAL CONDITION]) which included the following: [MEDICAL CONDITION] is a mental health disorder that can develop after you experience a shocking, scary, or dangerous event. [MEDICAL CONDITION] symptoms can include: repeated, unwelcome memories, thoughts and/or nightmares about the event, having flashbacks, which is feeling or acting as if the event is happening again, avoidance of thoughts and feeling about the event or things that remind you of the event, feeling on-edge or easily startled, difficulty sleeping or concentrating, feeling irritable most of the time or having angry outbursts, having more negative mood and beliefs (shame, guilt, self-blame, despair, fear, horror, etc.), not wanting to do things you used to enjoy or spending less time with family and friends. Further review of discharge instructions revealed it was normal to experience these symptoms after a trauma and if symptoms disrupted daily life to contact the primary care physician. Review of the MDS for Resident #113 dated 02/07/20 revealed the resident was coded negative for a [DIAGNOSES REDACTED]. Review of a nurse progress note dated 03/14/20 for Resident #113 revealed resident was readmitted to the facility with surgical incision to his right hip with 43 staples in place related to hip surgery following the incident involving Resident #138 on 03/08/20. Review of the medical record for Resident #138 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the face sheet for Resident #138 revealed the resident was [AGE] years of age. Review of the MDS for Resident #138 revealed the resident was cognitively intact, was coded for behavioral symptoms not directed towards others, and required supervision and set up help with ADL's. Review of the care plan for Resident #138 dated 08/12/17 revealed the resident had the potential to demonstrate physical behaviors and aggression related to poor impulse control and had a history of [REDACTED]., provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, if resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later, redirect away from other male residents when attempting to engage in play fighting/wrestling, attempt to educate risk and explain why this behavior is not acceptable, monitor/document/report to physician of danger to self and others. Review of the nurse progress note for Resident #138 dated 03/08/20 revealed the resident pushed his roommate (Resident #113) against the wall. Further review of the note revealed Resident #138 was assessed and sustained no injuries and was taken from the facility by the police immediately following the incident. Review of a nurse progress note for Resident #138 revealed the resident's representative was notified the resident was taken to jail on 03/08/20. Review of the MDS for Resident #138 dated 03/08/20 revealed the resident was discharged from the facility with a return not anticipated. Review of the facility SRI dated 03/08/20 revealed the facility investigated an allegation of abuse. Review of the SRI revealed the following events occurred in the evening of 03/08/20: Resident #138 pushed Resident #113 against the wall in a playful way not realizing his strength, Resident #113 fell to the floor, Resident #138 assisted Resident #113 into bed, Resident #138 went out of the room to tell the nurse what occurred. Review of the SRI revealed the facility interviewed Resident #113, but he did not describe specifically what happened but when asked if he had been abused or intentionally hurt resident stated no. Further review of the SRI revealed Resident #113 had a right [MEDICAL CONDITION] as a result of the incident and was treated at the hospital. Resident #138 was arrested following the incident and was taken into police custody. The facility did not substantiate abuse. Review of the county clerk of court documents revealed Resident #138 was charged with felonious assault on 03/16/20 with a bond set at $5000. Review of the interdisciplinary team investigation into the incident on 03/08/20 between Residents #138 and #113 dated 03/18/20 revealed the facility was unable to interview Resident #138 due to the fact the resident continued to remain in jail since the incident. Interview on 11/03/20 with the Administrator and Director of Nursing (DON) confirmed the facility interviewed Resident #138 who alleged he was playing around with Resident #113 and did not intend to hurt him. The Administrator and DON confirmed they interviewed Resident #113 at the hospital in the evening of 03/08/20 and the resident denied being abused by Resident #138. Interview on 11/04/20 at 10:08 A.M. with Registered Nurse (RN) #400 confirmed she was passing medications in the evening on 03/08/20 when Resident #138 approached the medication cart and said Resident #113 was not feeling well. RN #400 confirmed she questioned Resident #138 for details and the resident told her he had pushed Resident #113 to the wall and then he had pushed him down. RN #400 confirmed she asked Resident #138 why he pushed Resident #113 down and the resident said, I don't know. I just pushed him down. RN #400 confirmed she then went to Resident #113's room and found Resident #113 in bed complaining of pain level nine to his right hip. RN #400 confirmed Resident #113 exhibited swelling to his right hip, a bruise to his knee, and skin tear to his elbow. RN #400 confirmed she asked Resident #113 if Resident #138 had pushed him down but said Resident #113 denied this. RN #400 confirmed she called emergency medical personnel and asked them to send to send the police as well. RN #400 confirmed the emergency medical personnel arrived quickly and took Resident #113 to the hospital. RN #400 confirmed the police questioned Resident #138 regarding the incident, placed handcuffs on the resident, told her they were arresting the resident related to the incident and taking him to jail, and then the resident left the facility in police custody. Review of facility policy titled Abuse, Neglect and Misappropriation revised 04/01/19 revealed it was the intent of the facility to prevent abuse towards the residents. The definition of abuse in the facility's policy included the willful infliction of injury, and further clarified the word willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. As a result of the incident, the facility took the following actions to correct the deficient practice by 03/20/20: · On 03/08/20, RN #400 assessed Resident #113 and #138 for injuries and arranged for transfer to the hospital for Resident #113. · On 03/08/20, the staff separated Residents #113 and #138 immediately upon being made aware of incident by Resident #138. · On 03/08/20, RN #400 notified police of the incident and cooperated with law enforcement as Resident #138 was taken into custody. The facility provided one-on-one supervision to Resident #138 until the police arrived. The facility planned to send Resident #138 to the hospital as a follow-up to the incident but were unable to do so due to the resident's arrest. · The Administrator and Director of Nursing (DON) went to the hospital on the evening of 03/08/20 to interview Resident #113. · On 03/08/20, RN #500 interviewed the other residents on the unit to see if they had witnessed the incident or had witnessed any issues between Resident #113 and #138 prior to the incident. Residents were also interviewed to determine if they had any concerns. There were no other reports of abuse. · On 03/08/20, RN #500 interviewed the staff working on the unit on 03/08/20. There were no other reports of abuse. · On 03/09/20, the Administrator and the DON interviewed an outside visitor who had visited Resident #138 on 03/08/20 and who alleged he was in the room at the time of the incident but did not have a clear view and was unsure how Resident #113 fell . · On 03/08/20, the DON and RN #475 began all staff education on the abuse policy. The education was completed on 03/09/20. · On 03/09/20, all residents were monitored for abuse concerns during daily Ambassador Rounds Audits conducted by the DON, the Administrator, or RN #500 and no additional concerns were identified regarding abuse. The facility completed daily monitoring through 03/20/20 without any additional abuse concerns. · Interviews on 11/10/20 at 2:50 P.M. with State tested Nursing Assistant (STNA) #175 at 2:55 P.M. with Receptionist #450, and at 3:00 P.M. with Licensed Practical Nurse (LPN) #425 confirmed they received re-education on the facility's abuse policy. · On 11/10/20, two additional residents (#26 and #47) were sampled and reviewed for abuse. No concerns regarding abuse were identified. · On 11/10/20, review of the facilities SRI's revealed there were no further concerns identified regarding abuse.

