Every finding on record at Concordia at Sumner

Based on observation and interview, the facility failed to prepare food in a sanitary manner. This had the potential to affect all 43 residents who received meals from the kitchen. The census was 43.Findings include:Observation on 01/22/26 at 9:16 A.M. of Dietary Aide #709 in the kitchen revealed he was wearing a hairnet that only covered the top of his head. The hairnet did not cover his ponytail which was approximately eight inches long. Dietary Aide #709 also had a long beard that was not covered by a beard guard. Interview on 01/22/26 at 9:17 A.M. with Dietary Aide #709 thought he only had to wear it during meals. Interview on 01/22/26 at 9:17 A.M. with Registered Dietitian #838 verified the observation.Review of the facility policy titled Dietary Employee Personal Hygiene, dated 01/16/23 revealed all dietary staff must wear restraints to prevent hair from contacting food during food preparation.

Based on record reviews, observations and interviews with staff the facility failed to prevent Resident #28 from eloping from the facility without staff knowledge. This affected one resident (Resident #28) of four residents reviewed for elopements. The census was 42. Findings include:Initial tour was conducted on 11/13/25 from 9:00 A.M. to 9:21 A.M. The facility was divided into two buildings ([NAME] and [NAME]) connected by a hallway. Each building was set up in a square formation with an enclosed courtyard. Each building could house 24 residents. Review of the medical record for the Resident #28 revealed an admission date of 04/27/23. Diagnoses included were dementia, dysphagia, paroxysmal atrial fibrillation and hypertension.Review of the plan of care dated 04/30/23 revealed the resident was at risk for elopement/wandering behavior due to cognitive impairment. Interventions included redirecting as needed and having a wanderguard bracelet (a bracelet worn by a resident which secured doors when near to prevent elopement) in place.Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/30/25, revealed the resident had impaired cognition. The assessment identified the resident to be independent with maneuvering a manual wheelchair over 150 feet. He had physical behaviors against self and others. Resident had no behaviors of wandering. Review of the elopement risk assessment dated [DATE] revealed the resident was at risk for elopement.Review of the nurses notes dated 11/08/25 and timed for 2:17 P.M. revealed Resident #28 was observed sitting in his wheelchair in the front parking lot by a visitor. The visitor brought him inside and notified a staff member. Wandergaurd was on his left ankle and was not working or sounding. Resident #28 was immediately given a new bracelet. Resident was given 1:1 supervision at that time by the nurse. Nurse manager, nurse practitioner were notified and a message was left for the guardian.Review of physician orders for November 2025 revealed resident was to wear wanderguard bracelet on right wrist. Resident #28 was identified as at risk for elopement on 06/19/24.Review of the elopement investigation dated 11/08/25 revealed three witness statements. Certified Nursing Assistant (CNA) #307 stated she was walking down the hall when a family member stopped her by the front door and told her Resident #28 was in the parking lot. CNA #307 brought him back in at approximately 12:00 P.M. CNA #301 stated she was doing care on another resident. When she was finished, the other CNA informed her a visitor saw Resident #28 in the parking lot and the wanderguard bracelet was not working. Licensed Practical Nurse (LPN) #205 was notified by CNA #307 she was told by a visitor Resident #28 was observed in the parking lot in his wheelchair. Resident #28 was brought inside. Wanderguard bracelet was on his left ankle but the alarm was not sounding. LPN #205 last saw him around 11:00 A.M.Interview on 11/13/25 at 9:30 A.M. with Administrator and Director of Nursing (DON) revealed a Self-Reported Incident was not completed based on Ohio Department of Health (ODH) criteria. Administrator sent an email to ODH on 11/08/25 reporting the incident and requesting additional guidance if needed. They suspected Resident #28 eloped through Door #1, the front door. He stated the cameras were down. Unrelated to this issue, Door #2 was not functioning properly, it had an alarm on it that had to be manually shut off. He stated no staff had to reset that alarm on 11/08/25 at the time of the elopement. The facility was supposed to be doing every 15-minute checks on Resident #28 prior to the elopement because of Door #2.Interview on 11/13/25 at 12:33 P.M. with CNA #301 revealed Resident #28 had a fall between 9:30 A.M. and 10:15 A.M. and was found in the doorway to the enclosed courtyard, and the resident had been with a nurse since the fall. CNA #301 and CNA #307 were getting residents ready for lunch when CNA #307 told her a visitor informed her Resident #28 was found in parking lot. CNA #301 stated she was unaware the wanderguard alarm was not working. She stated the nurse reached out to management about it and was told a different door was not working prior to this and staff were told to do fifteen-minute checks of the four residents who wore wanderguard bracelets until it was fixed. CNA #301 revealed none of them were informed about doing every 15-minute checks due to Door #2 not working. She stated they started to do 15 minute checks after Resident #28 eloped. CNA #301 stated they were busy the day Resident #28 eloped and revealed Resident #28's behaviors were normal on the day of elopement.Interview and review of documentation on 11/13/25 at 1:24 P.M. with Systems Administrator (IT) #500 revealed he checked the doors every week and showed weekly audits. The audit indicated Door #2, a side door, was not functioning. It had a note for an outside company coming to fix it on 11/14/25. According to the audit. Door #2 was functioning on 11/04/25. IT #500 stated there was a temporary alarm on this door that had to be manually turned off. He stated they suspected Resident #28 eloped from Door #1, the front door, because none of the staff heard Door #2's alarm on 11/08/25, nor did anyone manually turn off any alarm. IT #500 also stated Door #2 was used by staff with a key fob to get to the parking lot on the side of the building. IT #500 revealed they started doing every 15-minute checks on 11/06/25 when they discovered the issue with Door #2.Interview on 11/13/25 at 1:43 P.M. with LPN #205 revealed CNA #307 notified her on 11/08/25 at approximately 12:00 P.M. an unknown visitor said Resident #28 was found outside in the parking lot. She assessed him and when she brought him through the doors, the alarm did not sound or secure the doors. She replaced his wanderguard and stayed with him one one one (1:1). LPN #205 notified nursing manager (LPN #600) who was in the other building who then informed the DON. LPN #205 notified the guardian. LPN #205 also spoke to the DON who told her to initiate every 15-minute checks on the four residents with wanderguard bracelets after learning the dayshift staff had not been doing them. LPN #205 told the DON they did not get that information in report. The DON had said they should have been doing every 15-minute checks due to Door #2 not functioning properly. LPN #205 reiterated she was never told about this. LPN #205 revealed she last saw Resident #28 around 11:00 A.M. and he had a t-shirt, pants and tennis shoes on. She stated he did not look distressed. LPN #205 revealed she did not get in report about the every 15-minute checks nor did she see any paperwork for the checks. LPN #205 revealed Resident #28's behaviors were no different than normal. She stated he had frequent falls and had one that morning around 10 A.M. at the entrance of the enclosed courtyard. She stated they had normal staffing, one nurse and two CNAs for up to 24 residents.Interview on 11/13/25 at 2:13 P.M. with LPN #600 revealed she happened to be working as a CNA in the other building on 11/08/25 when she received a text about the elopement from LPN #205. She called the DON then went to the other building to get witness statements and start investigation. LPN #600 recounted what LPN #205 told her about the situation.Observations on 11/13/25 from 2:34 P.M. to 3:55 P.M. revealed Resident #28 was in his room. Other residents with wandergaurd bracelets (Residents #11, 24, and 35) were in the dining room for an activity. Multiple staff were present. Observation of Door #2 alarm sounding when staff exited showed a staff member manually turning it off. Observation of the front hallway revealed a set of unmarked doors which led to the lobby. There was a set of doors with the wanderguard keypad leading to vestibule and a second set of doors that lead to the parking lot. LPN #205 tested the alarm by bringing a resident with a wandergaurd bracelet near the door. The keypad turned red (from green) and would not open when the nurse briefly pushed on it. The keypad was reset by the nurse after removing the resident from the area.Interview on 11/13/25 at 4:12 with Administrator and DON revealed DON learned of Resident #28's elopement on 11/08/25 by LPN #600. She stated all residents' wanderguards were checked and Resident #28 was assessed. DON found out on 11/08/25 first shift did not know about the every 15-minute checks because of Door #2 malfunctioning. She was unable to determine if the prior shift shared that in report or not as they claimed to tell the next shift and the staff on 11/08/25 dayshift denied getting it in report. DON expected them to start every 15-minute checks at that point. Wanderguards were moved to residents' wrist if it was on ankle. Orders were changed on Monday to check the wanderguard bracelet every Monday. They started using a handheld device to check the bracelets wherever the resident was instead of taking them to a door. The DON provided education to staff starting 11/08/25.Review of the every 15-minute checks forms revealed some pages had initials for all four residents who used a wanderguard bracelet plus initials of the staff. Staff also drew arrows down the page instead of making an entry for every 15 minute increment. DON verified on 11/13/25 at 4:22 P.M. the form was blank on 11/08/25 for the dayshift until after the elopement occurred.Review of facility policy titled Elopements and Wandering Resident, dated 12/22/2023, revealed the policy read the facility was equipped with door locks/alarms to help avoid elopements. Alarms were not a replacement for necessary supervision. Adequate supervision would be provided to help prevent accidents or elopements.This deficiency represents non-compliance investigated under Complaint number 2664797.

