Every finding on record at Copley Health Center

Based on resident interviews, observation of lunch meal, observation of test tray, review of resident council minutes, and review of facility policy, the facility failed to ensure meals were served at a palatable temperature. This had the potential to affect all residents who received meals from the kitchen. The facility identified eight residents (#4, #23, #94, #96, #127, #131 #144, and #149) who were on nothing by mouth (NPO) diet and did not receive food from the facility's kitchen. The facility census was 124.Findings include: Review of the resident council meeting minutes from 03/12/26 revealed residents complained of cold food.Interview on 03/16/26 at 11:09 A.M. with Resident #128 revealed the food was not palatable.Interview on 03/16/26 at 12:19 P.M. with family member of Resident #75 revealed the food was not always hot.Interview on 03/16/26 at 1:34 P.M. with Resident #2 revealed she voiced the food sucks. Interview on 03/17/26 at 8:55 A.M. with Resident #36 revealed the food was not always warm.A resident council meeting was held on 03/17/26 at 3:00 P.M. with Residents #31, #61, #64, #77, and #83. Residents reported food was frequently cold and the kitchen was not always using warming plates to keep food hot.Observation on 03/18/26 from 11:51 A.M. to 1:11 P.M. of the lunch meal service revealed the temperatures at the start of service were 190 degrees Fahrenheit (F) for hot dogs, 175 degrees F for baked beans, and 32 degrees F for coleslaw. At 1:11 P.M. the last cart for hallway trays was completed and contained a test tray. The cart arrived to the unit at 1:13 P.M. and staff completed passing trays at 1:17 P.M. Temperatures were obtained from the test tray by District Manager (DM) #913 using the facility's digital thermometer. Temperatures were 105 degrees F for the hot dog, 109 degrees F for the baked beans, and 36 degrees F for the coleslaw. Taste test of the hot dog and baked beans revealed the food was not a palatable temperature. DM #913 participated in tasting the test tray.Interview on 03/18/26 at 1:17 P.M. with DM #913 confirmed the hot dog and baked beans were not at an acceptable or palatable temperature.Review of the facility policy titled Food: Quality and Palatability dated September 2017 revealed food would be palatable, attractive, and served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number 1273862 (OH00163626) and 1273861 (OH00163574).

Based on record review, interview, and review of the facility policy, the facility failed to ensure consistent and accurate advanced directives were maintained throughout the electronic and physical medical records. This affected five residents (#9, #14, #18, #96, and #128) of five residents reviewed for advanced directives. The facility census was 124.Findings include:1.Review of Resident #9's electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar, moderate vascular dementia, delusional disorder, generalized anxiety disorder, cognitive communication deficit, uncomplicated hallucinogen abuse and chronic post-traumatic stress disorder.Review of Resident #9's physician orders in the EMR revealed her code status was for Cardiopulmonary Resuscitation (CPR) [full code]. Review of the advanced directive tab in the physical (paper) medical record revealed there was no documentation under the tab to indicate what the resident's advance directives were. Interview on [DATE] at 4:13 P.M. Registered Nurse (RN) #500 and Licensed Practical Nurse (LPN) #550 verified there was nothing under the advanced directives tab in Resident #9's paper chart and they did not have a separate code status book.2.Review of Resident #14's EMR revealed an original admission date of [DATE] and was re-admitted on [DATE]. Diagnoses included nonactive primary progressive multiple sclerosis, hypertensive heart and chronic kidney disease, chronic kidney disease stage two (mild), paraplegia and unspecified moderate dementia with mood disturbance. Review of Resident #14's orders in the EMR revealed her code status was Do Not Resuscitate-Comfort Care Arrest (DNR-CCA). Review of the advanced directive tab in the physical (paper) medical record revealed Resident #14 was Do Not Resuscitate-Comfort Care (DNR-CC).Interview on [DATE] at 4:13 P.M. with RN #500 and LPN #550 verified the advanced directives tab in the paper chart revealed Resident #14 was DNR-CC. They did not have a separate code status book. 3.Review of Resident #18's EMR revealed she was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder Bipolar, heart failure and essential hypertension. Review of Resident #18's orders in the EMR revealed a code status was CPR. Review of the advanced directive tab in the physical (paper) medical record revealed there was no documentation under that tab.Interview on [DATE] at 4:13 P.M. with RN #500 and LPN #550 verified the advanced directive tab in the paper medical record was empty of any documentation/paperwork. There was no separate code status book. 4.Review of Resident #96's EMR revealed he was admitted to the facility on [DATE] and re admitted on [DATE]. Diagnoses included unspecified intracranial injury with loss of consciousness of unspecified duration, aphasia and essential hypertension.Review of Residents #96's orders in the EMR revealed his code status was DNR-CCA. Review of the advanced directive tab in the physical (paper) medical record revealed there was no information regarding his code status.Interview on [DATE] at 4:13 P.M. with RN #500 and LPN #550 verified the advanced directive tab in the paper medical record was empty. There was no documentation under the advanced directive tab. There was no separate code status book.5.Review of Resident #128's EMR revealed an admission date to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's disease, moderate dementia in other disease with mood disturbance, diabetes mellitus II with hyperglycemia and hypertensive heart disease with heart failure.Review of Resident #128's orders in the EMR revealed his code status was CPR. Review of the advanced directive tab in the physical (paper) medical record revealed the code status for Resident #128 was DNR-CC.Interview on [DATE] at 4:13 P.M. with RN #500 and LPN #550 verified the advanced directive tab in the paper chart stated Resident #128 was DNR-CC. There was no separate code status book. Review of the facility policy, Advance Directive (Resident's Right to Choose), with a revision date of [DATE] revealed should the resident have an Advance Directive, copies will be made and filed in the resident's electronic health record and in the resident's physical (paper) medical record as well as communicated to the staff.

Based on observation, interview, record review, review of manufacturer information, and facility policy review, the facility failed to ensure strength of wound care solutions were specified in a physician order. This affected one Resident #15 of three residents observed for wound care. The facility census was 124. Findings include: Review of the medical record for Resident #15 revealed diagnosis of Alzheimer's, atrial fibrillation, malnutrition, depression and dysphagia.Review of Resident #15's physicians' order dated 03/05/26 for a wound dressing to the sacrum stated to cleanse with wound cleaner, pack with Dakin's solution moistened gauze and apply triad cream, zinc oxide based, around the outside of the wound. and cover with boarder foam dressing. The wound order to the sacrum did not identify a strength for Dakin's Solution.Review of the undated available Dakin's Solution products on the manufacturer's website revealed Dakin's solution is available in full strength (0.5 percent) (%), half strength (0.25%), quarter strength (0.125%) and as a Diluted Dakin's solution with the lowest strength of 0.0125%. Observation on 03/18/26 at 10:46 A.M. with Registered Nurse (RN) #544 providing wound care to Resident #15 revealed the nurse gathered supplies, including Dakin's 0.0125 % solution. RN #544 stated the Dakin's solution was quarter strength. RN #544 cleansed the wound with wound cleanser and packed the wound with gauze saturated with Dakin's 0.0125%, applied Triad cream around edges of the wound and applied a foam dressing. Interview on 03/18/26 at 11:00 A.M. with RN #544 verified the wound order did not have a specified strength to the Dakin's solution. RN #554 stated the order was not clarified to obtain the desired strength of the Dakin's solution. RN #544 thought Dakin's 0.0125% was quarter strength. RN #544 stated she would notify the resident's Nurse Practitioner (NP) to get a one-time order to use Dakin's 0.0125% for the wound dressing she had already completed. Review of the facility policy titled Medication Management undated policy stated to administer medication only as prescribed by the provider and observe the five rights in giving each medication. The right resident, the right time, the right medicine, the right dose, and the right route.

Based on record review, policy review and interview, the facility failed to ensure transportation to and from scheduled eye surgery for Former Resident #120. This affected one (Former Resident #120) of three residents reviewed for transportation assistance. Findings include: Review of medical record for Former Resident #120 noted an admitted [DATE] and discharge date of [DATE]. Diagnoses included schizophrenia, glaucoma, and non-compliance with medication regimen. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Former Resident #120 had intact cognition and required supervision for activities of daily living. Review of Former Resident #120's scheduled outside appointments for September 2024 through January 2025 revealed Former Resident #120 was scheduled to leave the facility on 01/27/25 at 5:30 A.M. for laser eye surgery related to a diagnosis of glaucoma. Review of a nurse progress note dated 01/27/25 timed 5:56 A.M. revealed Former Resident #120 was unable to go to appointment because no staff was available. Interview on 03/03/25 at 12:50 P.M. with the Director of Nursing (DON) revealed she was not sure why Former Resident #120 was not taken to her scheduled eye surgery on 01/07/25. The DON stated she met with the Transportation Coordinator weekly to set up transportation to outside appointments. Staff did not contact her on 01/27/25 regarding the appointment. Interview on 03/03/25 at 1:06 P.M. with Transportation Coordinator (TC) #200 revealed she was told there was not enough staff to take Former Resident #120 to her scheduled eye surgery. TC #200 stated she was responsible for tracking the appointments but was unable to provide specific information related to why Former Resident #120 was not taken to her scheduled surgery on 01/27/25. Review of the undated facility policy Resident Transportation revealed the facility would assist residents in making transportation arrangements to and from any needed services, such as dental visits or physician visits in the event the resident required such assistance. This deficiency represents non-compliance investigated under Complaint Number OH00161972.

Based on observation, interview and record review, the facility failed to ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four residents (Resident #13, Resident #18, Resident #32, Resident #18, and Resident #105) of five residents observed for sanitary wheelchairs. Findings include: 1. Record review for Resident #32 revealed an admitted [DATE]. Diagnosis included Parkinson's disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 used a wheelchair for mobility. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit and required assistance with ADL's related to Parkinson's. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in a bedside chair. Observation revealed Resident #32's back rest on his wheelchair was fringed with multiple tears. Observation revealed the seat cushion had a large tear exposing the foam inside. Under the cushion revealed a large amount of dried food crumbs and particles. The frame of the wheelchair was covered in a thick film of dust and the foot pedals had a large amount of embedded dirt. Observation and interview on 11/20/24 at 10:15 A.M. with Certified Nursing Assistant (CNA) #321 confirmed the condition of Resident #32's wheelchair. CNA #321 revealed night shift was supposed to clean wheelchairs. Interview on 11/20/24 at 11:28 A.M. with Resident #32 revealed They never clean my wheelchair, it's always dirty, I am just use to it. 2. Record review for Resident #18 revealed an admitted [DATE]. Diagnosis included postprocedural seroma of the skin and subcutaneous tissue, need for assistants with personal care and muscle weakness. Review of the Brief Interview for Mental Status dated 11/14/24 revealed Resident #18 was cognitively intact. Review of the Fall Risk Observation tool revealed Resident #18 used a wheelchair for mobility. Review of the Nursing Admission assessment dated [DATE] at 3:43 P.M. revealed Resident #18 required a wheelchair for longer distances, the wheelchair was provided by the facility. Observation on 11/20/24 at 10:32 A.M. revealed Resident #18 was sitting in the lounge. The right armrest of Resident #18's wheelchair had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. Interview with Resident #18 at this time revealed the facility had not cleaned his chair. Observation and interview on 11/20/24 at 10:36 A.M. with Director of Maintenance confirmed Resident #18's wheelchair right armrest had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. 3. Record review for Resident #105 revealed an admitted [DATE]. Diagnosis included paraplegia, muscle weaknesses, lack of coordination, and need for assistance with personal care. Review of the Admission Medicare five-day MDS dated [DATE] revealed Resident #105 was cognitively intact. Resident #105 used a wheelchair for mobility. Resident #105 required substantial/maximum assistants with transfers. Observation on 11/20/24 at 10:34 A.M. revealed Resident #105 was sitting in the lounge. Resident #105 revealed staff never cleaned his wheelchair. Observation revealed the entire frame and behind the locks had thick filmy dust covering. Observation and interview on 11/20/24 at 10:35 A.M. with Director of Maintenance confirmed Resident #105's wheelchair frame and behind the locks had a thick filmy dust covering. 4. Record review for Resident #13 revealed an admitted [DATE]. Diagnosis included surgical aftercare following surgery on the circulatory system, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, and need for assist with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #13 was severely cognitively impaired. Resident 13 used a wheelchair for mobility and required supervision or touch assistants with transfers to and from the bed. Observation on 11/20/24 at 10:37 A.M. revealed Resident #13 was sitting in the lounge. Observation of the wheelchair revealed a large amount of very thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. Observation and interview on 11/20/24 10:38 A.M. with Director of Nursing (DON) confirmed Resident #13's wheelchair had thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. DON revealed the resident wheelchairs had a weekly cleaning schedule and Resident #13's wheelchair should have been cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00159291.