Based on medical record review, resident and staff interviews the facility failed to ensure a residents pain was effectively managed. This resulted in actual harm to Resident #18 who was assessed as being in very severe pain yet wasn't administered prescribed his every four hour routine pain medication for over 18 hours, and the physician wasn't contacted timely for guidance. This affected one Resident (#18) of three residents reviewed for pain management. The facility reported 19 residents receiving pain medication. The census was 124. Findings include: Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed intact cognitive skills for daily decision making, limited assistance was required with transfers, and supervision was required with personal hygiene, toileting, and eating. Review of the physician orders [REDACTED]. A physician order [REDACTED].M. revealed [MEDICATION NAME] 5 mg, give two tablets by mouth every four hours as needed for pain. Only give if routine [MEDICATION NAME] 10 mg was not available for administration. A physician order [REDACTED]. Review of the Medication Administration Record [REDACTED].M. or on 01/29/17 at 12:00 A.M., 4:00 A.M., or 8:00 A.M. with instructions to see nurse note. Review of the MAR indicated [REDACTED]see nurse note. The MAR indicated [REDACTED]. Resident #18 continued to receive Humalog insulin and have blood sugars monitored three times a day. Review of the nursing progress notes dated 01/29/17 at 12:52 A.M. revealed Resident #18 missed his 8:00 P.M. and 12:00 A.M. doses of [MEDICATION NAME]. The pharmacy was contacted and reported the medications would be delivered on the 2:00 A.M. run. Review of the nursing progress note dated 01/29/17 at 6:35 A.M. revealed awaiting delivery of [MEDICATION NAME] 10 mg from the pharmacy. A nursing progress note on 01/29/17 at 8:13 A.M. revealed the pharmacy was contacted and reported the [MEDICATION NAME] 10 mg would be delivered sometime today. On 01/29/17 at 10:42 A.M. a nursing progress note revealed the [MEDICATION NAME] was delivered and administered as ordered. Resident #18 complained of withdrawal from missing medication doses. There wasn't any sweating, tremors, or changes in heart rate. Blood pressure was only increased due to anger. Review of the nursing progress note dated 01/24/17 at 9:19 P.M. revealed awaiting pharmacy delivery of the [MEDICATION NAME] insulin. On 01/25/17 at 9:20 P.M. a nursing progress note revealed [MEDICATION NAME]wasn't in stock. Review of the ain assessment flow record revealed on 01/28/17 at 7:00 P.M., Resident #18's pain was recorded as a level eight which indicated very severe pain. His pain level remained an eight upon administration of [MEDICATION NAME] 10 mg by mouth on 01/29/17. An interview on 02/02/17 at 3:39 P.M. with Resident #18 reported he was always in pain but the pain medications provided relief and made activities of daily living tolerable. Resident #18 reported he did not receive his routine ordered pain medication for 18 hours which resulted in severe pain, inability to relax, and withdrawal symptoms including shaking. Resident #18 reported the nurses informed him it was the pharmacy's fault. He also reported his routine insulin wasn't available or administered for two nights until another nurse went and obtained some off another medication cart. An interview with the Director of Nursing (DON) on 02/02/17 at 5:12 P.M. reported medications were ordered from the pharmacy over the computer, fax, or via a telephone call. If a medication wasn't available for administration the pharmacy was contacted to check on the problem and the physician was contacted for guidance. An emergency box was available at the facility which contained some medications. The DON reported she spoke with the pharmacy about Resident #18's [MEDICATION NAME] 10 mg on 01/29/17 at which time they confirmed there was a current order for the medication and was ordered by the facility on 01/27/17 but wasn't delivered to the facility until 01/29/16. The physician was contacted on 01/29/17 and gave an order to administer two 5 mg tablets of [MEDICATION NAME] if the 10 mg tablets were unavailable as 5 mg tablets were available in the facility emergency box. The medication was then delivered by pharmacy so the medication was never obtained from the emergency box. This deficiency substantiated Complaint Number OH 307.