Based on observation, interview, and facility policy review, the facility failed to ensure infection control protocols were maintained during incontinence care and Hoyer (mechanical) lift transfers. This affected one resident (#8) out of one resident observed for incontinence care and Hoyer lift transfers. The facility census was 42.Findings included: Review of the medical record for Resident #8 revealed an admission date of 01/05/22. Diagnoses included but not limited to chronic kidney disease, anxiety disorder, and unsteadiness on feet.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 was dependent on staff for incontinence care and transfers and was always incontinent of bladder and bowel.Observation on 08/21/25 at 7:08 A.M. of incontinence care for Resident #8 revealed Certified Nursing Assistant (CNA) #261 gathered supplies, provided privacy, and explained the procedure to Resident #8. CNA #261 used hand sanitizer in Resident #8's room and went to don gloves and the box was empty. At 7:09 A.M., CNA #261 left the room and went to the supply room, touched the doorknob and went in and received a box of gloves. At 7:11 A.M., CNA #261 returned to Resident #8's room and donned gloves without performing hand hygiene. CNA #261 removed Resident #8's brief which was soiled with a moderate amount of urine. CNA #261 provided perineal care, then with the same gloves on, she touched Resident #8's basin and moved multiple items around in basin to find the barrier cream container. CNA #261 then proceeded to put barrier cream on her gloves and applied it to Resident #8's buttocks. CNA #261 then applied a new brief with the same soiled gloves. CNA #261 then, with same gloves still applied, got the sling pads for the Hoyer lift and positioned the sling pad underneath Resident #8. CNA #261 then got the Hoyer life, attached the sling to the lift, raised Resident #8, and transferred the resident into the electric wheelchair. CNA #261 then gathered garbage and linens and before exiting room where she removed the glove from her right hand and the glove on the left hand remained. Before exiting room CNA #261 used hand sanitizer located on Resident #8's wall on her right ungloved hand and rubbed her right hand, moving fingers around and on palm of right hand and exited room, glove on the left hand remained. CNA #261 then went to the Hopper room, a designated utility room, with the glove still intact to her left hand. In the Hopper room she removed her left glove and then rubbed her left hand together with her right ungloved hand. At this point there was no visible hand sanitizer remaining on her right hand. Interview on 08/21/25 at 7:29 A.M. with CNA #261 confirmed she did not perform hand hygiene or glove usage correctly during incontinence care or with Hoyer lift. CNA #261 reported she just forgot.Interview on 08/21/25 at 8:34 A.M. with the Director of Nursing (DON) and Clinical Nurse Consultant (CNC) #400 confirmed hand hygiene is to be performed before and after glove usage, after perineal care, before applying barrier cream, and before and after each procedure. Review of the facility document, Aide Skills: Providing Perineal Care, undated, revealed to perform hand hygiene and don new gloves before starting the procedure.Review of the facility policy, Hand Hygiene procedure, dated 2022, revealed all staff will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors, and the use of gloves does not replace hand hygiene. If task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Further states, hand hygiene is indicated and will be performed under the condition listed in the attached hygiene table to include the following: before applying and removing personal protective equipment (PPE), including gloves, before and after handling clean or soiled linens, before performing resident care procedures, after handling items potentially contaminated with excretions/body fluids, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions to include elimination, and when in doubt.

Based on observations, interview, and policy review the facility failed to serve food in a sanitary manner. This had the potential to affect all residents who ate meals prepared in the kitchen. The census was 43. Findings include: Observations on 02/13/25 from 12:03 P.M. to 12:55 P.M. revealed [NAME] #100 plating food and Kitchen Aide (KA) #101 placing food trays consisting of open roast beef sandwiches with mashed potatoes, gravy, fruit cup and coleslaw into the food cart for transportation. KA #101 did not cover the fruit or coleslaw before putting the trays in the transport cart. [NAME] #100 was observed donning and doffing gloves throughout lunch service without washing his hands between glove changes. In addition, after donning clean gloves Cook#100 was observed opening refrigerator doors, kitchen drawers and picking up non-food items then picking up food items. [NAME] #100 was observed picking up the mechanical altered roast beef with a gloved hand and spreading it on the bread. A cell phone charger and cell phone were observed on the serving counter amongst beverages and food items to be placed on the meal trays. An interview with [NAME] #100 at the time of the observation revealed a scoop was available which he could retrieve and use for placing the roast beef onto the bread. Review of the facility policy titled Food Safety Requirements, dated 2023 noted food should be covered when traveling down the hallway. Gloves should be worn when directly touching ready-to-eat foods, and staff should not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. Interview with the Director of Nursing on 02/13/25 at 3:45 P.M. revealed all residents received food served in the kitchen. There were no residents who had orders to receive nothing by mouth. This deficiency represents non-compliance investigated under Complaint Number OH00162594.

Based on observation, interviews, and policy review the facility failed to serve food at an appropriate temperature. This affected the 22 residents observed for lunch service, Residents #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43. Census was 43. Findings include: Observations on 12/13/25 at 12:55 P.M. revealed a test tray left the kitchen with resident meals trays and arrived at the unit at 12:59 P.M. Certified Nurse Assistant (CNA) #102 started passing the meal trays to the residents at 1:09 P.M. At 1:29 P.M., after the last resident was served, the test tray was sampled. The temperature of the roast beef and mashed potatoes was 100 degrees Fahrenheit. The roast beef was dry and the gravy was salty. The food temperatures were verified by CNA #102. The residents who received meal trays from the food cart with the test tray included Residents #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43. Interviews on 02/13/25 from 1:33 P.M. to 1:40 P.M. with Resident #33, #34, and #43 revealed the food was not hot, it was warm. The residents also stated the meat was dry. Review of the facility policy Record of Food Temperatures, dated 2023 revealed foods were to be held at 135 degrees Fahrenheit or greater. This deficiency represents non-compliance investigated under Complaint Number OH00162594.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #45's funds were disbursed timely after discharge. This affected one resident (#45) of three residents reviewed for resident funds. Facility census was 44. Findings include: Review of Resident #45's closed medical record revealed an admitted [DATE] with diagnoses including cardiac murmur, depression, anxiety disorder, dementia with mood disturbance, pneumonia and hyperlipidemia. Resident #45 discharged to another facility on 09/05/23 and did not return to this facility. Review of Resident #45's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively intact and required supervision to limited assistance for most activities of daily living. Review of a nurses' note dated 09/05/23 revealed Resident #45 was discharging that date to another facility. Review of Resident #45's life care contract with the facility signed by the resident on 09/30/04 revealed she would be charged $800.00 per month for care at the facility for the rest of her life, even upon move-in to assisted living or skilled nursing from her villa. Review of Resident #45's financial ledger dated 02/13/24 revealed the following monthly charges during her skilled nursing stay: May 2023: Haircuts (2), perm and set, shampoo and tip totaling $124.50 June 2023: $350.00 per day from 06/02/23 to 06/19/23 totaling $6300.00 July 2023: $325.00 per day from 07/10/23 to 07/31/23 totaling $7150.00 August 2023: $340.00 per day from 08/01/23 to 08/31/23, hair set, tip and shampoo totaling $10579.60 September 2023: $340.00 per day from 09/01/23 to 09/04/23 totaling $1360.00 The bottom of the ledger indicated there was a credit of $25,514.10. Interview on 07/23/24 at 8:50 A.M. with Executor of Estate (EE) #299 revealed back in 2023, the facility had overcharged Resident #45 while she was a resident in the skilled nursing facility. In January 2024, he identified there was a mistake with Resident #45's accounting due to this overcharging, the facility's corporation had been contacted and a credit was due to Resident #45's estate but the credit had not been received as of the time of the interview. Interview on 07/23/24 starting at 2:20 P.M. with Accounting Manager (AM) #310 and [NAME] Specialist (BS) #309 revealed Resident #45 was a resident here before the facility's corporation came along. Resident #45 had a special life care contract in place which indicated she would be charged $800.00 per month regardless of her level of care. Over Resident #45's time on the facility's campus, she lived in a villa but was admitted to this skilled nursing facility on 05/20/23 where she resided until 09/05/23. At some point (date not known) the facility's corporate billing personnel determined Resident #45 was overcharged while she was in the facility for six months and the money was going to be returned to Resident #45 but neither AM #310 or BS #309 could state if this had actually been done. Phone interview on 07/23/24 at 2:22 P.M. with Corporate Accounts Receivable Director (CARD) #311 with AM #310 and BS #309 present revealed Resident #45 had a specialized contract that dictated she would be charged a set amount per month for care needs. CARD #311 stated around February 2024 there was discussion about a discrepancy between Resident #45's contract and her charges while she had been a resident of the skilled nursing facility. CARD #311 indicated the last correspondence with EE #299 regarding the overpayment had been on 06/28/24 and she was unaware of any further movement with the credit since this date. CARD #311 also shared refunds of resident accounts did not take this long and were usually resolved under 90 days. Review of a financial statement dated 03/31/24 revealed Resident #45's account had a credit of $25,514.10. Review of e-mails between the facility and EE #299 revealed he provided the facility with needed wire transfer information on 06/27/24 at 8:39 P.M. to obtain the overpayment. There were no e-mails after 06/28/24. Follow-up phone interview on 07/24/24 at 10:28 A.M. with CARD #311 confirmed she learned of Resident #45's life care contract in February 2024 and that is when the adjustments to her account were made leading to a credit of $25,514.10. CARD #311 verified there was no evidence the facility's corporation had disbursed the overpayment to Resident #45's estate as of the time of the interview. Review of the facility policy, Resident Personal Funds, revised 04/01/24 revealed upon the discharge, eviction or death of a resident the facility will convey within 30 days the residents' funds and a final account of those funds to the resident or in the case of death, the individual or probate jurisdiction administering the resident's estate in accordance with state law. This deficiency represents noncompliance investigated under Complaint Number OH00154864.