Based on observation, interview, and record review, the facility failed to assure infection control was maintained during and after aerosol treatments for Resident #32 and #113. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for infection control. Findings include: 1. Record review for Resident #32 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, acute and chronic respiratory failure, chronic diastolic congestive diastolic congestive heart failure, Parkinson's disease, muscle weakness and altered mental status. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 dated 09/22/21 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit, requires assistance with ADL's related to Parkinson's, COPD/SOB on rest, exertion and lying flat, chronic respiratory failure/, CHF, and morbid obesity. Interventions included to administer medications per medical provider's orders. Review of the physician orders for Resident #32 dated 11/14/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day for COPD and every four hours as needed for wheezing and shortness of breath. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in his chair next to his bed. Observation revealed multiple items were lying on top the bed including dried food items, empty used Styrofoam cups, an aerosol tubing and mouthpiece (not in a bag), cans, lotion, socks toilet paper rolls and empty wrappers. Observation on 11/21/24 at 10:31 A.M. revealed Resident #32 was sitting up in his chair. Observation revealed the medicine cup connected to the aerosol tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed unbagged. Observation of medication administration on 11/21/24 at 11:48 A.M. with Licensed Practical Nurse (LPN #255) revealed when the nurse entered the resident room, Resident #32 had his aerosol machine on, and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. LPN #255 confirmed she also worked on 11/20/24 and confirmed Resident #32's aerosol tubing, cup, and mouthpiece were never kept in a bag during her shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. 2. Record review for Resident #113 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 verified the tubing, cup, and mouthpiece were not in a bag. LPN #255 confirmed she also worked on 11/20/24 during the day shift and Resident #113's aerosol tubing, cup and mask were not placed in a bag the entire shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Interview on 11/20/24 at 11:58 A.M. with Registered Nurse (RN) Unit Manager (UM) #274 revealed after completing an aerosol treatment the nurse was to rinse the aerosol cup out and restore the aerosol tubing, cup and mouthpiece in a plastic bag. Interview on 11/20/24 at 12:02 P.M. with DON revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of Device Cleaning and Infection Control in Aerosol Therapy/Respiratory Care dated 06/01/15 revealed cleaning an aerosol tubing or mouthpiece after each use is crucial to prevent the buildup medication residue, bacteria and potential contaminants that can lead to infection, clog the device, and affect the proper delivery of medication when used again. Storage included to store in a plastic bag or and airtight container.

Based on observation, record review, review of the facility policy and procedure, and interview, the facility failed to ensure Resident #32 and #113's aerosol treatments were administered per the physician order. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for medication administration records. Findings include: 1. Record review for Resident #32 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, acute and chronic respiratory failure, chronic diastolic congestive diastolic congestive heart failure, Parkinson's disease, muscle weakness and altered mental status. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 dated 09/22/21 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit, requires assistance with ADL's related to Parkinson's, COPD/SOB on rest, exertion and lying flat, chronic respiratory failure/, CHF, and morbid obesity. Interventions included to administer medications per medical provider's orders. Review of the physician orders for Resident #32 dated 11/14/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day for COPD and every four hours as needed for wheezing and shortness of breath. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in his chair next to his bed. Observation revealed multiple items were lying on top the bed including dried food items, empty used Styrofoam cups, an aerosol tubing and mouthpiece (not in a bag), cans, lotion, socks toilet paper rolls and empty wrappers. Observation on 11/21/24 at 10:31 A.M. revealed Resident #32 was sitting up in his chair. Observation revealed the medicine cup connected to the aerosol tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed unbagged. Observation of medication administration on 11/21/24 at 11:48 A.M. with Licensed Practical Nurse (LPN) #255 revealed when the nurse entered the resident room, Resident #32 had his aerosol machine on, and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. Observation revealed LPN #255 did not assess Resident #32's lung status prior to administration. LPN #255 confirmed she did not observe to see if Resident #32 completed the morning aerosol dose. Review of the Medication Administration Record (MAR) for Resident #32 revealed on 11/21/24 the aerosol treatments were scheduled for 6:00 A.M., 2:00 P.M. and 10:00 P.M.; As needed doses were also scheduled but not signed on 11/21/24 as used. The last dose provided prior to 11/21/24 at 11:48 A.M. was 11/21/24 at 6:00 A.M. 2. Record review for Resident #113 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. Resident #113 dropped the aerosol tubing and mask on the floor, LPN #255 obtained a new mask, placed the new Ipratropium-Albuterol Solution dose in the aerosol med cup and initiated the aerosol treatment. Observation revealed LPN #255 did not assess Resident #113's lung status prior to administration. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Review of the MAR for Resident #113 revealed on 11/21/24 the aerosol treatments were scheduled for A.M., afternoon and HS; The last dose provided prior to 11/21/24 at 11:53 A.M. was 11/21/24 A.M. Interview on 11/20/24 at 11:58 A.M. with Registered Nurse Unit Manager #274 revealed prior to administering an aerosol treatment, the nurse was required to check the residents pulse ox, check lung sounds pre and post treatment. The nurse was required to stay with the resident until the treatment was complete. Interview on 11/20/24 at 12:02 P.M. with Director of Nursing (DON) revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of the facility policy titled, Nebulizer Treatments undated revealed a nebulizer was a medication delivery system that creates a fine mist or aerosol that is directly inhaled for delivery of the medication to the bronchial tree. Collect data for respirations, pulse and breath sounds pretreatment. Place medication in the dispensing container per provider/physician order. Assist resident to administer the treatment including correct holding of the nebulizer dispenser and placing mouth on mouthpiece sealing with closed lips and breathing through mouth. Turn machine on, nurse to remain in close vicinity during treatment. Repeat collection of data for respirations, pulse and lung sounds post treatment. This deficiency represents non-compliance investigated under Complaint Number OH00159291.

Based on observation, record review, interview, and facility policy review the facility failed to ensure tube feeding was administered according to physician orders. This affected two residents (#35 and #86) of three residents reviewed for enteral nutrition. The facility census was 122. Findings include: 1. Observation of Resident #86 at 12:05 P.M. on 03/26/24 revealed she was not interviewable. Her tube feed was Nutren 2.0 running at 50 milliliters (ml) per hour with a programmed water flush of 240 ml every four hours. Record review of Resident #86 revealed she was admitted [DATE] and had diagnoses including anoxic brain damage, tracheostomy status, and chronic respiratory failure. She had an active order dated 02/26/24 for Nutren 2.0 to run at 55 ml per hour, and an active order dated 03/29/23 to flush with 200 ml of water every four hours. Interview with Licensed Practical Nurse (LPN) #203 on 03/26/24 at 12:14 P.M. confirmed Resident #86's tube feed was not running at the ordered rate. 2. Observation of Resident #35 at 12:07 P.M. on 03/26/24 revealed she was not interviewable. Her tube feed was Vital 1.5 running at 50 ml per hour with a programmed water flush of 150 ml every four hours. Record review of Resident #35 revealed she was admitted [DATE] and had diagnoses including unspecified dementia, malignant neoplasm of colon, and type II diabetes. She had an active order dated 03/08/24 for Vital 1.5 to run at 60 ml per hour, and an active order dated 02/26/24 to flush with 50 ml of water every hour. Interview with LPN #203 on 03/26/24 at 12:14 P.M. confirmed Resident #35's tube feed was not running at the ordered rate. Review of the facility's undated enteral nutrition policy revealed tube feeds administered via electronic pump were to be programmed according to the physician's ordered rate. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, record review and facility policy review, the facility failed to ensure each resident was treated in a respectful and dignified manner. This affected one (Resident #9) of three residents reviewed for toileting. The facility census was 111. Actual Psychosocial Harm occurred on 01/09/24 at 3:16 P.M. when Resident #9 was humiliated upon asking State tested Nurse Aide (STNA) #581 to assist her to the bathroom to use the toilet and STNA #581 told Resident #9 to go to the bathroom in her incontinence brief. Interview of Resident #9 on 01/10/24 at 10:43 A.M. revealed when STNA #581 told her to go to the bathroom in her incontinence brief it made her feel bad and sad. Resident #9 stated sometimes she cried when she had to go to the bathroom because she had to hold it so long, no one would help her, she could not hold it any longer and went to the bathroom in her pants like a baby. Findings include: Review of Resident #9's medical record revealed an admitted [DATE] and diagnoses including muscle weakness, type two diabetes mellitus and dementia. Review of Resident #9's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 was dependent on staff for toileting and personal hygiene. Review of Resident #9's care plan dated 12/26/23 revealed Resident #9 was totally dependent of one staff member for toileting hygiene, helper did all the effort; Resident #9 used a sit to stand lift and required substantial, maximal assistance, Resident #9 was totally dependent of one staff for toilet transfer and helper did all the effort. Observation on 01/09/24 at 3:16 P.M. revealed Resident #9 was sitting in a wheelchair in her room and asked STNA #581 to assist her to the bathroom to use the toilet. STNA #581 told Resident #9 to go to the bathroom in her incontinence brief multiple times and she would change the incontinence brief after she went to the bathroom. Interview of STNA #581 on 01/09/24 at 3:16 P.M. revealed she thought it was alright to ask Resident #9 to go to the bathroom in her incontinence brief. STNA #581 stated a nurse told her to tell Resident #9 to go to the bathroom in her incontinence brief, but the nurse was not at the facility now and she could not remember her name. STNA #581 stated Resident #9 took forever in the bathroom. Interview of the Director of Nursing on 01/09/24 at 3:20 P.M. revealed it was not alright for STNA #581 to tell the Resident #9 to go to the bathroom in her incontinence brief and Resident #9 should be assisted to the bathroom when requested. Interview of Resident #9 on 01/10/24 at 10:43 A.M. revealed she kept asking staff to take her to the bathroom and was told she would have to wait. Resident #9 stated when STNA #581 came in the room and told her to go to the bathroom in her incontinence brief it made her feel bad and sad. Resident #9 stated sometimes she cried when she had to go to the bathroom because she had to hold it so long, no one would help her, she could not hold it any longer and went to the bathroom in her pants like a baby. Resident #9 stated her room was at the end of the hall, it was hard to get help and she was often ignored. Review of the facility policy titled Resident Rights revealed the policy included residents had a choice and a voice in how they would be treated. Residents had a right to participate in the decisions that affected the resident's care. Review of the undated facility policy titled Routine Resident Care revealed it was the policy of the facility to 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. The facility would provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to maintaining a bladder and bowel training program, providing an environment that contributed to a positive self-image preserved dignity and promoted privacy, routine care by a nursing assistant included but was not limited to the following, toileting.