Based on observations, interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 35 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. Findings Include: A tour of the kitchen on 02/20/24 from 8:00 A.M. to 8:15 A.M. revealed the reach-in refrigerator had dried milk on the bottom of it and a container of gravy was not labeled or dated and had a plastic spoon in it, the microwave had dried food splatter inside, the steam table had food splatter on it, the reach-in freezer had a bag of chicken not labeled or dated and stuck to the bottom of the freezer. This was verified by the Administrator on 02/20/24 at 8:17 A.M. Interview on 02/22/24 at 10:27 A.M. with Registered Dietitian (RD) #264 revealed that she does not inspect the kitchen. Corporate staff inspects the kitchen. Review of the facility policy titled, Food safety Requirements, dated 01/16/23, revealed basic cleaning equipment will be maintained in a clean and sanitary condition after every use to ensure food safety. Leftovers and opened items shall be clearly labeled with date the food item is to be discarded.

Based on record review and interview, the facility failed to ensure the facility assessment was accurate and thorough regarding facility staffing. This had the potential to affect all 35 residents in the facility. Findings Include: Review of the facility assessment dated [DATE] revealed staffing was sufficient regarding the current amount of staff needed to care for the number and acuity of residents. There was no indication of the type and number of staff needed to provide care and services. Interview on 02/21/24 at 11:09 A.M. with Corporate Registered Nurse (RN) #298 confirmed the facility assessment was not thorough and accurate.

45441 Based on record review, staff interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of the pain medication for Residents #9, #10, #16, and #341 and did not ensure as needed (PRN) pain medications and failed to ensure parameters were in place for Resident #10's PRN pain medication. In addition, the facility failed to ensure PRN antianxiety were not used for longer than 14 days without rationale or review for Resident #16. This affected four residents (#9, #10, #16, and #341) of five residents reviewed for unnecessary medications. The facility census was 35. Findings include: 1. Record review revealed Resident #341 was admitted to the facility on [DATE] with diagnoses including fracture of right pubis, hemiplegia, and hemiparesis following cerebrovascular disease and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #341 was cognitively intact and required partial or moderate assistance with for activities of daily living. Review of the physician's orders for February 2024 revealed Resident #341 was ordered to receive opioid pain medication, Oxycodone 5 milligrams (mg) every six hours as needed (PRN). Review of the medication administration record (MAR) revealed Resident #341 received doses of PRN Oxycodone from 02/03/24 to 02/20/24 at least once a day except for 02/10/24. Review of Resident #341's Care Pathways in the medical record revealed to administer pain medication per order if non-medication interventions are ineffective. Review of the resident's medical record revealed no evidence non-pharmacological interventions were attempted prior to the use of the PRN Oxycodone for the dates noted above. Interview on 02/20/24 at 9:35 A.M. with Resident #341 revealed that she would like a shower daily to help her with her lower back pain. Resident #341 stated that she gets her regularly scheduled showers but not extra ones. Interview on 02/21/24 at 10:49 A. M. with Director of Nursing (DON) revealed a resident could get a shower whenever they want one. The DON could not produce documented evidence Resident #341 received showers except for scheduled shower days. DON also verified that there was no documented evidence nonpharmacological interventions were attempted prior to administrating pain medication for Resident # 341. 2. Review of the medical record for Resident #9 revealed and admitted [DATE] with diagnosis including multiple sclerosis, dementia, bipolar disorder, muscle contracture, schizoaffective disorder, depression, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 was cognitively intact. He required setup help for eating and oral hygiene and was dependent for toileting, showering, and personal hygiene. Review of the physician's orders for February 2024 revealed an order for Acetaminophen 325 mg (analgesic) by mouth (PO) every four hours PRN for pain. Review of the physician's orders for January 2024 revealed an order Hydrocodone 325 mg (opioid pain medication) PO every 12 hours PRN for severe pain of eight to ten on a one to ten pain scale, beginning on 01/24/24. Review of the MAR for December 2023 revealed Resident #9 received one dose of Acetaminophen on 12/07/23 for a pain level of eight. Review of the MAR for January 2024 revealed Resident #9 received one dose of Acetaminophen on 01/09/24 for a pain level of eight. Review of the MAR for February 2024 revealed Resident #9 received one dose of Acetaminophen on 02/02/24 for a pain level of six. Review of the medical record revealed no documented evidence non-pharmacological interventions were attempted prior to the administration of Acetaminophen at any time for Resident #9. Interview on 02/21/24 at 3:05 P.M. with the DON confirmed the facility had no documented evidence nonpharmacological interventions should be or were attempted for Resident #9's PRN pain medications. 3. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including dementia, depression, kidney failure, muscle weakness, and pain. Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 was severely cognitively impaired. She required supervision for eating, and was dependent for oral hygiene, personal hygiene, and toileting. Review of the physician's orders for February 2024 revealed an order for Acetaminophen 325 mg PO every six hours PRN for pain and Tramadol 50 mg (opioid pain medication) PO every eight hours PRN for pain. There were no parameters for at what pain level the Tramadol would be administered. Review of the MAR for January 2024 revealed Resident #10 received Tramadol one time on 01/25/24 for a pain level of seven. Interview on 02/21/24 at 3:05 P.M. with the DON confirmed the facility had no documented evidence nonpharmacological interventions should be or were attempted for Resident #10's PRN pain medications. She also confirmed there were no parameters for the use of Tramadol for Resident #10. 4. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including dementia, insomnia, depression, muscle weakness, anxiety, and abnormal posture. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. She required set-up help for eating, partial to moderate assistance for oral hygiene, and was totally dependent for toileting, showering, and personal hygiene. Review of the physician's orders for February 2024 revealed an order for morphine sulfate 100 mg (opioid pain medication) PO every hour PRN for moderate to severe pain, an order for Acetaminophen 325 mg PO every six hours PRN for pain and Ativan 1 mg (antianxiety medication) every four hours PRN for anxiety. There was no end date for the distribution of the PRN Ativan. Review of the MAR for December 2023 revealed Resident #16 received morphine one time on 12/03/23 for a pain level of eight, one time on 12/05/23 for pain level of eight, one time on 12/11/23 for a pain level of eight, one time on 12/12/23 for a pain level of six, one time on 12/15/23 for a pain level of seven, and one time 12/17/23 for pain level of seven. The resident received PRN Ativan one time each on 12/03/23, 12/11/23, 12/13/23, 12/17/23, and 12/27/23. Review of the MAR for January 2024 revealed Resident #16 received morphine one time on 01/21/24 for pain level of six, one time on 01/23/24 for a pain level of seven, one time on 01/27/23 for a pain level of eight, one time on 01/28/23 for a pain level of seven, three times on 01/28/24 for a pain level of five, seven, and seven, and one time on 01/30/24 for a pain level of seven. The resident received PRN Ativan one time each on 01/08/24, 01/17/24, 01/18/24, 01/19/24, 01/20/24, and 01/24/24. Review of the MAR for February 2024 revealed Resident #16 received morphine one time on 01/01/24 for a pain level of ten and one time on 01/01/24 for a pain level of eight, one time on 01/09/24 for a pain level of nine, one time on 01/10/24 for pain level of eight, one time on 01/11/24 for pain level of a eight, one time on o1/15/24 for a pain level of eight ,and one time on 01/20/24 for a pain level of nine. The resident received PRN Ativan one time each on 01/01/24, 01/02/24, and 01/03/24 and two times on 01/19/24 and 01/20/24. Review of the medical record revealed no evidence non-pharmacological interventions were attempted prior to the administration of morphine at any time for Resident #16. Interview on 02/21/24 at 3:05 P.M. with the DON confirmed the facility had no documented evidence nonpharmacological interventions should be or were attempted for Resident #16's PRN pain medications. She also confirmed there was no stop date or rationale for the PRN Ativan for Resident #16. Review of the facility policy titled Pain Management, dated 10/17/22, revealed the facility would attempt non-pharmacological interventions as part of the pain management process.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure Resident #5 and Resident #292 received assistance with activities of daily living (ADL). This affected two residents (#5 and #292) of 35 residents reviewed for ADL care. The facility census was 35. Findings Include: 1. Review of the medical record for Resident #5 revealed an admitted on 03/04/16. Diagnoses include multiple sclerosis and muscle weakness. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was dependent for personal hygiene, toileting, and showers. Review of the plan of care dated 11/21/22 for ADL due to multiple sclerosis revealed inventions included assist Resident #5 with ADL completion as needed, and resident will participate in activities as ordered. Showers were to be given Tuesdays and Fridays. Interview on 02/20/24 at 11:54 A.M. with Resident #5 revealed she does not always get her showers per shower schedule. Resident #5 stated she does not feel there was enough staff to provide residents with all of their showers and grooming. Resident #5 was very upset that she had visible chin hairs and wanted them shaved. Observation at the time of the interview revealed visible chin hairs approximately one inch long. Review of the shower sheets and shower task documentation revealed Resident #5 did not receive a shower or bed bath from 01/23/24 through 02/02/24 (10 days). Interview on 02/21/24 at 3:00 P.M. with the Director of Nursing (DON) verified there was no documented evidence Resident #5 received showers from 01/23/24 to 02/02/24. Review of the facility policy Resident Showers, dated 10/17/22, revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 2. Review of the medical record for Resident #292 revealed admitted [DATE]. Diagnosis included depression, cognitive communication deficit, unsteadiness on feet, and surgical aftercare. Review of baseline assessment dated [DATE] revealed Resident #292 required two assists for bed mobility, toileting, and showers. Review of the shower sheets and shower task documentation revealed no documented evidence showers were provided for Resident #292 since admission on 02/14/24 through 02/20/24. Interview on 02/20/24 at 11:05 A.M. with Resident #292 stated she would love to be shaved. Resident #292 stated she does not like having long chin hair. Observation at the time of the interview Resident #292 had chin hair approximately one inch to one and a half inches on chin. Interview on 02/20/24 at 3:39 P.M. with Licensed Practical Nurse (LPN) #200 verified Resident #292 has long chin hair and needed to be shaved. Review of the facility policy Activities of Daily Living (ADL), dated 10/17/22, revealed residents who are unable to carry out ADL will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interview, and record review the facility did not ensure Resident #10 had her wound dressing changed as ordered by the physician. This affected one resident (#10) of one resident reviewed for wound care. The facility census was 35. Findings Include: Review of the medical record revealed an admitted [DATE]. Diagnoses included dementia, depression, stage four pressure ulcer of the sacral region and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. She was totally dependent on staff for oral hygiene, showering or bathing, personal hygiene, and toileting. Review of the physician's orders for February 2024 revealed an order dated 02/18/24 to cleanse the right upper buttock with saline, apply a small amount of Santyl (ointment used to remove damaged tissue) to the wound bed and cover it with an island border foam dressing. The treatment was to be completed daily and as needed in the morning. Review of progress note dated 02/18/24 revealed a wound to the right upper buttock was identified. The wound appeared to be white in color with pink surrounding tissue. Review of the wound assessment dated [DATE] revealed right upper buttock was evaluated by the wound nurse, and a dressing was applied. The wound measured 2.2 centimeters (cm) by 2.0 cm in size, stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough). Review of the Treatment Administration Record for February 2024 revealed no documented evidence the dressing change was completed on 02/20/24. Observation on 02/21/24 at 10:00 A.M. of Resident #10's wound care with Licensed Practical Nurse (LPN) #209 revealed the dressing on Resident #10's right upper buttock revealed a dressing was dated 02/19/24. Interview on 02/21/24 at 10:15 A.M. with LPN #209 verified Resident #10's right upper buttock wound should have been changed on 02/20/24 and was last changed on 02/19/24. 45441

Based on observation, interview, record review, and review of manufacture guidelines for urinary drainage bag the facility failed to ensure proper infection control practices for Resident #4 when his indwelling Foley catheter bag was lying on the floor. This affected one resident (#4) of one resident reviewed for indwelling Foley catheter care. The facility census was 35. Findings Include: Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnosis including neuromuscular dysfunction of bladder and diabetes mellitus. Review of the physician orders for February 2024 revealed an order for an indwelling Foley catheter care every shift. Review of the plan of care 01/18/24 for indwelling Foley catheter due to urinary obstruction. Intervention included staff will keep the indwelling Foley catheter drainage bag off the floor and below bladder level. Observation on 02/20/24 at 10:28 A.M. of Resident #4 revealed observation of the resident sitting in a recliner with the indwelling Foley catheter bag lying on the floor. Interview on 02/20/24 at 10:30 A.M. with Resident #4 revealed staff puts his indwelling Foley catheter bag on the floor or hangs it on the bottom of his wheelchair. Interview on 02/20/24 at 3:20 P.M. with Licensed Practical Nurse (LPN) #200 verified no indwelling Foley catheter bag should be lying on the floor at any time. The indwelling Foley catheter bag should be hung up and below the level of the bladder. Review of the manufacture guidelines for urinary drainage bag revealed hang bag utilizing the hanger or rope. Do not place bags on floor.

Based on observation, record review, and interview the facility failed to ensure Resident #6 and Resident #12 who were dependent on staff assistance for activities of daily living (ADL) received proper assistance with transfers. This affected two residents (Resident #6 and Resident #12) out of four residents reviewed for ADL. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnosis of chronic kidney disease, abnormal posture, lack of coordination, unsteadiness on feet, acute kidney failure, morbid severe obesity, hypertension, and hypothyroidism. Review of the initial Physical Therapy Evaluation for Resident #6 done on 09/07/22 revealed to transfer the resident with mechanical lift and assist of one. Review of the physician orders dated 10/26/22 revealed Resident #6 orders included transfer/mobility with full body mechanical lift assist of one. Review of the plan of care, dated 12/09/22 for transfer and mobility revealed the resident required a full body mechanical lift assist of one. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 required total dependence of two plus assistance for transfers. Review of Resident #6's medical record revealed the plan of care and physician orders were not updated to reflect the residents most recent MDS on 06/04/23 assessment identifying the resident required two person assistance with transfers. There was no evidence the resident was assessed by therapy after the MDS identified the resident needing two person assistance. Interview on 07/03/23 at 11:46 A.M. with Therapy Director (TD) #144 revealed all residents are screened upon admission for transfer status by therapy department and as needed. TD #144 reported she provided in-service to staff on the use of mechanical lifts. Observation on 07/05/23 at 12:52 P.M. revealed State tested Nursing Aide (STNA) #145 transfer the resident with the electric mechanical lift without locking the brakes when transferring Resident #6 into his electric wheelchair. During the transfer Resident #6 was leaning towards his left side. Interview on 07/05/23 at 1:03 P.M. with STNA #145 confirmed she did not lock the brakes on the mechanical lift as she should have. STNA #145 reported Resident #6 always leans to one side and that is why she didn't lock the brakes on the mechanical lift when lowering resident #6 into his electric wheelchair as required. Interview on 07/05/23 at 3:15 P.M. with Director of Nursing (DON) revealed residents are assessed for the level of transfer assistance required on admission and quarterly. Interview on 07/06/23 at 8:05 A.M. with DON confirmed mechanical lifts are required to have the brakes locked. Review of the manufacturer's guide for Maxi Move (electric mechanical lift) revised 03/2020 revealed on page six the policy on the number of staff members required for patient transfer. Stated lifts are designed for safe usage with one caregiver. However, there are circumstances such as combativeness, obesity, contracture etc. of the individual that may dictate the need for a two-person transfer. It is the responsibility of each facility or medical professional to determine if a one or two-person transfer is more appropriate, based on the task, resident load, environment, capability, and skill level of the staff members. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] and diagnosis included nontraumatic intracerebral hemorrhage, unsteadiness on feet, lack of coordination, dysphagia, hypertension, chronic kidney disease, stage 3, and dysphagia. Review of the the initial Physical Therapy Evaluation for Resident #12 dated 06/06/23 revealed the resident required assist of one with the manual sit to stand ([NAME] Stedy). Review of the plan of care, dated 06/08/23 revealed no evidence of the level of transfer assistance the resident required. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 required extensive with two plus assistance for transfers. Review of the progress notes dated 06/16/23 at 10:27 A.M. revealed Resident #12 had a witnessed fall with STNA #122 present to lower to floor using the manual sit to stand with only one assist. Progress notes further stated contributing factors to include two assist needed with resident due to right sided weakness. Interview on 07/03/23 at 11:46 A.M. with Therapy Director (TD) #144 revealed all residents are screened upon admission for transfer status by therapy department and as needed. TD #144 reported she provided in-service to staff on the use of mechanical lifts. Observation on 07/05/23 at 9:14 A.M. revealed STNA #122 transfer Resident #12 using a manual sit to stand lift. It took STNA #122 numerous attempts to get the resident up from the sitting position to transfer. STNA #122 had to give the resident many cues to complete the transfer. Interview on 07/05/23 at 9:23 A.M. with STNA #122 confirmed Resident #12 should have been a two person assist with the manual sit to stand after pulling up the Kardex on her computer. STNA #122 reported she doesn't usually check the Kardex in the computer. Observation of the Kardex with STNA #122 confirmed Resident #12 required two person assistance with transfers. Interview on 07/05/23 at 9:51 A.M. with Director of Nursing (DON) confirmed Resident #12 required a manual sit to stand with two assist for transfers. DON reported Resident #12 had a fall on 06/16/23 with the manual sit to stand lift with one assist. DON reported the new intervention was two assist for sit to stand transfers. Review of the manufacturer's policy, [NAME] Stedy, dated 12/2022, revealed on page 11 safety instructions, Warning: To avoid injury, a full clinical assessment of the patient's condition and suitability must be carried out by qualified personnel before attempting to use [NAME] Stedy for rehabilitation activities. This deficiency represents non-compliance investigated under Complaint Number OH00140148.