Based on observation, interview, record review, and facility policy review the facility failed to ensure appropriate care and services to prevent the devopement of an in house pressure ulcer and decline of the pressure ulcer to a Stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). This affected one (Resident #76) of three residents reviewed for pressure ulcers. The facility census was 111. Actual Harm occurred on 11/12/23 when Resident #76, who was non-verbal, dependent on staff for turning and repositioning and had limitations in neck mobility was noted to have deterioration to a left ear wound in which there had been no previous documentation. Documentation dated 11/16/24 indicated the left ear wound declined to a Stage 4 pressure injury measuring 2.8 centimeters (cm) in length by 2.5 cm width with 0.1 cm depth with exposed tissues including muscle, fascia without evidence of adequate interventions being in place to prevent the development of the ulcer. The pressure ulcer wound base was assessed to have 50 to 74 percent granulation, 1 to 24 percent slough and 1 to 24 percent eschar with a moderate amount of serosanguinous drainage. Findings include: Review of Resident #76's medical record revealed and admitted [DATE] and diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, and abnormal posture. Review of Resident #76's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was rarely or never understood. Resident #76 had upper and lower extremity impairment on both sides. Resident #76 was dependent on staff for activities of daily living and used a manual wheelchair. Review of Resident #76's care plan dated 01/16/23 revealed Resident #76 would not have complications from altered skin integrity (for example, infection) through the review date. Interventions included to apply appropriate pressure reducing appliances such as low air loss mattress, off loading boots, offloading ear pillow, and wheelchair cushion, complete weekly skin checks, encourage Resident #76 to turn and reposition, and physical therapy (PT) and Occupational Therapy (OT) evaluation and treatment as needed for positioning and wound care. Review of Resident #76's progress notes from 07/01/23 through 11/12/23 did not reveal documentation related to a left ear wound. Review of Resident #76's physician orders dated 11/06/23 revealed PT to discharge Resident #76 per discharge summary. There were no orders for a PT consult to evaluate Resident #76 for clavicle, neck brace or offloading. Review of Resident #76's Therapy Referral to Restorative dated 11/06/23 revealed passive range of motion (PROM) to bilateral lower extremities (BLE) to prevent contractures and daily brace application to left knee to be completed one to two times a day, three to five times per week. Range of motion (ROM) to be 15 minutes and brace application for two to four hours. There were no recommendations related to clavicle, neck brace or offloading. Review of Resident #76's progress notes dated 11/12/23 revealed deterioration noted in left ear wound, Telehealth notified, no new orders at this time, would continue with current treatment orders, wound nurse to follow up. Review of Resident #76's Telehealth progress notes dated 11/12/23 timed 2:46 P.M. revealed Resident #76 had a left ear wound for some time. Resident #76 had orders for Dakin's solution (topical antiseptic) and wound care twice a day, however there had not been much improvement. Ear did not appear to be infected and would continue with current orders. Recommend primary provider evaluate this week. Resident #76 might benefit from debridement of the ear. Review of Resident #76's Skin and Wound Note dated 11/16/23 timed 4:54 P.M. revealed Resident #76 had a new Stage 4 pressure injury to her left ear. Measurements were length 2.8 centimeters (cm), width 2.5 cm and depth was 0.1 cm. Calculated area was 7 square cm, exposed tissues included muscle, fascia. Wound base had 50 to 74 percent granulation, 1 to 24 percent slough and 1 to 24 percent eschar. There was a moderate amount of serosanguinous drainage. Treatment recommendations were to cleanse with normal saline, apply silver alginate to base of the wound, and secure with bordered foam. Change dressing daily and as needed. The notes further included Resident #76 was high risk for pressure ulcer formation including impaired nutrition, severe contractures of multiple joints, comorbidities, decreased mobility and history of previous pressure injury. A physical therapy consult was recommended to evaluate for clavicle, neck brace or offloading. Review of Resident #76's Skin and Wound Note dated 01/03/24 revealed Resident #76's left ear Stage 4 pressure ulcer was improving without complications. Measurements were length 1.5 cm, width 1.0 cm, depth 0.1 cm and wound base was 50 to 74 percent epithelial, 50 to 74 percent granulation, 0 percent slough and eschar (dead tissue). Observation of Resident #76 on 01/09/24 at 1:38 P.M. revealed she was sitting in a padded chair in her room, her head was leaning down and to the left, and appeared to be resting on her left shoulder. Resident #76's arms were bent in an upwards position and held against her chest. Resident #76 had her eyes closed and did not respond when spoken to. Interview of Unit Manager/Licensed Practical Nurse (UM/LPN) #603 and Licensed Practical Nurse (LPN) #576 on 01/09/24 at 3:51 P.M. revealed Resident #76 was nonverbal. LPN #576 stated she was not sure why Resident #76 had a pressure ulcer on her left ear, and Resident #76 tended to lay in a way that put pressure on her ear. LPN #576 stated Resident #76 always held her head down and to the left, it was very hard to change her position and it was a never ending battle. Observation of Resident #76 on 01/10/24 at 10:34 A.M. with Clinical Manager/Registered Nurse (CM/RN) #595 revealed Resident #76 was lying in bed, with her head held down and to the left, both arms were bent and held tightly against Resident #76's chest and her hands were clenched shut. Observation of Resident #76's left ear revealed she had a foam border dressing and the date the dressing was applied could not be read. CM/RN #595 removed the dressing revealing an open area on the left ear, the wound bed was red, and a small to moderate amount of yellow brown drainage was noted. CM/RN #595 stated the area was very moist and confirmed Resident #76 held her head down and to the left and it appeared to be resting on her shoulder. CM/RN #595 stated Resident #76 was contracted on both sides and she used to have a neck pillow which kind of helped, but did not help much. CM/RN #595 stated Resident #76 was not eligible for long term therapy, and was turned every two hours or as needed. Interview of Director of Rehab (DOR) #722 on 01/10/24 at 11:22 A.M. revealed Resident #76 was discharged from PT on 11/06/23. Resident #76 wore a left knee brace at night and her therapy was mostly related to positioning with a body pillow for pressure ulcers on the buttocks. Resident #76 was not recommended for restorative for positioning after she was discharge from therapy because she needed repositioned often and the staff should be doing that. Resident #76 had a neck pillow but DOR #722 did not know what happened to the pillow. DOR #722 stated in July 2023 staff was educated for Resident #76's left leaning and pillow placement; however, evidence of the education could not be provided. Resident #76 had no specific therapy related to her head and neck positioning. Resident #76 had a custom wheelchair ordered which came in the third week of December, but the wheelchair had not been adjusted for Resident #76 because she had not been feeling well. Interview of Physical Therapy Assistant (PTA) #501 on 01/10/24 at 11:45 A.M. revealed Resident #76 was not currently receiving PT. When Resident #76 was receiving PT she had a personal neck pillow. The pillow was not required due to tonal abnormalities and was more for comfort. No training was completed regarding head and neck positioning because it was not necessitated. PTA #501 was not aware Resident #76 had a left ear pressure ulcer. Interview of Occupational Therapist (OT) #553 on 01/10/24 at 11:56 A.M. revealed she worked with Resident #76 for positioning but it was more for the trunk and not specifically for the neck. OT #553 confirmed the nursing staff gave Resident #76 a cervical pillow, but she did not know what happened to the pillow and did not remember the last time she saw Resident #76 with the pillow. Interview of State tested Nursing Assistant (STNA) #511 on 01/10/24 at 12:13 P.M. revealed Resident #76 had a neck pillow, but she did not know what happened to it. STNA #511 last saw the pillow a few months ago. Interview of the Director of Nursing (DON) on 01/10/24 at 3:59 P.M. revealed Resident #76's left ear pressure ulcer was facility acquired. The DON confirmed there was no documentation of Resident #76's left ear wound prior to 11/16/23 except for the documentation on 11/12/23. The DON stated Resident #76's weekly skin check on 11/09/23 did not have documentation of a left ear skin issue. The only documentation the DON could find for Resident #76's left ear was dated 05/04/23 indicating preventative measures using Dakin's solution and Skin Prep (upon application to intact skin Skin Prep forms a protective film the help reduce friction) were initiated. Interview of STNA #505 on 01/11/24 at 1:16 P.M. confirmed Resident #76 had a neck pillow; it was a cloth pillow from the store and probably was thrown away because it was soiled. STNA #505 stated Resident #76 always laid with her head down and to the left, arms bent to her chest and her hands clenched shut. STNA #303 stated when Resident #76 was first admitted she did not lay with her head down and to the left the way it was now and her head position had gradually gotten worse. Review of the facility policy titled Skin Care and Wound Management dated 07/01/16 revealed the policy indicated to develop a care plan for pressure ulcer prevention. Monitor for consistent implementation of interventions and evaluate effectiveness of interventions. Revise intervention and or goals as indicated.

Based on observation, record review, and interviews with staff and residents the facility failed to have sufficient staffing. This affected Residents #6, #10, #50, #36, #54, #59 and #105 and had the potential to affect all residents. The census was 111. Findings include: 1. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed she waited over two hours for her call light to be answered on occasions. Interview on 01/08/24 at 10:34 A.M. with Resident #10 revealed she did not get her medications in a timely manner most days, it was inconsistent. She stated she did not get regular showers or bed baths. Interview on 01/08/24 at 2:20 P.M. with Resident #50 regarding staffing revealed They need more. When are they going to close this place? Interview on 01/08/24 at 2:41 P.M. with Resident #36 revealed he was told on more than one occasion not to put his call light on during meal tray pass. He also stated he made his own bed because staff did not get to it timely. Interview on 01/09/24 at 7:46 A.M. with Resident #54 revealed staff had not provided timely assistance into bed. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. 2. Observations throughout the survey from 01/08/24 through 01/11/24 revealed excessive call lights use and State tested Nurse Aides (STNAs) appeared to be rushed and overwhelmed. Residents were observed in the halls looking for staff assistance. Interview on 01/10/24 at 2:15 P.M. with STNA #624 revealed concerns related to staffing. STNA #624 stated he was aware of residents on the C and D hall that had not received timely care that included incontinence care and showers. STNA #624 stated call lights had not been answered timely on occasions due to not enough staff. Interviews on 01/10/24 from 4:00 P.M. through 500 P.M. with STNA #505, STNA #539 and STNA #549 revealed they had up to 12 to 17 residents on their assignment at times. They stated there were many residents who required mechanical lifts and the acuity levels of the residents on Units C and D was high. STNA #505 stated charting did not get completed because they did not have time. Interview on 01/11/24 at 11:40 A.M. with STNA #559 revealed concerns related to staffing. STNA #559 stated there was not enough staff to provide timely incontinence care on occasions. STNA #559 stated residents had to wait long periods of time for their call lights to be answered and sometimes it took 45 minutes or longer to answer call lights. Review of the assignment sheets for Units C and D revealed there were 23 residents who needed assistance with transfers via a mechanical lift requiring two staff members. Interview with Licensed Practical Nurse #603 on 01/10/24 at 5:10 P.M. verified the number of residents on the C and D units needing mechanical lifts. 3. Review of Resident #54's medical records revealed an admitted [DATE]. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed resident had self care deficits. Interventions included two or more staff for toileting, transfers and bathing. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 was dependent for toileting and transfers. Interview on 01/10/23 at 11:06 A.M. with Resident #54 revealed she had requested to be out of bed earlier in the morning and stated State tested Nurse Aide (STNA) #585 had told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who not provided timely assistance for Resident #54's transfers. STNA #585 stated there had been staff that refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch, however she had not had time before the end of her shift at 2:30 P.M. to assist Resident #54 out of bed. STNA #585 stated there was not enough staff to provide timely care on occasions and stated at times she was lucky to be able to perform two rounds of incontinence care during her shifts. STNA #585 said the residents on the C and D hall had a hight acuity level and there was not enough staff to provide timely care to those residents. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603 at time of observation revealed they were aware Resident #54 preferred to out of bed prior to lunch time and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation. 4. Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, type two diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 revealed she was dependent for showers. Review of Resident #10's shower sheets revealed she received bed baths on 12/11/23, 12/18/23, 01/04/24 and 01/08/24. Interview on 01/10/24 at 5:10 P.M. with Licensed Practical Nurse #603 revealed there was no other documentation regarding showers/bed baths for Resident #10. 42013 5. Review of Resident #59's medical record revealed an admitted [DATE] and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview on 01/08/24 at 9:49 A.M. revealed Resident #59 did not always get out of bed, even though she would like to get out of bed. Resident #59 often chose not to get out of bed because when she did agree to get out of bed the State tested Nurse Aides (STNAs) did not put her back to bed when she was ready. Resident #59 stated the STNAs told her she had to wait and the STNAs on the next shift would put her to bed. Resident #59 indicated she waited long periods of time before she was assisted into her bed. Observation of STNAs #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Interview on 01/11/24 at 1:42 P.M. of STNA #549 revealed staffing could be better. STNA #549 stated the residents on the long term care hall, which is where she was usually assigned, required a lot of care and often two people were needed for transfers and to provide care for the residents. STNA #549 stated residents often had to wait for their care because she had to search for another STNA or nurse to help her and it took time to find someone. STNA #549 stated charting often did not get completed because she was too busy caring for residents. 6. Observation on 01/08/24 at 2:14 P.M. of Resident #105 revealed he was sitting in a wheelchair in the entrance to his room and asked the surveyor to put him back to bed. Resident #105 resided in a room towards the end of the hall and there were no staff in the hall or at the nursing station. Resident #105 stated a little louder than the first time he asked, please put me back to bed, I am tired. There were still no staff in sight and the surveyor told Resident #105 she would find a staff person to assist him into bed. Resident #105 stated even louder please, please put me back to bed. Resident #105 said please help me. Observation of Resident #105's bed revealed the mattress was bare and did not have sheets or bed linens on it. The surveyor searched for a few minutes and found State tested Nursing Assistant (STNA) #585 to help Resident #105. STNA #585 stated Resident #105 was not in her assignment, but she would put him back to bed. STNA #585 had to find sheets and a blanket and make the bed before she could help Resident #105 to lay down.