Based on observation, record review, and interview the facility failed to ensure Resident #6 was transferred safely and Resident #12's fall interventions were in place. This affected one Resident (Resident #6) out of two residents reviewed for accident hazards. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnosis of chronic kidney disease, abnormal posture, lack of coordination, unsteadiness on feet, acute kidney failure, morbid severe obesity, hypertension, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 required total dependence of two plus assistance for transfers. Observation on 07/05/23 at 12:52 P.M. revealed State tested Nursing Aide (STNA) #145 transfer the resident with the electric mechanical lift without locking the brakes when transferring Resident #6 into his electric wheelchair. During the transfer Resident #6 was leaning towards his left side. Interview on 07/05/23 at 1:03 P.M. with STNA #145 confirmed she did not lock the brakes on the mechanical lift as she should have. STNA #145 reported Resident #6 always leans to one side and that is why she didn't lock the brakes on the mechanical lift when lowering resident #6 into his electric wheelchair as required. Interview on 07/06/23 at 8:05 A.M. with DON confirmed mechanical lifts are required to have the brakes locked. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] and diagnosis included nontraumatic intracerebral hemorrhage, unsteadiness on feet, lack of coordination, dysphagia, hypertension, chronic kidney disease, stage 3, and dysphagia. Review of the the initial Physical Therapy Evaluation for Resident #12 dated 06/06/23 revealed the resident required assist of one with the manual sit to stand ([NAME] Stedy). Review of the plan of care, dated 06/08/23 revealed no evidence of the level of transfer assistance the resident required. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 required extensive with two plus assistance for transfers. Review of the progress notes dated 06/16/23 at 10:27 A.M. revealed Resident #12 had a witnessed fall with STNA #122 present to lower to floor using the manual sit to stand with only one assist. Progress notes further stated contributing factors to include two assist needed with resident due to right sided weakness. Interview on 07/03/23 at 11:46 A.M. with Therapy Director (TD) #144 revealed all residents are screened upon admission for transfer status by therapy department and as needed. TD #144 reported she provided in-service to staff on the use of mechanical lifts. Observation on 07/05/23 at 9:14 A.M. revealed STNA #122 transfer Resident #12 using a manual sit to stand lift. It took STNA #122 numerous attempts to get the resident up from the sitting position to transfer. STNA #122 had to give the resident many cues to complete the transfer. Interview on 07/05/23 at 9:23 A.M. with STNA #122 confirmed Resident #12 should have been a two person assist with the manual sit to stand after pulling up the Kardex on her computer. STNA #122 reported she doesn't usually check the Kardex in the computer. Observation of the Kardex with STNA #122 confirmed Resident #12 required two person assistance with transfers. Interview on 07/05/23 at 9:51 A.M. with Director of Nursing (DON) confirmed Resident #12 required a manual sit to stand with two assist for transfers. DON reported Resident #12 had a fall on 06/16/23 with the manual sit to stand lift with one assist. DON reported the new intervention was two assist for sit to stand transfers. Review of the manufacturer's policy, [NAME] Stedy, dated 12/2022, revealed on page 11 safety instructions, Warning: To avoid injury, a full clinical assessment of the patient's condition and suitability must be carried out by qualified personnel before attempting to use [NAME] Stedy for rehabilitation activities. This deficiency represents non-compliance investigated under Complaint Number OH00140148.

Based on observation, staff interview, and review of facility policy the facility failed to ensure kitchen staff wore appropriate hair coverings. This had the potential to affect 39 residents who received food from the kitchen. The facility census was 39. Findings include: Observation on 02/22/22 at 8:30 A.M. during tour of the kitchen, revealed Food Service Manager (FSM) #538 was not wearing a hairnet. Interview on 02/22/22 at 8:30 A.M. with FSM #538 confirmed he was not wearing a hairnet. Observation on 02/22/22 at 11:02 A.M. of the kitchen located on the [NAME] unit revealed Cook #580 was not wearing a hairnet. Interview on 02/22/22 at 11:02 A.M. with Cook #580 revealed she did not wear a hairnet because she wore her hair in braids and the hairnets did not fit. Cook #580 confirmed she was not wearing a hairnet. Observation on 02/22/22 at 12:14 P.M. revealed Cook #546 enter the kitchen located on the [NAME] unit without a hairnet. Interview on 02/22/22 at 12:14 P.M. with Cook #546 confirmed he was not wearing a hairnet. Observation on 02/22/22 at 12:30 P.M. of the door used to enter the kitchen located on the [NAME] unit, revealed a sign that informed staff that hair restraints and masks must be worn in the kitchen area. Review of the facility documents titled Dietary Services undated, revealed the facility had a policy in place to prevent contamination of food products and therefore prevent foodborne illness that included wearing hair nets. Review of the document revealed the facility did not implement the policy.

Based on observation, record review and interview the facility failed to properly prevent the potential spread of infections such as COVID-19 as evidenced by failing to ensure all staff and visitors were consistently screened for COVID-19 when entering the facility. This had the potential to affect all 39 residents currently residing in the facility. Findings include: Review with the Administrator of Staffing Schedules and the staff COVID-19 screening log form dated 02/15/22 revealed State tested Nursing Assistant (STNA) #502, STNA #504, Licensed Practical Nurse (LPN) #506, STNA #508, Housekeeping (HSK) #519 (tested positive for COVID-19 on 02/17/22), Cook #525, HSK #529, STNA #541, Activity Director (AD) #550, STNA #551, Activity Aide (AA) #553, LPN #558, STNA #559, STNA #567, STNA #572 Cook #580, AA #582, STNA #905, Kitchen #912 and Kitchen #913 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/16/22 revealed STNA #500, STNA #502, STNA #504, HSK #519, Cook #525, LPN #527, HSK #529, AD #550, Food Service #538, Cook #546, STNA #551, STNA #556, STNA #565, STNA #566, STNA #567, Medical Records #572, AA #573, AA #582, Kitchen #912 and Kitchen #913 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/17/22 revealed STNA #504, STNA #523, Cook #525, LPN #527, HSK #529, STNA #530, Food Service #538, Cook #546, STNA #555, STNA #556, STNA #560, STNA #564, STNA #565, STNA #566, STNA #570, STNA #572, Cook #580 and Kitchen #911 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/18/22 revealed STNA #500, STNA #508, STNA #509, Cook #525, LPN #526, HSK #529, STNA #530, HSK #537, Food Service #538, Cook #546, AD #550, AA #553, STNA #555, STNA #560, STNA #567, Medical Records #572, Cook #580, AA #582, STNA #906 and Kitchen #911 were not screened for COVID-19 prior to their work shift. Interview on 02/23/22 at 9:55 A.M. with STNA #567 indicated she was screened for COVID-19 on the [NAME] Unit upon entrance into the facility. Review of the staff COVID-19 screening log form dated 02/23/22 revealed STNA #567 did not sign the form indicating she was screened for COVID-19. Interview on 02/23/22 at 9:56 A.M. with LPN #521 confirmed STNA #567 did not screen for COVID-19 on the COVID-19 screening form as required. Interview on 02/23/22 at 9:57 A.M. with STNA #559 indicated she was screened for COVID-19 on the [NAME] Unit upon entry into the facility. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed STNA #559 did not sign the form confirming she was screened for COVID-19. Interview on 02/23/22 at 10:03 A.M. with STNA #566 indicated she had been employed in the facility two weeks and she forgot to screen for COVID-19 upon entry into the facility and prior to her work shift. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed STNA #566 did not sign the form confirming she was screened for COVID-19. Interview on 02/23/22 at 10:06 A.M. with Cook #580 indicated she was screened for COVID-19 upon entry into the building. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed Cook #580 did not sign the form confirming she was screened for COVID-19. Interview on 02/23/22 at 10:07 A.M. with Cook #546 indicated he was rushed and did not self-screen for COVID-19 upon entry into the building. Interview on 02/23/22 at 10:20 A.M. with Cook #580 confirmed she did not self-screen for COVID-19 prior to entrance into the building. Observation on 02/23/22 at 12:35 P.M. with Visitor #900 indicated he was in the facility to visit the nurse. Visitor #900 did not screen for COVID-19 prior to entering the nursing station. Interview on 02/23/22 at 12:36 P.M. with Visitor #900 confirmed he came into the facility to visit the nurse and did not self-screen for COVID-19 upon entry into the building. Observation on 02/23/22 at 2:09 P.M. with Resident #920's husband revealed the visitor did not self-screen for COVID-19 and sign the visitor COVID-19 screening log form upon entry into the building. Interview on 02/23/22 at 2:20 P.M. with Physical Therapist (PT) #901 confirmed Resident #920's husband did not appropriately screen for COVID-19 upon entry into the building. Interview on 02/24/22 from 9:54 A.M. with the Administrator confirmed staff (activity, dietary, nursing, housekeeping) and visitors were not consistently screening for COVID-19 upon entry into the building. Interview on 02/24/22 at 11:04 A.M. with Housekeeping Supervisor #540 confirmed her housekeeping staff did not screen for COVID-19 symptoms from 02/15/22 to 02/18/22. She indicated she self-screened on 02/24/22 in the assisted living portion of the facility. She also confirmed when staff entered the facility through the back entrance designated for employees, her staff were required to travel in the hall past two resident rooms to the nurses' station to screen for COVID-19 symptoms (on the [NAME] Unit). Housekeeping Supervisor #540 confirmed there was not a screening station at the back employee entrance. When asked, Housekeeping Supervisor #540 stated when staff were not screened consistently, COVID-19 infection may enter the building and the facility would have an outbreak. Interview on 02/24/22 at 11:26 A.M. with the Director of Nursing (DON) revealed she was not aware she had to screen for COVID-19 upon entry into the building to prevent potential transmission of COVID-19 to other staff and residents. She confirmed she signed the screening log form that she screened for COVID-19 on 02/24/22 which was the only entry on the form. The DON confirmed staff and visitors were required to self-screen for COVID-19 upon entry into the building. The DON was unable to provide the staff self-screening policy for COVID-19. When asked, the DON stated that when staff were not screened consistently, there was a risk of a COVID-19 outbreak. Review of the facility Visitation Policy dated 11/18/21 indicated visitors who have a positive [CONDITION(S)] test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility and facilities should screen all who enter for these exclusions. Review of the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 02/02/22 revealed options could include (but are not limited to) individual screening on arrival at the facility or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/infection-control-recommendations.html). This deficiency substantiates Complaint Number OH 581.

Based on observation, record review and interview the facility failed to implement their vaccination policy and monitor staff members, contract employees and visitors to ensure that 100% (percent) of staff have received at least one dose of a COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 97.3%. This had the potential to affect all 39 residents currently residing in the facility. Findings include: Observation on 02/22/22 at 10:10 A.M. revealed Volunteer #666 and Volunteer #667 were providing communion services to various residents. Both volunteers visit the facility approximately every three weeks to provide communion services. Observation on 02/22/22 at 10:13 A.M. revealed hospice State tested Nursing Assistant (STNA) #668 was in the nursing station on the [NAME] Unit. Interview on 02/22/22 at 10:14 A.M. with hospice STNA #668 confirmed she was in the facility to provide care for Resident #30 and she usually provided the resident's care on Tuesdays and Thursdays. Interview on 02/22/22 at 3:11 P.M. with the Director of Nursing (DON) confirmed the hospice companies did not provide the vaccination or exemption status of the employees and were not tracked by the facility according to the policy. The DON also revealed she thought Volunteers #666 and #667 were visitors and thus exempt from tracking for COVID-19 vaccination or exemption status. Interview on 02/23/22 at 10:50 A.M. with Volunteer #667's husband indicated he was called this morning for the COVID-19 vaccination card and he sent it in to the facility. Review of the undated COVID-19 Staff Vaccination Status for Providers form did not reveal evidence Volunteer #666, Volunteer #667 or STNA #668 were placed on the form to track for the vaccination status, exemption or temporary delay. Calculation of vaccination status including all three revealed the vaccination rate was 97.3% versus 100%when calculated without them. Review of the facility Vaccination Policy revised 02/08/22 confirmed within 30 days, the facility would have policies and procedures developed and implemented for ensuring all facility staff were vaccinated against COVID-19 and ensure that 100% of staff have received at least one dose of a COVID-19 vaccine, having a pending request for exemption, or have been identified as appropriate for a temporary delay per the CDC.

Based on personnel file review and interview the facility failed to ensure all new employees were checked against the State of Ohio Nurse Aide Registry. This affected seven of twelve staff reviewed and 39 residents in the facility. Findings include: Review of personnel files for the Administrator, Director of Nursing (DON), Food Service Manager (FSM) #538, Licensed Practical Nurse (LPN) #522, LPN #503, Registered Nurse (RN) #557, and RN #510 revealed their names were not verified through the State of Ohio Nurse Aide Registry (NAR) for findings concerning abuse, neglect, exploitation, misappropriation of property, or mistreatment. Interview on 02/24/22 at 11:30 A.M. with the Human Resource Manager (HRM) #574 verified the Administrator, DON, FSM #538, LPN #522, LPN #503, RN #557, and RN #510 were not checked against the Nurse Aide Registry upon hire. All seven employees were subsequently checked against the NAR.

Based on observation, interview and record review the facility failed to develop and implement an individualized care plan related to the hygiene and application of a palm guard for Resident #12 regarding bilateral hand contractures. This affected one of three residents reviewed for activities of daily living (#12, #16, #40 and #398) and one resident (#12) reviewed for position and mobility. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for hygiene. Night shift to cleanse palms nightly with soap and water. Review of the comprehensive assessment (MDS 3.0) dated 12/17/21 indicated Resident #12 had severe cognitive impairment. She displayed other behavioral symptoms not directed toward others and rejected evaluation or care on one to three days of the assessment period. Resident #12 required the extensive assistance of two staff for bed mobility and personal hygiene. Review of the Activities of Daily Living (ADL) care plan indicated the interventions included Resident #12 will follow rehabilitation recommendations, receive pain medication prior to participation, utilize adaptive equipment as ordered and assist with completion with ADLs as necessary. There was no care plan found that specifically addressed use of a palm guard or hand hygiene related to contractures. Interview with and observation of Resident #12 on 02/22/22 at 11:45 A.M. indicated she was not able to open her left hand at all and the right hand opened slightly but her fingers did not extend. Her left hand was tightly fisted and bent in at the wrist. Her nails were chipped and jagged on both hands and her nails on her right hand were full of debris. She reported doing her own nail care by picking away at them. There was a sign posted in the bathroom indicating to cleanse and place a rolled-up wash cloth in her left hand. Resident #12 reported they used to something put in her left hand but was unable to say the last time that was done. She said she did her own exercises but both hands were painful. On 02/23/22 at 10:15 A.M. Resident #12's left hand remained closed tightly with no washcloth in her palm and the nails remained the same. She reported her hands had not been washed and there was no washcloth in her left hand. On 02/24/22 at 10:00 A.M. State tested Nurse Aide (STNA) #566 was observed completing hand hygiene on Resident #12. STNA #566 had never worked with Resident #12 previously. She prepared by running the water until it was warm, soaked a washcloth with the water and added a small amount of soap on the washcloth. STNA #566 began by wiping the outside of the left hand with the washcloth. Resident #12 winced a few times and when STNA #566 attempted to wipe the inside of the left hand the resident said she was hurting her wrist. With the first wipe, there was a yellow/brown thick plaque and debris on the washcloth. STNA #566 referred to the debris as gunk and said there was a lot in there verifying her hand not been cleansed in some time. STNA #566 kept turning the washcloth after each attempt at cleaning the left palm and between the fingers. An excessive amount of debris was removed after each wipe. Resident #12 said ouch, don't do it anymore and moved her hand away from the STNA, wincing in pain. STNA #566 stopped and got a new washcloth to clean the right hand. Resident #12 continued to complain while her right hand was cleansed. The fingernails were long and jagged and filled with old food and other brown debris. STNA #566 confirmed the resident's hands and nails had not been cleansed in a while. Resident #12 also confirmed her hands were not cleansed routinely. On 02/24/22 at 10:10 A.M. the Director of Nursing (DON) was informed of the observation. On 02/24/22 at 11:28 A.M. the DON verified a care plan had not been developed to address application of a palm guard or hand hygiene related to contractures.