Based on observation and interview the facility failed to ensure expired medications were discarded. This had the potential to affect 51 residents residing on the A and C halls. Facility census was 111. Findings include: Observation of medication administration on 01/09/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) #576 for Resident #51 revealed LPN #576 obtained a bottle of aspirin 81 milligrams (mg). Further observation revealed the aspirin had an expiration date of December 2023. LPN #576 confirmed the expiration date and stated she did not check the expiration date prior to preparing the medications. Further observation of the medication cart with LPN #576 revealed a bottle of oyster shell supplement with an expiration date of November 2023 and multiple loose unidentifiable pills in various areas of the drawers. LPN #576 confirmed the loose pills and expired medications and stated she did not check the medication cart and was not aware of who was responsible for checking the carts. Observation of another medication cart on 01/09/23 with Registered Nurse (RN) #529 revealed a bottle of vitamin C with an expiration date of October 2023, a bottle of Optium (vitamin supplement) with an expiration date of December 2023 and aspirin 325 mg with an expiration date of August 2023. RN #529 verified the expired medications and stated she did not check the expiration dates prior to administering medications. Review of facility's undated policy titled Stock Medications revealed medications were to be discarded when out of date.

Based on observation and interview the facility failed to ensure monitoring of residents on oxygen for complications such as skin integrity issues, failed to ensure protective foam was applied to oxygen tubing to protect skin integrity, and failed to ensure current physician orders for the use of oxygen. This affected four (#6, #22, #40 and #45) of five residents observed for oxygen therapy. The facility census was 110. Findings include: 1. Review of Resident #6's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the care plan dated 12/03/23 revealed Resident #6 had COPD. Interventions included provide oxygen therapy as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Interview on 01/08/24 at 11:07 A.M. with Resident #6 revealed she wore her oxygen continuously and she had a sore area to the back of her right ear. Resident #6 stated she had requested foam ear pieces to be placed on her oxygen tubing over a month ago, however she had not been given them. Observation at time of interview revealed a reddened area to the back of Resident #6's right ear with a small amount of blood around the reddened area. Interview on 01/09/24 at 3:03 P.M. with Resident #6 revealed she still did not have any foam placed on her oxygen tubing. At time of interview Registered Nurse (RN) #595 entered Resident #6's room and confirmed no foam on the oxygen tubing and Resident #6 had a reddened area to her right ear. RN #595 stated foam should be placed on the oxygen tubing for residents who wore continuous oxygen. 2. Review of Resident #40's medical records revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD). Review of care plan dated 09/22/23 revealed Resident #40 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed Resident #40 was ordered oxygen at four liters per minute. Observation on 01/09/24 at 3:20 P.M. revealed Resident #40 was in a wheelchair in his room. Resident #40 had toilet tissue wrapped around his oxygen tubing near his ear. Interview with Resident #40 at time of observation revealed the oxygen tubing had irritated his ears and he had asked the staff to place foam to the tubing over a month ago. Resident #40 further stated he had cut a piece of the oxygen tubing a long time ago (unable to state specific timeframe) that was placed in his nose because it had irritated the inside of his nose and caused a blister. Observation revealed the prong intended to sit inside the left nostril had been cut. LPN #576 confirmed the observations and stated Resident #40 should have had foam dressing to his oxygen tubing to protect the skin behind his ears and his oxygen tubing should have been changed once Resident #40 had cut the nasal prong off. 3. Review of Resident #45's medical records revealed an admitted [DATE]. Diagnoses included asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of Resident #45's care plan dated 10/12/23 revealed Resident #45 had asthma. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders regarding oxygen therapy. Observation on 01/09/24 at 3:14 P.M. revealed Resident #45 was resting in bed. Further observation revealed no foam to Resident #45's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #45's ears. LPN #576 stated Resident #45 should have had foam placed on the oxygen tubing. 4. Review of Resident #22's medical records revealed an admitted [DATE]. Resident #22 had a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the care plan dated 12/18/23 revealed Resident #22 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Observation on 01/09/24 at 3:17 P.M. revealed Resident #22 was up in a wheelchair in her room. Further observation revealed no foam to Resident #22's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #22's ears. LPN #576 stated Resident #22 should have had foam placed on the oxygen tubing.

Based on observation, interview, record review, and facility policy review the facility failed to ensure restorative therapy services were initiated and completed for Residents #20, #54, #80, #100 and #360 per discharge recommendations from therapy. This affected five (Residents #20, #54, #80, #100 and #360) of 14 residents who had restorative services recommended by therapy. The facility census was 111. Findings include: 1. Review of Resident #80's medical record revealed an admitted [DATE] and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Physical Therapy Discharge Summary dated 09/04/23 included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #80 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with interdisciplinary team (IDT), Range of Motion (ROM) (active) and ROM (passive). Review of Resident #80's care plan did not reveal a care plan related to restorative services. Review of Resident #80's Therapy Referral to Restorative dated 09/04/23 revealed active range of motion (AROM), passive range of motion (PROM) of bilateral lower extremities (BLE) to prevent contractures, skin breakdown one to two times a day, five to seven times a week for 10 to 15 minutes. Review of Resident #80's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Observation on 01/10/24 at 8:30 A.M. revealed Resident #80 was lying in bed on his left side with his legs bent and pulled up towards his chest. Resident #80 stated it was hard for him to move around because his legs did not want to stretch out. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the residents' medical records for the aides to complete. The DON confirmed Resident #80's medical record aide charting did not have documentation aides provided restorative services. The DON could not say if a referral was not received from DOR #722 or the referral was not put in Resident #80's aide charting. The DON confirmed Resident #80 did not receive restorative services after his discharge from therapy. Interview of State tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #80 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 2. Review of Resident #100's medical record revealed an admitted [DATE] and diagnoses included unspecified abnormalities of gait and mobility, weakness, and metabolic encephalopathy. Review of Resident #100's Therapy Referral to Restorative dated 11/20/23 revealed walk to dine or walking daily one to two times a day, four to five times per week for 10 to 15 minutes. Resident #100 required contact guard times one and needed to stay close to walker. Resident #100 was recommended to walk 100 to 150 feet using a front wheeled walker. Review of Resident #100's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #100 was independent and not appropriate for restorative services. Interview of State tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #100 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 3. Review of Resident #360's medical record revealed an admitted [DATE] and diagnoses included chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility. Review of Resident #360's Therapy Referral to Restorative dated 12/08/23 revealed Resident #360 was recommended transfers to chair, toilet in room, sit-to-stand (STS) transfers to front wheeled walker (FWW) one to two times per day, three to five times a week for 10 to 15 minutes. Amount of assistance was contact guard times one and safety cues for hand placement. Review of Resident #360's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #360 was continent, used a wheelchair to go to the bathroom and she did not feel he was appropriate for restorative services. Interview of State tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #360 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 4. Review of Resident #20's medical record revealed an admitted [DATE] and diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, contracture of muscle right and left hands, and need for assistance with personal care. Review of Resident #20's Physical Therapy Discharge Summary dated 05/15/23 included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #20 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with the interdisciplinary team (IDT): bed mobility and range of motion (ROM), active. Review of Resident #20's Wellness/Restorative Referral Form dated 05/15/23 included to increase, maintain bilateral lower extremity (BLE) knee, ankle ROM. Exercises to improve BLE mobility and strength. This was to be completed two to three times per day, six to seven times a week for 10 to 15 minutes. The exercises could be completed by one staff person, and the packet was in Resident #20's room. The exercises included knee, hip, ankle active and passive ROM. Review of Resident #20's care plan revised 05/30/23 did not reveal a care plan related to restorative services. Review of Resident #20's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #20 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 5. Review of Resident #54's medical record revealed an admitted [DATE] and diagnoses included multiple sclerosis, unspecified abnormalities of gait and mobility, and weakness. Review of Resident #54's Therapy Referral to Restorative included right knee brace four to five hours daily, hip abduction brace daily one time a day, six to seven times a week for four hours. Amount of assistance was one person to don brace. Review of Resident #54's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #54 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility.

Based on resident interviews and record review the facility failed to promptly address concerns regarding palatability of food. This affected 105 residents who received meals from the kitchen. Six residents received nothing by mouth (#3, #18, #20, #53, #76 and #90). The census was 111. Findings include: Review of the food council minutes for the past year revealed the following concerns from 01/10/23 through 12/23/23. On 01/10/23: The food is cold mostly at breakfast. Staff are telling residents they do not have something because they don't want to make it. Not using hot plates on the weekends. On 02/21/23: Burnt grilled cheese. Can we have a whole baked potatoe, not half? On 03/15/23: Roast pork and beef could be more tender. On 05/16/23: Condiments are missing on trays. Breakfast is usually cold-are pellet warmers on? and Not getting what is on ticket. On 06/20/23: Cold food. On 07/11/23: Rice is always overcooked. Broccoli is overcooked. Chicken was dry. On 08/24/23: Chicken tenders and patties are hard. Broccoli is overcooked. Diced potatoes are overcooked and mushy; more meat. On 09/12/23: Roast pork and beef are tough. On 10/02/23: Cook fish longer-feels slimy. On 12/13/23: Oven roasted potatoes are rock hard. Interviews on 01/08/24 and 01/09/24 revealed the following 11 complaints about the food. 1. Interview on 01/08/24 at 9:51 A.M. with Resident #59 revealed the food is terrible. It is cold at times. Dinner yesterday had meat that was so hard you could not cut it or put a fork in the fish. I only ate the potatoes, portions are small. 2. Interview on 01/08/24 at 10:06 A.M. with Resident #49 revealed the food was inedible. 3. Interview on 01/08/24 at 10:19 A.M. with Resident #28 revealed meat was tough. Food was cold at times and the portions are small. 4. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed they have small portions. 5. Interview on 01/08/24 at 11:30 A.M. with Resident # 1 revealed The food is hard as a rock. 6. Interview on 01/08/24 at 1:56 P.M. with Resident #31 revealed The eggs are burnt and they try to hide it underneath. They are not following the preferences and the meat is hard. 7. Interview on 01/08/24 at 2:39 P.M. with Resident #7 revealed The food is horrible. 8. Interview on 01/09/24 at 7:51 A.M. with Resident #54 revealed The food is cold everyday. The portions are small and they need more meat. 9. Interview on 01/09/24 at 10:23 A.M. with Resident #260 revealed The food is horrible. They do not use pellets [plate warmers] on the weekends. 10. Interview on 01/09/24 at 10:51 A.M. with Resident #21 revealed Sometimes the food is horrid. Can't cut it with a knife. We eat PBJ's. Sick of it! 11. Interview on 01/09/24 at 4:00 P.M. with Resident #51 revealed they never use pellets on the weekends. Review of the facility policy titled Food: Quality and Palatability, revised 09/2017, revealed food would be palatable, attractive and served at a safe and appetizing temperature. Review of the facility policy titled Ohio Resident Grievance, dated 05/30/19, revealed the facility was to provide resident centered care meeting psychosocial , physical and emotional needs and concerns of the residents.