Based on observation, interview and record review the facility failed to provide adequate hand hygiene and apply a palm guard as ordered for Resident #12 who was dependent for activities of daily living care. This affected one (Resident #12) of four residents (#12, #16, #40 and #398) reviewed for activities of daily living. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for hygiene. Night shift to cleanse palms nightly with soap and water. Review of the comprehensive assessment (MDS 3.0) dated 12/17/21 indicated she had severe cognitive impairment. She displayed other behavioral symptoms not directed toward others and rejected evaluation or care on one to three days of the assessment period. Resident #12 required the extensive assistance of two staff in bed mobility and personal hygiene. Review of the Activities of Daily Living (ADL) care plan indicated the interventions included Resident #12 will follow rehabilitation recommendations, receive pain medication prior to participation, utilize adaptive equipment as ordered and assist with ADLs as necessary. There was no care plan found that specifically addressed application of a palm guard or hand hygiene related to contractures. Review of the February 2022 Treatment Administration Record (TAR) revealed the nurses had signed indicating her left hand was cleansed with soap and water, allowed to dry, and a palm guard was applied twice daily and night shift cleansed her palms nightly with soap and water. Interview with and observation of Resident #12 on 02/22/22 at 11:45 A.M. indicated she was not able to open her left hand at all and the right hand opened slightly but her fingers did not extend. Her left hand was tightly fisted and bent in at the wrist. Her nails were chipped and jagged on both hands and her nails on her right hand were full of debris. She reported doing her own nail care by picking away at them. There was a sign posted in the bathroom indicating to cleanse and place a rolled-up wash cloth in her left hand. Resident #12 reported they used to something put in her left hand but was unable to say the last time that was done. She said she did her own exercises but both hands were painful. On 02/23/22 at 10:15 A.M. Resident #12's left hand remained closed tightly with no washcloth in her palm and the nails remained the same. She reported her hands had not been washed and there was no washcloth in her left hand. Interview with Licensed Practical Nurse (LPN) #522 on 02/23/22 at 10:28 A.M. reported Resident #12 complained of pain in her hands but would allow a washcloth to be put into it for periods of time per her request. She indicated Resident #12 refused to have her nails filed or cut by staff. On 02/24/22 at 10:00 A.M. State tested Nurse Aide (STNA) #566 was observed completing hand hygiene on Resident #12. STNA #566 had never worked with Resident #12 previously. She prepared by running the water until it was warm, soaked a washcloth with the water and added a small amount of soap on the washcloth. STNA #566 began by wiping the outside of the left hand with the washcloth. Resident #12 winced a few times and when STNA #566 attempted to wipe the inside of the left hand the resident said she was hurting her wrist. With the first wipe, there was a yellow/brown thick plaque and debris on the washcloth. STNA #566 referred to the debris as gunk and said there was a lot in there verifying her hand not been cleansed in some time. STNA #566 kept turning the washcloth after each attempt at cleaning the left palm and between the fingers. An excessive amount of debris was removed after each wipe. Resident #12 said ouch, don't do it anymore and moved her hand away from the STNA, wincing in pain. STNA #566 stopped and got a new washcloth to clean the right hand. Resident #12 continued to complain while her right hand was cleansed. The fingernails were long and jagged and filled with old food and other brown debris. STNA #566 confirmed the resident's hands and nails had not been cleansed in a while. Resident #12 also confirmed her hands were not cleansed routinely. On 02/24/22 at 10:10 A.M. the Director of Nursing (DON) was informed of the observation. On 02/24/22 at 11:28 A.M. the DON confirmed the nurses had been signing the TAR to indicate Resident #12's hands were cleansed and the palm guard was applied twice a day and her hands were cleansed nightly.