Based on observation, interview, record review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected four residents (#7, #42, #65 and #88) and had the potential to affect eight residents (#17, #26, #42, #47, #52, #56, #71 and #102) residing on the D hall. The facility census was 110. Findings include: 1. Review of Resident #42's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required set up assistance with eating and was dependent with toileting. Review of physician orders dated 01/05/24 revealed Resident #42 was on droplet precautions related to Covid positive results. Observation on 01/08/24 at 8:40 A.M. revealed signs posted outside of Resident #42's room that indicated Resident #42 was on isolation precautions and gown, gloves, mask and face shield were required prior to entering the room. Further observation revealed State tested Nursing Assistant (STNA) #527, who was wearing a surgical mask, don a gown and gloves prior to entering Resident #42's room. Observation of the isolation bin located outside of Resident #42's room revealed the bin only contained gowns. Interview with STNA #42 upon exiting Resident #42's room revealed Resident #42 was Covid positive. STNA #42 confirmed she did not wear an N95 mask or eye protection while in Resident #42's room. STNA #527 was unaware a N95 was required when entering Resident #42's room. STNA #527 confirmed the isolation bin located outside of the room did not contain masks or face shields and stated surgical masks were located at the nurses station and she was unaware of where to locate a N95 mask or face shield. Interview on 01/10/24 at 12:45 P.M. with Registered Nurse (RN) #595 revealed she was the infection preventionist. RN #595 confirmed Resident #42 was Covid positive and stated staff were required to wear gown, gloves, N95 mask and eye protection prior to entering a Covid positive room. Review of facility policy titled Precaution and Transmission Based Precautions, revised 06/25/21 revealed staff were required to wear N95 mask, face shield, gown and gloves during care of Covid positive residents. Review of the CDC guidance updated 11/30/23 revealed recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection includes health care providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, or a face shield that covers the front and sides of the face. 2. Observation of wound care for Resident #88 with Licensed Practical Nurse (LPN) #569 and the Wound Nurse Practitioner (WNP) on 01/09/24 at 2:20 P.M. revealed Resident #88 had a wound to his sacrum (tailbone) area and wounds to his left foot. LPN #569 and WNP did not disinfect the bedside table before placing the wound care supplies onto the bedside table. LPN #569 and WNP cleansed Resident #88's sacral wound and did not change their gloves prior to placing a clean dressing to the wound. LPN #569 and WNP proceeded to cleanse Resident #88's wounds on his left foot, wearing the same gloves that were worn during care of the sacral wound. LPN #569 and WNP cleansed Resident #88's foot wound and did not change their gloves prior to placing a new dressing to the foot wounds. Interview with LPN #569 and the WNP, after completion of wound care, confirmed they did not disinfect the beside table prior to placing wound supplies on it and they did not change their gloves or complete hand hygiene during wound care. 3. Observation of incontinence care for Resident #65 with State tested Nurse Aide (STNA) #585 on 01/10/24 at 10:48 A.M. revealed Resident #65 was incontinent of stool. STNA #585 provided Resident #65 with incontinence care and did not remove her soiled gloves or wash her hands prior to assisting Resident #65 with dressing. Interview with STNA #585 on 01/10/24 at 11:57 A.M. confirmed STNA #585 did not change her soiled gloves after providing incontinence for Resident #65 stating I guess I never thought of doing that. 4. Observation of incontinence care for Resident #7 with State tested Nurse Aide (STNA) #585 on 01/10/24 at 11:57 A.M. revealed Resident #7 was incontinent of urine. STNA #585 provided Resident #7 with incontinence care and did not remove her soiled gloves or wash her hands prior to applying lotion to Resident #7's arms and legs. Interview with STNA #585 confirmed she did not change her soiled gloves after providing incontinence care for Residents #7 and stated I guess I never thought of doing that. After the incontinence care was completed for Resident #7, Licensed Practical Nurse (LPN) #576 entered Resident #7's room to administer insulin. LPN #576 administered the insulin into the subcutaneous tissue of Resident #7's abdomen without wearing gloves. Interview with LPN #576 at time of observation revealed she should have worn gloves during insulin administration but she had forgotten.

Based on observation and interview the facility failed to ensure prompt physician notification and timely care related to Resident #65's reddened and painful external genitals. This affected one (#65) of two residents observed for skin impairment. The facility census was 110. Findings include: Review of Resident #65's medical records revealed an admitted [DATE]. Diagnoses included multiple sclerosis, muscle weakness and neuromuscular bladder. Review of the care plan dated 12/10/23 revealed Resident #65 was at risk for impaired skin integrity. Interventions included apply barrier cream after incontinence care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent for toileting and personal hygiene. Review of skin assessments dated 12/28/23 and 01/05/24 revealed Resident #65 had no skin impairment. Observation of incontinence care on 01/10/24 at 10:48 A.M. for Resident #65 with State tested Nursing Assistant (STNA) #585 revealed reddened areas to the head of Resident #65's penis, shaft of penis and scrotum. STNA #585 stated she had not cared for Resident #65 for at least two weeks and was not aware of the reddened areas prior to the current observation. STNA #585 completed Resident #65's incontinence care and applied barrier cream to the reddened areas. Interview with Resident #65 at the time of the observation revealed he had pain in his penis area. Interview on 01/11/24 at 10:23 A.M. with STNA #559 revealed she had cared for Resident #65 the previous week and had observed his reddened penis and scrotum. STNA #559 reported the reddened areas to Licensed Practical Nurse (LPN) #519. At the time of interview STNA #559 performed incontinence care for Resident #65 and indicated the reddened areas to his penis and scrotum appeared to be worse from when she had cared for him the previous week. During the provision of incontinence care STNA #559 exited Resident #65's room and returned with LPN #519. LPN #519 observed Resident #65's penis and scrotum and stated she had not been aware of the reddened areas previously. STNA #559 then stated to LPN #519 she had informed her of the reddened areas the previous week.

Based on observation, interview, record review and policy review the facility failed to provide care and services to ensure Resident #59 was provided incontinence care timely and Resident #80's urine specimen was sent to the lab timely and urinary tract infection treated promptly. This affected one resident (Resident #59) of three residents reviewed for incontinence and one resident (Resident #80) of three residents reviewed for urinary tract infections. The facility census was 111. Findings include: 1. Review of Resident #59's medical record revealed an admitted [DATE] and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview of Resident #59 on 01/08/24 at 9:46 A.M. revealed Resident #59 had not had her incontinence brief changed since last night. Resident #59 stated it often happened that her incontinence brief was not changed timely and sometimes it was not changed until after lunch was served. Resident #59 stated it was uncomfortable lying in urine. Observation of State tested Nursing Assistants (STNAs) #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Review of Resident #59's aide charting revealed Resident #59's incontinence brief was changed on 01/07/24 at 11:27 P.M. and there was no further evidence Resident #59's incontinence brief was changed until 01/08/24 at 1:14 P.M. Interview of the Director of Nursing (DON) on 01/11/24 at 7:09 A.M. revealed typically it would not be alright for a resident to have two incontinence briefs on, but if it was their preference it would be allowed. The DON was not aware Resident #59 requested two incontinence briefs because she was not changed timely and would look into the matter. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to 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. The facility would provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to toileting, providing care for incontinence with dignity and maintaining skin integrity. 2. Review of Resident #80's medical record revealed an admitted [DATE] and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderate cognitive impairment. Resident #80 was dependent on staff for Activity of Daily Living (ADL). Review of Resident #80's care plan dated 03/24/23 revealed Resident #80 was incontinent of urine related to impaired cognition, impaired mobility, neurological conditions. Resident #80 would decrease frequency of incontinence episodes. Interventions included to observe for signs and symptoms of a urinary tract infection such as pain, burning, cloudiness, fever, altered mental status, foul smelling urine etcetera. Observe and report to medical provider if identified. Review of Resident #80's progress notes dated 12/22/23 at 10:26 A.M. revealed Resident #80 was having hematuria (blood in urine). The Nurse Practitioner was notified and new orders were given for a STAT (immediate) Complete Blood Count with differential, Basic Metabolic Panel, and urinalysis, culture and sensitivity. The Nurse Practitioner was made aware the urinalysis and urine culture and sensitivity could not be collected until 12/26/23 due to the holiday. Review of Resident #80's physician orders from 12/22/23 through 12/28/23 did not reveal orders for a urinalysis or a urine culture and sensitivity. Review of Resident #80's physician orders dated 12/28/23 revealed urine for urinalysis and urine culture and sensitivity to be collected for pickup on 12/29/23. Review of Resident #80's progress notes from 12/23/23 through 01/02/24 did not reveal further documentation related to the appearance of Resident #80's urine or symptoms of a urinary tract infection. The progress notes did not have documentation regarding Resident #80's orders for a urinalysis and urine culture and sensitivity. Review of Resident #80's progress notes dated 01/02/24 at 12:51 P.M. revealed an order was placed for a urinalysis and a urine culture and sensitivity to be completed on 01/03/24. Review of Resident #80's physician orders dated 01/02/24 revealed an order for a urinalysis and a urine culture and sensitivity to be collected for lab pickup on 01/03/24. Review of Resident #80's progress notes dated 01/02/24 at 3:10 P.M. revealed a urine specimen was collected via straight catheter for lab pick up on 01/03/24. Review of Resident #80's progress notes dated 01/04/24 at 12:25 P.M. revealed Resident #80's urinalysis results showed white blood cells greater than 50, culture and sensitivity pending. Review of Resident #80's Lab Results Report revealed Resident #80's urinalysis with culture and sensitivity was reported on 01/07/24 at 2:51 P.M. The Report included Resident #80's urine had greater than 100,000 colony forming units per milliliter of Escherichia Coli (E Coli). Review of Resident #80's progress notes dated 01/08/24 at 2:47 P.M. revealed Resident #80's urinalysis was reviewed by the Nurse Practitioner and new orders for Cipro (antibiotic) 250 milligrams (mg) by mouth two times a day for three days for urinary tract infection. Review of Resident #80's physician orders dated 01/08/24 at 2:56 P.M. revealed Ciprofloxacing HCl Oral tablet 250 mg, give 250 mg by mouth every morning and at bedtime for E Coli for three days. Interview of Clinical Manager/Registered Nurse (CM/RN) #595 on 01/09/24 at 4:27 P.M. revealed she was the Infection Preventionist for the facility. CM/RN #595 revealed when a resident (not hospice)had symptoms of a urinary tract infection the Nurse Practitioner was notified and orders were obtained for a urinalysis and culture and sensitivity. The specimen was usually collected within 48 hours. Pain with urination, change in color or smell, and blood in urine were all symptoms of a urinary tract infection. If the nurse was not able to obtain the urine specimen within 48 hours for reasons like she was not able to straight cath the resident, the resident was incontinent, or the resident refused then the Nurse Practitioner or physician would be notified. Interview of Licensed Practical Nurse (LPN) #584 on 01/10/24 at 8:53 A.M. revealed on 12/22/23 an aide told her Resident #80 had blood in his urine. LPN #584 contacted the Nurse Practitioner and received an order for a urinalysis and culture and sensitivity. LPN #584 could not obtain the urine specimen right away because the lab was closed for the Christmas holiday and Resident #80's urinalysis and culture and sensitivity would have to wait until 12/26/23 to be collected. The lab would not collect a STAT urine on the weekends or holidays. LPN #584 stated Resident #80 was for sure straight cathed on 12/26/23 because she was told on 12/27/24 that a urinalysis was pending. Interview of the Director of Nursing (DON) on 01/10/24 at 1:27 P.M. revealed an attempt to collect Resident #80's urine was made on 12/28/23's night shift for pick up on 12/29/23. The attempt to collect Resident #80's urine was unsuccessful because enough urine could not be collected from the straight cath. The DON stated Resident #80's urine was unable to be collected until 01/02/24 because the lab would not take urine specimens on any weekend. The DON did not see any documentation in Resident #80's progress notes regarding why the urine specimen was not collected before 01/02/24 including if the Nurse Practitioner or Physician was informed that the urine could not be collected. The DON was off work on those days and did not know why the urine was not collected sooner. The DON stated she would think the antibiotics should have been started before 01/08/24. The urinalysis results were reported on 01/03/24 and the urine culture and sensitivity results were reported on 01/07/24. Review of the facility lab STAT (immediately) Test List dated 10/2022 included urinalysis.

Based on observation, interview, record review and facility policy review the facility failed to ensure Resident #76 received the necessary services to maintain clean hair. This affected one (Resident #76) out of three residents reviewed for activities of daily living. The facility census was 111. Findings include: Review of Resident #76's medical record revealed and admitted [DATE] and diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, and abnormal posture. Review of Resident #76's care plan dated 01/25/23 revealed Resident #76 had an activity of daily living (ADL) self-care performance deficit and required assistance with all ADLs. Resident #76 would maintain current level of function. Interventions included Resident #76 was dependent for shower, bathing and required two or more helpers to assist. Review of Resident #76's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not conducted due to Resident #76 was rarely or never understood. Resident #76's upper and lower extremities had impairment on both sides. Resident #76 was dependent on staff for ADLs and used a manual wheelchair. Observation of Resident #76 on 01/08/24 at 3:35 P.M. revealed she was lying in bed with her eyes closed and did not respond when spoken to. Resident #76's hair was very greasy. Observation of Resident #76 on 01/09/24 at 1:38 P.M. revealed she was sitting in a padded chair in her room and her hair remained very greasy. Interview of State tested Nursing Assistant (STNA) #585 on 01/09/24 at 1:50 P.M. confirmed Resident #76's hair was very greasy. STNA #585 stated Resident #76 was not usually on her assignment and she was shocked at how greasy Resident #76's hair was. STNA #585 stated Resident #76's hair needed washed. Interview of Licensed Practical Nurse (LPN) #508 on 01/09/24 at 1:53 P.M. confirmed Resident #76 had very greasy hair. LPN #508 stated Resident #76 sweated a lot and that contributed to her greasy hair. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to 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. The facility would provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse including but not limited to bathing, dressing, eating and hydration and toileting.