Based on review of a closed medical record, the facility policy related to Cardiopulmonary Resuscitation, the American Red Cross Cardiopulmonary Resuscitation (CPR) steps, Department of Public Health and Human Services CPR information, Emergency Medical Service (EMS) care record, and staff interview the facility failed to initiate CPR timely for one resident (Resident #40) who was found unresponsive, without a pulse or respirations, and was identified as a full code status. This resulted in Immediate Jeopardy and life-threatening harm when Resident #40 did not immediately receive CPR and expired in the nursing facility. This affected one of three residents reviewed for full code status and death. The facility identified 17 residents residing in the facility designated with full code status. The facility census was 39. On [DATE] at 5:35 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 3:54 A.M. when Resident #40 was found unresponsive lying face down on the floor next to his bed by State tested Nursing Assistant (STNA) #51. STNA #51 immediately alerted Licensed Practical Nurse (LPN) #50. Upon entering the room LPN #50 took a photo of Resident #40, sent the photo to the Assistant Director of Nursing (ADON) and called for further instruction, incontinence care was provided, and then Resident #40 was lifted back into his bed, all prior to initiating CPR or calling EMS. When EMS arrived, CPR was discontinued, and pronouncement of death was made at 4:23 A.M. Immediate Jeopardy was removed on [DATE] when the facility implemented the following: · On [DATE], the Director of Nursing (DON) assigned an educational handout to be read by all nurses and STNAs on the facility ' s policy for CPR and change of condition. The educational handout was placed in a educational binder which staff are required to review monthly. After reading the educational handout staff sign, they have read and understood the information. The educational assignment is to be completed by [DATE]. · On [DATE] at 5:35 P.M., the DON verbally educated the ADON, Registered Nurse (RN) #55 and LPN #56, who were part of the nursing management staff, and the day shift nurses RN #57 and LPN #58 on the facility's change of condition policy and initiating the ABC's (refers to A-airway, B-breathing, and C-circulation) of CPR. · On [DATE] at 8:45 P.M. the DON created a handout on initiating and the ABC's of CPR. The handout was emailed to LPN #60 and RN #61, the night shift nurses scheduled on [DATE]. The DON verbally educated LPN #60 an LPN #61 via phone as they followed along with handout on CPR. The handouts were signed and returned to the DON's mailbox. · The remaining nursing staff including STNAs will be educated verbally one on one by the DON, Minimum Data Set (MDS) Nurse or the Nursing Supervisor prior to starting their next shift. The education will include Change of Condition policy, CPR policy and ABC's of CPR. All education to be completed by [DATE]. · On [DATE] at 2:30 P.M., LPN #50 was counseled on failure to initiate CPR timely. LPN #50 was educated on the ABC's of CPR, the facility's Change of Condition policy and procedure, the CPR policy, Resident's Rights and Social Media policy. · Starting on [DATE] weekly audits will be conducted by the DON, MDS Nurse or the Nursing Supervisor on residents who ceased breathing to determine if CPR was initiated according to Advanced Directives. Audits will be conducted for three months ending [DATE]. The weekly findings will be reported to Quality Assurance and Performance Management (QAPI) committee on a weekly basis. · Starting on [DATE] weekly audits will be conducted by the DON, MDS nurse or the Nursing Supervisor on five resident charts to ensure accuracy of Advanced Directives. Audits will be conducted for three months ending [DATE]. The weekly findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee on a weekly basis. · Interviews on [DATE] from 6:15 A.M. to 12:30 P.M. with RN #63, RN #64, LPN #60, LPN #65, STNA #62 and STNA #66 revealed they were trained on the change of condition policy, the CPR policy and where to locate code status. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine further action if required. Findings Include: Review of Resident #40's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the advance directive order in the electronic medical record dated [DATE] revealed Resident #40 was a full code. Review of the care plan dated [DATE] revealed the resident's code status was not included. Review of Resident #40's compressive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance with bed mobility, transfers and toileting, ambulation did not occur. Review of a nurse progress note dated [DATE] timed 5:40 A.M. revealed an STNA notified the nurse Resident #40 was unresponsive, code status was verified, CPR started, and 911(EMS) was contacted. Review of a nurse progress note dated [DATE] timed 6:00 A.M. revealed EMS pronounced time of death at 4:23 A.M. and family and physician were notified. Review of the nurse progress noted dated [DATE] timed 12:19 P.M. and marked as a late entry for 9:30 A.M. revealed the funeral home was contacted and arrangements made to pick up Resident #40. Review of the facility investigation dated [DATE] revealed the STNA notified the nurse Resident #40 had fallen from bed and was unresponsive. Upon walking in the room, the resident was on his left side face down with a leg immobilizer on his left leg and protective boots on his feet. The resident's code status was verified. The resident was absent of respirations and pulse and CPR was started and 911 was called. Review of five witness statements regarding the events of Resident #40's death revealed the statements did not include dates or times. The information in the witness statements included the following: 1. STNA #51 indicated he found Resident #40 laying on the floor unresponsive and notified LPN #50. 2. STNA #53 indicated when she arrived the resident had stool up his back and incontinence care was provided. The nurses checked his vitals, and none were detected. Resident #40 was rolled on to a draw sheet and placed into bed. Someone stated he was a full code and the nurse started CPR. 3. LPN #52 indicated she was called by LPN #50 to bring supplies to take vital signs including a stethoscope. She checked the resident ' s vitals, and none were present. CPR was initiated by LPN #50 and LPN #52 called 911. LPN #52 switched out and continued compressions. 4. LPN #50 indicated the resident was found on the floor unresponsive, code status was checked, and CPR was initiated. Another nurse called 911 and the STNA got the crash cart. EMS arrived and were unsuccessful in reviving Resident #40. 5. The ADON indicated she received a photo from LPN #50 during an emergency situation. The nurse was instructed to initiate CPR and phone 911. Interview with STNA #53 on [DATE] at 4:22 P.M. revealed she was at the nurses' station with LPN #50 on [DATE] when STNA #51 notified LPN #50 Resident #40 was found unresponsive on the floor. STNA #53 entered the room and found Resident #40 lying face down on the floor perpendicular to the bed. Resident #40 s head was located near the foot of the bed, he had an immobilizer on one leg and stool on his buttocks. STNA #53 provided incontinence care. LPN #52 came from another unit and they lifted Resident #40 back into bed and LPN #50 started CPR. STNA #53 was unsure of the time and stated she was getting ready to go on break with LPN #50. Interview with LPN #50 on [DATE] at 4:42 P.M. revealed on [DATE] at 4:00 A.M. she was at the nurses' station with STNA #53 and was notified Resident #40 was unresponsive. LPN #50 checked the resident's code status while at the nurses' station, determined the resident was a full code, and proceeded to Resident #40's room. Upon arrival Resident #40 was lying on the floor not breathing. LPN #50 took vitals, put Resident #40 back into bed, called 911 and started CPR. LPN #52 came down to assist with CPR and they traded off. EMS arrived and instructed her to stop CPR and pronounced time of death. Interview with STNA #51 on [DATE] at 11:19 A.M. revealed on [DATE] between 3:30 A.M. and 4:00 A.M. he found Resident #40 unresponsive laying on the floor next to his bed. Resident #40 was not wearing a gown, his incontinence brief was lying to the side, he had heel protectors on his feet, and a leg immobilizer was in place. There was a smear of stool on the resident's buttocks. STNA #51 went to the nurses' station and immediately notified LPN# 50. LPN #50 and STNAs #51 and #53 returned to the room. STNA #51 saw LPN #50 take a picture of the resident. LPN #53 came from another unit and they lifted Resident #40 into bed and LPN# 50 started CPR. STNA #51 left the room. Interview with LPN #52 on [DATE] at 1:36 P.M. revealed on [DATE] (no time provided) she was called by LPN #51 to come to Resident #40 ' s room and upon arrival found the resident on floor. The resident had no breath sounds and she took vital signs. Resident #40 was lifted back into bed and she instructed LPN #50 to start CPR, called 911 and got the crash cart. LPN #50 and #53 took turns providing CPR. Interview with the ADON on [DATE] at 8:37 A.M. revealed LPN #50 called her hysterically on [DATE] about 4:00 A.M. Resident #40 was found on the floor unresponsive. The ADON instructed her to start CPR and call 911. Later that morning she noticed LPN #50 had sent her a picture of Resident #40 on the floor which she deleted. Review of the EMS patient care record dated [DATE] revealed call received for male subject full arrest and a full code at 4:10 A.M. (16 minutes after Resident #40 was discovered), dispatched 4:12 A.M., at patient 4:20 A.M. Resident #40 was found to be asystolic (no heart beat) and cold to touch with no signs of life. Due to being last seen at approximately 2:00 A.M. and cold to the touch, CPR was not continued by EMS and all lifesaving efforts were stopped. Review of the camera footage dated [DATE] revealed at 3:54 A.M. STNA #51 entered Resident #40's room; at 3:56 A.M. LPN #50 entered the room; at 4:01 A.M. LPN # 52 entered the room; at 4:09 A.M. LPN #52 entered the room with the crash cart; at 4:12 A.M. EMS entered the room, and at 4:18 A.M. EMS exited room. Review of the American Red Cross CPR Steps at https://www.redcross.org/take-a-class/cpr/performing-cpr/cpr-steps revealed Step one is to tap the person on the shoulder and shout are you okay. Step two is to call 911 for assistance. Step 3 is to open airway and tilt head back. Step four is to check for breathing and initiate CPR. Review of the Department of Public Health and Human Services website regarding CPR dated [DATE] revealed circulating blood that contains oxygen is required to keep tissues in the body alive and functioning. The brain may sustain damage after blood flow has been stopped for about four minutes. There is irreversible damage to the brain after blood flow has stopped for seven minutes. To be successful, CPR should be started within six minutes of a person having a sudden [MEDICAL CONDITION]. Low body temperatures (hypothermia), seen in near-drownings and exposure to the cold, prolong the time that the brain can survive. Review of the facility policy titled CPR Cardiopulmonary Resuscitation dated [DATE] revealed in the case of cardiac or [MEDICAL CONDITION] arrest, basic life support is instituted immediately. This deficiency substantiates Complaint Number OH 863.

Based on record review and interview, the facility failed to ensure daily skin assessments and treatment were provided to prevent the developement of a pressure ulcer. This deficient practice resulted in harm to one resident who developed an avoidable, stage three (full thickness skin loss) pressure ulcer to the back. This affected one (Resident #104) of three residents reviewed for pressure ulcers. The facility census was 44. Findings include: Review of the medical record revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Acute Care Transfer paperwork dated 12/19/14 revealed the presence of one stage II (partial thickness skin loss) pressure ulcer located on the coccyx. Review of admission physician orders [REDACTED]. Review of the nurses progress notes dated between 12/19/14 and 12/24/14 contained no documentation pertaining to daily skin assessments of the resident's back. Review of the Treatment Administration Record (TAR) dated December 2014 revealed no documentation pertaining to daily skin assessments of the resident's back. Review of weekly documentation from the Wound Management Service dated 12/23/14 verified Resident #104 had one stage II pressure ulcer located at the sacral (coccyx) area. The report documented onset of the pressure ulcer was 12/19/14. There was no documentation of any other pressure ulcer on this weekly report. Review of weekly documentation from the Wound Management Service dated 12/31/14 verified the stage II pressure ulcer noted on 12/23/14 and an additional wound, a stage III (full thickness skin loss) to Resident #104's back. A new treatment was ordered and a measurement of the pressure ulcer for monitoring was completed. Interview with registered nurse (RN) #101 on 01/28/14 at 2:45 P.M. verified there was no documentation of the pressure area to Resident #104's back on admission and RN #101 verified the admitting nurse did not communicate the presence of pressure ulcer. RN #101 also verified the system was broken and the proper process was not followed by the admitting nurse. The admitting nurse was not available for interview. Interview with LPN #100 on 01/28/15 at 3:00 P.M. verified discovery of the pressure ulcer on Resident #104's back by LPN #100 on 12/24/14 when the physician was notified of the pressure ulcer and the treatment was initiated. Interview with RN #101 on 01/28/15 at 3:15 P.M. verified that the stage III pressure ulcer had not been identified, monitored or treated between 12/19/14 and 12/24/14. RN #101 verified there was no evidence skin assessments to the resident's back were completed daily as ordered prior to the developement of the stage III pressure ulcer.