Based on interview, observation and record review, the facility failed to honor Resident #54's preferences regarding when she wanted to get out of bed and how long she remained out of bed. This affected one of resident reviewed for preferences. Findings include: Review of Resident #54's medical records revealed an admitted [DATE]. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed Resident #54 had self care deficits. Interventions included two or more staff for transfers. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and was dependent for transfers. Interview with Resident #54 on 01/09/24 at 7:46 A.M. revealed staff did not return her to bed as she requested. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. Interview with Resident #54 on 01/10/23 at 11:06 A.M. revealed she requested to be out of bed earlier in the morning and State tested Nurse Aide (STNA) #585 told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who did not provide timely assistance for Resident #54's transfers. STNA #585 stated there were staff who refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch; however, she had not assisted Resident #54 out of bed because she did not have time. STNA #585 indicated her shift was over at 2:30 P.M. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603, at time of observation, revealed they were aware Resident #54 preferred to out of bed prior to lunch and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO ,d+[DATE]-ALL dated [DATE], record review, review of the facility COVID-19 positive timeline, review of the county community COVID-19 transmission rate, staff time sheets, facility census, staff screening forms, resident and staff rapid point of care (POC) test results, residents' vaccination logs, staff interviews, review of the facility COVID-19 procedure policy, and observations, the facility failed to ensure staff reported respiratory symptoms timely, staff screened for signs and symptoms of COVID-19 prior to working, reported COVID-19 cases timely to the local health department, and wore the proper Personal Protective Equipment (PPE) while in COVID-19 positive rooms to help reduce the potential spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy placing residents at risk for the likelihood of harm, complications, and/or death on [DATE] when State tested Nursing Assistant (STNA) #104 who did not screen for signs and symptoms of COVID-19 prior to working, developed respiratory symptoms (sore throat, fever, and general malaise), did not notify the facility of symptoms, and provided direct care to 14 residents on the C-100 hall (Residents #5, #6, #10, #11, #15, #19, #20, #38, #53, #55, #62, #66, #74, and #84) from 7:03 A.M. to 2:25 P.M. STNA #104 reported off work on [DATE] for respiratory symptoms and had tested herself for COVID-19 at home and tested positive on [DATE]. Furthermore, on [DATE], STNA #103, who did not screen for signs and symptoms of COVID-19 prior to working, developed respiratory symptoms (sinus symptoms and headache), did not notify the facility of her symptoms, and provided direct care to seven residents on the C-split assignment (residents #17, #36, #43, #60, #65, #80 and #95) from 6:23 A.M. to 2:24 P.M. STNA #103 was scheduled off on [DATE] through [DATE]. On [DATE], STNA #103 returned to work and tested positive during routine staff COVID-19 testing. STNA #103 worked from 6:24 A.M. to 10:46 A.M. on [DATE] and provided direct care to 18 residents on the D-200 hall. After STNA #104 tested positive for COVID-19 on [DATE], a total of 11 staff and 30 residents contracted COVID-19. The facility failed to screen 10 of the 11 employees for COVID-19 signs and symptoms before they tested positive and Licensed Practical Nurse #100 failed to wear proper PPE and maintain infection control precautions in a COVID-19 positive room. It was determined of the 30 residents that became infected with COVID-19, two of the residents were hospitalized (Resident #80 and Resident #92), and one resident died in the facility (Resident #30). This affected 30 residents (Resident #9, #10, #11, #12, #17, #23, #25, #27, #28, #30, #34, #35, #36, #40, #47, #54, #58, #60, #65, #68, #74, #78, #79, #80, #88, #90, #92, #93, #94, and #95) who contracted COVID-19 with the potential to affect all 90 residents residing in the facility. On [DATE] at 1:54 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] when STNA #104 and STNA #103 were not screened for COVID-19 signs and symptoms prior to working, developed respiratory symptoms, failed to notify the facility of COVID-19 symptoms, and provided direct care to residents while symptomatic. STNA #104 tested positive for COVID-19 on [DATE] and STNA #103 tested positive on [DATE]. From [DATE] through [DATE], 11 staff tested positive for COVID-19, with no evidence 10 of the staff were screened for COVID-19 prior to working and testing positive. Furthermore, staff were observed not wearing proper PPE and maintaining infection control precautions in a COVID-19 positive room. Of the 68 residents that resided in the facility, 30 of them became infected with COVID-19 between [DATE] and [DATE]. Two of the residents were hospitalized and one resident expired. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · On [DATE] at 2:30 P.M., Licensed Practical Nurse (LPN) #204, LPN #205 and LPN #206 completed Respiratory COVID Symptoms Evaluation for all 87 residents in the facility, with no residents having any changes or new onset of respiratory signs or symptoms. · On [DATE] at 2:30 P.M., Director of Nursing (DON) and Activity Director #207 toured the entire facility to observe for appropriate infection control practices, which included all units, departments, resident rooms and common areas to ensure the staff were following appropriate infection control practices such as; donning and doffing appropriate PPE, disposing of PPE appropriately, handwashing, wearing their masks appropriately to cover their nose and mouth with both straps in place, and trash receptacles were not overflowing and were emptied timely. · On [DATE] at 3:30 P.M., the Administrator reviewed the employee screening forms to ensure all staff working were screened in appropriately, had no typical or atypical symptoms of COVID-19. No concerns or discrepancies were noted with the screenings. · On [DATE] from 3:46 P.M. through [DATE] at 6:00 P.M. the DON, Assistant Director of Nursing (ADON) and Administrator educated all staff which included; three activity staff, 10 culinary staff, one maintenance staff, 11 housekeeping staff, two social service staff, one business office staff, one Administrator, two receptionist, 15 therapy staff, 29 licensed nurses, 47 STNAs and Personal Care Attendants (PCA) and one Dietician on the COVID Policy and procedure regarding employee screening process including symptoms arising during their scheduled shift, donning appropriate PPE, appropriately doffing PPE, appropriately maintain trash receptacles, wearing appropriate face mask covering mouth and nose with two straps properly positioned, appropriate eye protection. The agency corporate business was provided a copy of education and agency nurses will sign prior to their next shift. · Beginning [DATE] at 4:00 P.M., the DON or designee will audit screening logs daily for 30 days to ensure all staff had screened in and were free of typical or atypical signs and symptoms of COVID-19 prior to and during their shift. If there are any noted discrepancies with signing in or screening, staff will receive as needed education and the screening form will be signed by the employee. · The screenings will be audited as determined by the Quality Assessment and Assurance (QAA) committee. · Beginning [DATE] at 4:00 P.M., the DON or designee will conduct random daily rounds to observe for appropriate infection control practiced, including donning/doffing appropriate PPE, wearing appropriate mask covering mouth, nose, and straps positioned correctly, correct eye protection, trash receptacles emptied and maintained. Infection control rounds will be completed as determined by the QAA Committee. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Finding include: 1. Interview on [DATE] at 9:25 A.M., with the Director of Nursing (DON) revealed the facility currently had a COVID-19 outbreak. The DON revealed the facility currently had eight positive resident and two more were quarantined due to exposure. Review of the staff and resident four-week COVID testing log revealed the first case in the facility was STNA #104 on [DATE]. Review of the list of staff and residents who had tested positive in the previous four weeks provided by the facility dated [DATE] to [DATE] revealed: - On [DATE] one staff member (STNA #104) tested positive for COVID-19, - On [DATE] two staff members (LPN # 700 and STNA #103) and 18 residents (Resident #9, #10 #11, #17, #27, #34 #36, #40, #58, #60, #78, #79, #80 #90 #92, #93, #94, and #95,) tested positive for COVID-19, - On [DATE] two residents (Resident #28 and #30) tested positive for COVID-19, - On [DATE] two staff members (STNA #109 and #112) and two residents (Resident #23 and #88) tested positive of COVID-19, - On [DATE] one staff member (STNA #111) tested positive for COVID-19, - On [DATE] two staff members (Maintenance Director #602 and Floor Technician #603) and five residents (Resident #35, #47, #54, #65, and #68) tested positive for COVID-19 - On [DATE] two staff members (Housekeeper #604 and STNA #110) tested positive for COVID-19, - On [DATE] one resident (Resident #12) tested positive for COVID-19, - On [DATE] two residents (Resident #25 and #74) tested positive for COVID-19. Review of the county COVID-19 positivity rates dated [DATE] revealed the county the facility was located in (Summit County) was red with a 15.58 percent positivity rate with a high transmission rate. Review of the time sheet and staff schedule dated [DATE] revealed STNA #104 who developed respiratory symptoms (sore throat, fever, and general malaise) did not notify the facility of symptoms and provided direct care to 14 residents on the C-100 hall (Residents #5, #6, #10, #11, #15, #19, #20, #38, #53, #55, #62, #66, #74, and #84) from 7:03 A.M. to 2:25 P.M. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. She tested positive of COVID-19 on [DATE] at home. Review of the time sheets and staff schedule dated 07//,d+[DATE] revealed STNA #103, who developed respiratory symptoms (sinus symptoms and headache) did not notify the facility of symptoms, provided direct care to seven residents on the C-split assignment (Residents #17, #36, #43, #60, #65, #80 and #95) from 6:23 A.M. to 2:24 P.M. Review of the staff screening logs revealed she had not screened in on [DATE] prior to her shift. STNA #103 was scheduled off on [DATE] through [DATE]. On [DATE] STNA #103 returned to work and had tested positive during routine staff COVID-19 testing. On [DATE] STNA #103 worked from 6:24 A.M. to 10:46 A.M. and provided direct care to 18 residents on the D-200 hall on [DATE]. Review of time sheets revealed Culinary Aide #210 had worked from 6:00 A.M. to 8:09 A.M. on [DATE] while having signs and symptoms of COVID-19. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. She tested positive for COVID-19 on [DATE] after telling a supervisor she did not feel well. Review of time sheets and staff schedules revealed LPN #700 had provided direct care to 32 residents(#1,#4, #8, #13 ,#18, #23, #25, #27, #28, #29, #32, #33, #39 #40, #41, #47, #49, #51, #59, #61, #63, #67, #68, #72, #77, #79, #81, #83, #87, #88 #89, and #91) on the D-100 and D-200 halls from 6:37 A.M. to 10:00 A.M. on [DATE]. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. She tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of the time sheets and staff schedules revealed STNA #112 had provided direct care to 14 residents on the D-100 hall (Residents #1, #4, #13, #23, #25, #29, #40, #41, #49, #59, #61, #63, #67, and #89) and from 10:31 P.M. to 11:21 P.M. on [DATE]. She had also previously worked on [DATE] from 10:36 P.M. to 6:31 A.M. There was no documentation she had screened in on [DATE] or [DATE] prior to her shifts for signs and symptoms of COVID-19. She tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of time sheets and staff schedules revealed STNA #109 had provided direct care to 17 residents on the C-100 hall (Residents #5, #6, #10, #11, #15, #17, #19, #20, #38, #53, #55, #62, #65, #66, #74, #80 and #84) from 10:15 P.M. to 6:32 P.M. on [DATE]. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. STNA #109 did not work on [DATE] and she tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of time sheets and staff schedules revealed STNA #111 had provided direct care to 8 residents on the A-200 hall (Residents #21, #44, #48, #57, #73, #82, #85, and #96) from 11:30 A.M. to 3:00 P.M. on [DATE]. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. She tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of time sheets revealed Floor Technician #603 had worked from 6:00 A.M. to 9:00 A.M. on [DATE]. Review of the staff screening log revealed he had not screened in on [DATE] prior to his shift for signs and symptoms of COVID-19. He tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of time sheets revealed Maintenance Director #602 had worked from 6:00 A.M. to 9:00 A.M. on [DATE]. Review of the staff screening log revealed he had not screened in on [DATE] prior to his shift for signs and symptoms of COVID-19. He tested positive for COVID-19 on [DATE] during routine testing at the facility. Review of time sheets and staff schedules revealed STNA #110 had provided direct care to 14 residents on the D-100 hall (Residents #1, #4, #13, #23, #25, #29, #40, #41, #49, #59, #61, #63, #67, and #89) from 2:30 P. M to 3:42 P.M. on [DATE]. Review of the staff screening log revealed she had not screened in on [DATE] prior to her shift for signs and symptoms of COVID-19. She tested positive for COVID-19 on [DATE] during routine testing at the facility. Interview on [DATE] at 2:30 P.M. with LPN #204 indicated the facility was not able to pinpoint how the COVID- 19 outbreak had started but she stated they are completely open to visitors and vendors. She stated they tested the staff twice a week. She indicated the screening logs were placed at the front entrance during the day when the receptionist was on duty. LPN #204 indicated they were placed by the side entrance after hours and staff would come into the side door. She indicated all staff should have been screening in every day. Interview on [DATE] at 3:45 P.M. with Registered Nurse (RN) #208 verified there was no documentation any of the nursing staff (nurses and aides) had been screened for signs and symptoms prior to starting their shift to work on [DATE]. Interview on [DATE] at 8:55 A.M. with the Administrator indicated they notified the local health department through the online test reporting site. Interview on [DATE] at 9:30 A.M. with Local County Health Department (LHD) Employee #800 indicated historically the facility did not report timely to their office. LHD #800 stated the facility had been told they need to submit their positive cases to the health department office by Tuesday of every week so they can report it to the State Health Department, however they do not report their COVID-19 cases on time. She stated they usually submit their COVID-19 numbers a few days late and then those number do not get counted in the counties positivity rates. Interview on [DATE] at 10:10 A.M. with STNA #104 revealed she was at work on [DATE] and started to get a sore throat halfway through her shift, her voice got hoarse, and she just did not feel well, however she never told anyone. She stated she had called off on [DATE] because she felt worse, and she tested herself on [DATE] and was positive for COVID-19. She had not screened in on [DATE]. Interview on [DATE] at 10:04 A.M. with STNA #103 revealed she had a sore throat and headache a few days prior to testing positive on [DATE]. She never told anyone she was not feeling well because she thought it was just allergies, she had sinus pressure, headaches, and sore throat. She was tested per the facility testing schedule on [DATE] and she had tested positive for COVID-19. She indicated she never screened in for signs and symptoms of COVID-19 those days. Interview on [DATE] at 10:20 A.M. with Floor Technician # 603 revealed he was not having any signs or symptoms, however he had tested positive during routine testing. He stated he had screened in prior to working on [DATE]. However, his name was not on the screening log for [DATE]. Interview on [DATE] at 10:31 A.M. with Administrator revealed Resident #92 was admitted to the hospital for lactic acidosis and being tested for [CONDITION(S)]. She indicated once the hospital can confirm a negative [CONDITION(S)] test result and given approval through the LHD, he would likely be returning this week. Interview on [DATE] at 10:45 A.M. with Maintenance Director #602 revealed he had been having a sore throat and stuffy nose when he came to work on [DATE] and they tested him at the door, and he was positive, and he was sent home. He indicated he had screened in prior to work, however, there was no documentation on the screening log on [DATE] that he had screened in. Review of his time sheet revealed he had worked 7:26 A.M. to 8:30 A.M. Interview on [DATE] at 12:35 P.M. with Culinary Aide #210 revealed she had gone to work on [DATE] and after a few hours of working she started to not feel very good and felt like she was having a hot flash. She stated she asked to be tested , it was positive, and she left the building. She stated she was in the kitchen the whole time and had no contact with the residents. She stated she had not screened in for signs and symptoms of COVID prior to working that day. She stated she had been wearing a surgical mask. Interview on [DATE] at 1:45 P.M. with the DON revealed LPN #204 and RN #208 should have been checking the screening logs to ensure the staff were screening in prior to their shifts, however, it had not been done. Interview on [DATE] at 2:25 P.M. with STNA #111 indicated she was not having any signs and symptoms on [DATE]. She stated she had tested positive during routine testing on [DATE]. She stated she had screened in for signs and symptoms of COVID-19 prior to her shift. However, there was no documentation on the screening log she screened in on [DATE]. LPN #700, STNA #112, and STNA #109 was unavailable to interview. 2. Review of the nursing staffing schedule dated [DATE] revealed the staff working were STNA #101, STNA #102, STNA #103, STNA #104, STNA #105, STNA #106, STNA #107, STNA #108, LPN #500, LPN #400, LPN #600, LPN #100, LPN #200, and RN #300. Review of the Staff and Visitor COVID-19 screening sheets dated [DATE] revealed STNA #101, STNA #102, STNA #103, STNA #104, STNA #105, STNA #106, STNA #107, STNA #108, LPN # 500, LPN #400, LPN #600, LPN #100, LPN #200, and RN #300 had not been screened at the beginning of their shifts for signs and symptoms of COVID-19 on [DATE]. Interview on [DATE] at 1:45 P.M. with STNA #107 verified she had not screened in prior to the start of her shift on [DATE]. She indicated she did not screen in every day. Interview on [DATE] at 1:50 P.M. with STNA #101 verified she had not screened in prior to the start of her shift on [DATE]. She indicated she does not screen every day. Interview on [DATE] at 2:00 P.M. with STNA #105 verified she had not screened in prior to the start of her shift on [DATE]. She stated she thought they were supposed to screen in, but she does not screen in every day. Interview on [DATE] at 2:10 P.M. with STNA #103 verified she had not screened in prior to the start of her shift on [DATE]. Interview on [DATE] at 3:45 P.M. with RN #208 verified there was no documentation any of the nursing staff (nurses and STNAs) had been screened for signs and symptoms prior to starting their shift to work on [DATE]. Interview on [DATE] at 1:45 P.M. with the DON indicated LPN #204 and RN #208 should have been checking the screening logs to ensure the staff were screening in prior to their shifts however it had not been done. 3. Observation on [DATE] at 7:40 A.M. revealed Resident #35 was on isolation precaution with signage on her door and an isolation cart outside of her room in the hall. At this time, LPN # 100 was administering medication and went into the isolation room of Resident #35 to obtain her blood pressure. LPN #100 never put on an isolation gown or gloves. She was wearing a KN95 mask and a face shield. She came back out to the medication cart, placed the blood pressure cuff on top of the medication cart, sanitized her hands, retrieved the resident's medication and went back into the isolation room without putting on a gown or gloves. She came back out of the room and sanitized her hands. Interview on [DATE] at 7:48 A.M. with LPN #100 confirmed she had not worn a gown or gloves either time she had went into Resident #35 and the resident was on isolation for COVID-19 and she did not use a blood pressure cuff designated just for Resident #35. 4. Interview on [DATE] at 9:47 A.M. with the Administrator revealed there were no COVID-19 deaths or hospitalization from the current COVID-19 outbreak. Review of the medical records revealed two residents (#80 and #92) were hospitalized after testing positive for COVID-19 and one resident (Resident #30) expired after testing positive for COVID-19. Review of the Point of Care (POC) Binex COVID-19 test dated [DATE] confirmed Resident #92 tested positive for COVID-19. He was hospitalized on [DATE]. Review of the Point of Care (POC) Binex COVID-19 test dated [DATE] confirmed Resident #80 tested positive for COVID-19. He was hospitalized on [DATE]. Review of the Point of Care (POC) Binex COVID-19 test dated [DATE] confirmed Resident #30 tested positive for COVID-19. He expired in the facility on [DATE]. Review of the facility policy titled, Criteria for COVID-19 Requirements and Resident Placement, dated [DATE] revealed all staff, visitors, and vendors would complete a self-screen for illness or exposure to COVID-19 prior to entering any part of the facility, the self-screening tool directed employee, contractor, vendor, and visitor, to not enter the facility if they have symptoms or experienced exposure. All staff, visitors, and vendors would complete a self-screen for illness or exposure to COVID-19 prior to entering any part of the facility, The self-screening tool directed employee, contractor, vendor, and visitor, to not enter the facility if they have symptoms or experienced exposure. All staff were required to wear full PPE when entering a COVID-19 isolation room which would include: N95 mask, eye protection, gown, and gloves. Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,d+[DATE]-ALL dated [DATE], revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). This deficiency substantiates Complaint Number OH 321 and Complaint Number OH 314.

Based on record review and interview, the facility failed to ensure Resident #6's weights were obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when Resident #6 sustained a significant weight loss of 35.8 pounds, a 12.11 % weight loss, on [DATE], less than a month after his admission. There was no evidence any nutritional interventions or interventions to improve his appetite were considered or implemented. This affected one of three residents reviewed for nutrition. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 was a full code. Review of the dietary assessment on [DATE] indicated Resident #6 was on a regular diet and had no history of taking nutritional supplements. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #6 to be completed starting upon admission and then every Monday. Review of the weight record revealed Resident #6 weighed 295.6 pounds on [DATE]. Review of the minimum data set assessment dated [DATE] revealed Resident #6 was alert and oriented with a brief interview for mental status score of 14, with scores of 13 to 15 being indicative of intact cognition/memory. This assessment indicated Resident #6 required staff assistance for eating. The dietary progress note on [DATE] indicated Resident #6's diet was changed to a carbohydrate controlled diet and no added salt and indicated he needed assistance to eat. Review of the plan of care dated [DATE] revealed Resident #6 was at risk for nutritional deficits due to disease processes including asthma, diabetes mellitus, hypertension, congestive heart failure, GERD, and needing assistance with meals. Interventions included establishing a baseline weight, identifying preferences, and providing assistance with meals as needed. Review of the weight record revealed Resident #6 had no documented weekly weights on [DATE], [DATE], or [DATE] as ordered by the physician. On [DATE], Resident #6's weight was recorded at 259.8 pounds, a significant weight loss of 35.8 pounds, which is a 12.11 % loss for less than a month. Review of the dietary progress note on [DATE] indicated Resident #6 sustained an approximate 30 pound weight loss since admission. Interview with Resident #6 revealed he was not a picky eater, he just did not have the urge to eat. There were no dietary interventions implemented to attempt to prevent further weight loss or maintain his weight. Review of the dietary progress note date [DATE] document Resident #6's significant weight loss and reviewed abnormal laboratory tests from [DATE], including a low total protein level of 5.5 and a low [MEDICATION(S)] level of 3.2, which are indicators of malnutrition. There were no previous progress notes addressing these low levels and no interventions attempted for Resident #6. Interview with Resident #6's wife via telephone on [DATE] at 11:44 A.M. verified her husband lost a lot of weight at the facility. She verified the facility staff talked to her and her husband regarding his weight loss in [DATE] but said the facility staff never tried any interventions when his weight loss was identified. Interview on [DATE] at 12:15 P.M. with Dietitian #588 verified Resident #6 sustained a significant weight loss between [DATE] and [DATE]. Dietitian #588 verified weekly weights were not obtained/documented for [DATE], [DATE], or [DATE] as ordered by the physician and said the nurse aides were responsible for obtaining weights. Dietitian #588 indicated she met with Resident #6 and his wife on [DATE] and said no nutritional interventions were implemented since he was not eating much. Interview on [DATE] at 1:56 P.M. with Dietitian #588 again verified the facility attempted no interventions for Resident #6's weight loss. Resident #6 continued to decline overall and was admitted to hospice on [DATE] and died at the facility on [DATE]. Review of facility policy titled, Resident Weight, revised [DATE], revealed it was their policy for a resident's weight to be accurately obtained within 24 hours of admission if the resident is able, with changes in condition or as ordered by the physician or practitioner. This deficiency substantiates Complaint Number OH 732.

Based on observation, record review, review of facility policy and procedure and interview the facility failed to comprehensively assess and implement a pressure reduction/relieving plan of care for Resident #57, a new admission to the facility to prevent the development of pressure ulcers to the resident's bilateral heels. Actual harm occurred on 11/27/21 when Resident #57 was identified by hemodialysis staff to have a concern regarding the status of the left heel. The facility failed to assess the heel or implement any type of wound treatment at that time. On 11/28/21 the facility noted the resident's bilateral heels were darkened with an open area to the left heel and a strong odor. The bilateral heels were not assessed or staged at that time and no treatment or pressure reducing/relieving interventions were implemented. On 12/01/21 (four days after concerns were first identified) the resident's right heel was assessed to be dark purple with deep tissue injury that measured 2.8 centimeters (cm) long and 4.5 cm wide and the left heel had moist, scabbed, black eschar (dry, dark scab of dead tissue that sheds from the skin) and measured three cm long by five cm wide. There was no evidence of any pressure reducing/relieving interventions for the resident's heels prior to 12/01/21 to prevent the development of these pressure ulcers. This affected one resident (#57) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident received hemodialysis treatments. An admission skin assessment revealed the resident had no areas of skin impairment at the time of admission. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/11/21 revealed the resident was cognitively intact and required extensive assistance from one staff for bed mobility. Record review revealed no evidence a plan of care for skin integrity or pressure ulcer prevention was implemented at the time of the resident's admission even after the resident was identified to required extensive assistance from staff for bed mobility. There were no physician's orders or care plan interventions for pressure reduction/relief following the resident's admission. On 11/24/21 at 3:09 P.M. Resident #57 was observed without any type of pressure reducing/relieving devices to the bilateral heels. Review of a nursing progress note, dated 11/27/21 at 2:42 P.M. revealed a call was received from the [CONDITION(S)] center expressing a concern regarding the status of Resident #57's left heel. The note indicated the area would be assessed when the resident returned from [CONDITION(S)]. However, there were no additional notes on this date related to the left heel, no evidence of any type of skin assessment or implementation of pressure reducing interventions for the resident's heel(s). A nursing progress note, dated 11/28/21 at 10:43 A.M. revealed Resident #57's bilateral heels were darkened. There was an open area on left heel and a strong odor. No drainage was noted. The resident's bilateral heels were cleaned and an ABD (highly absorbent dressing that provides padding and protection) pad was put in place and wrapped with gauze. The note indicated a message was left for a wound doctor consult and nurse practitioner to follow up. There was no evidence the areas were comprehensively assessed or any type of skin assessment or implementation of pressure reducing interventions for the resident's heels at that time. Review of the physician's orders and treatment administration record revealed no evidence of any type of treatment or pressure reducing interventions during this time period (11/04/21 admission through 11/30/21). On 11/29/21 at 7:32 A.M. and 11/30/21 at 8:10 A.M. Resident #57 was observed without any type of pressure reducing/relieving devices to the bilateral heels. On 12/01/21 at 8:57 A.M. interview with Registered Nurse (RN) #333 revealed Resident #57 was to be seen by the wound doctor on this date. At the time of the interview, RN #333 verified there was not an order, treatment or wound measurements/comprehensive assessment in place for Resident #57's bilateral heels as of this time. RN #333 verified the facility had been notified of skin impairment to Resident #57's bilateral heels on 11/27/21. On 12/01/21 at 9:00 A.M. Resident #57 was observed without any type of pressure reducing/relieving devices to the bilateral heels. An additional interview on 12/01/21 at 12:06 P.M. with RN #333 revealed Resident #57 had a deep tissue injury (DTI) to the right heel. The national pressure injury advisory panel at npiap.com revealed a DTI was one of the most serious forms of pressure injury. The process leading to DTI precedes the visible signs of purple or maroon skin by about 48 hours. Within about 24 hours the epidermis lifts and reveals a dark wound bed. Within another week, the wound bed is often necrotic. The resident's left heel had moist, scabbed, black eschar (dry, dark scab of dead tissue that sheds from the skin). During the interview, RN #333 revealed Resident #57 reported using off loading boots at home but verified the boots had not been provided following the resident's admission to prevent the development of the resident's bilateral heels pressure ulcers. Review of a nursing progress note, dated 12/01/21 at 12:12 P.M. revealed Resident #57's right heel was dark purple with deep tissue injury that measured 2.8 centimeters (cm) long and 4.5 cm wide with no open area noted. Resident #57's left heel had hardened eschar that measured three cm long and five cm wide. On this date, a new order was received to cleanse the bilateral heels and apply skin prep (a liquid film-forming that forms a protective film). An ABD pad and gauze was to be placed to the bilateral heels and to be changed on Monday, Wednesday, Friday, and as needed. The note revealed off loading boots and an alternating air mattress would also be implemented at this time. Review of plan of care, initiated 12/02/21 revealed Resident #57 had impaired skin or was at risk for impaired skin integrity. Interventions included administer treatments as ordered and appropriate pressure reducing appliances applied. Review of facility policy titled Skin Care and Wound Management, dated 05/30/19 revealed residents admitted with or that developed skin integrity issues would receive treatment as indicated based on location, stage and drainage. This deficiency substantiates Complaint Number OH 853 and Complaint Number OH 662.

Based on observation, interview, record review, therapy discharge notes, and policy review the facility failed to ensure Resident #76 received restorative services necessary to maintain dexterity in his right hand. Actual harm occurred when Resident #76 was admitted back into the facility from the hospital, and the facility did not reorder the resident's splint or initiate restorative services as recommended by occupational therapy, resulting in a decline in the resident's ability to open his right hand. This affected one (Resident #76) resident of four reviewed for limited range of motion. The facility census was 96 residents. Findings include: Medical record review revealed that Resident #76 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #71's quarterly Minimum Data Set (MDS) 3.0 dated 04/06/21 revealed the resident received extensive assistance with one person assist for dressing and a noted impairment on one side. Interview on 05/05/21 at 11:23 A.M. with Resident #76 revealed that he was in therapy and had a splint for his right hand. He further revealed that the facility no longer has him in therapy, he is not receiving range of motion, and can no longer open his fingers enough to get his splint on his right hand since stopping therapy. Review of Resident #76's Occupational Therapy Discharge Summary revealed that on 09/24/20 the resident's right hand was tight and his current splint is unable to fit due to splint not being worn constantly. Patient has increased pain at seven out of ten with shoulder, forearm, wrist, and fingers. At the time of discharge from occupational therapy on 10/07/20 the note revealed the resident's right hand was contracted and the patient had an appropriate splint to prevent further tightness. It further revealed the patient had been tolerating splint for eight hours and will resume wearing as a night splint, and to reestablish restorative nursing program for range of motion and splint monitoring. Review of Resident #76's Restorative Care Program dated 10/07/20 that is given to the facility by occupational therapy revealed the facility should provide daily range of motion with right upper extremity, and apply right hand splint as a night splint with skin checks between application. Review of the Resident # 76's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/20 the resident order for a right hand splint to be worn as a night splint up to eight hours as tolerated with skin check before and after application every morning and at bedtime, monitor for redness and report any concerns to therapy or the doctor. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 05/05/21 at 1:10 P.M. with Registered Nurse (RN) #30 revealed that she is the restorative nurse and thought Resident #76 had a splint order, but upon review realizes not that he does not. She further revealed that Resident #76 was not receiving restorative services and has not since his discharge from occupational therapy in October 2020. She also revealed that the floor State tested Nursing Assistants (STNA) run the restorative programs. RN #30 revealed that she will have therapy reassess the resident. Interview on 05/05/21 at 1:21 P.M. with Therapy Manager #85 revealed Resident #76 was discharged from occupational therapy in 10/2020, and at this time he was tolerating a hand splint for eight hours a day. He further revealed that upon his discharge the therapy department also made a restorative referral. Interview on 05/05/21 at 1:31 P.M. with Licensed Practical Nurse (LPN ) #25 with revealed that Resident #76 does not have orders to wear a splint, and was not receiving any type of restorative services. Interview on 05/05/21 at 01:34 P.M. with STNA #50 revealed that she was not aware that Resident #76 had a hand splint, and that she does not provide any restorative services to Resident #76 including range of motion. Review of Resident #76's nursing notes from 10/2020 through 11/2020 revealed that Resident #76 was admitted to the hospital from 10/26/20 through 11/17/20. Interview on 05/05/21 at 1:59 P.M. with the Director of Nursing confirmed that when Resident #76 returned from the hospital on 11/17/20 the facility did not reorder his splint. She further confirmed that his splint and restorative range of motion should have been ordered when he returned from the hospital. Interview on 05/10/21 at 2:00 P.M. with Therapy Manager #85 confirmed that Resident #76 has less dexterity in his right hand at this time compared to 10/2021 when he was discharged from occupational therapy. He further revealed that Resident #76 now requires occupation therapy services again. Review of the facility's policy, Restorative Program (dated 07/26/18), revealed that the facility offers treatment options that may include active and passive range of motion. This deficiency substantiates Complaint Number OH 070.

Based on record review, interview, and policy review the facility failed to ensure appropriate assistance was provided to Resident #11 when the resident was served a hot beverage. This affected one of three sampled residents. Resident #11 sustained actual harm when the hot beverage spilled in her lap causing second [MEDICAL CONDITION] the left thigh. The facility census was 103. Findings include: Review of Resident #11's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's plan of care dated 11/02/20 revealed the resident required adaptive equipment at meals due to dementia and difficulty swallowing. Interventions included monitoring for signs and symptoms of chewing and swallowing difficulties that included coughing or choking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/20, revealed Resident #11 had impaired cognition. Review of a hot liquid evaluation assessment dated [DATE] revealed Resident #11 had severe impaired cognition. The evaluation did not include information regarding the resident's functional abilities. Review of a hot liquid evaluation assessment dated [DATE] revealed the resident had tremors, spasms and shaking and weakness of the upper extremities. The assessment did not the include the resident's cognitive status. Review of physician orders [REDACTED]. Further review revealed orders for occupational therapy to evaluate the resident and the resident was to have an adaptive cup with a lid to prevent spillage dated 12/22/20. Review of the nurses notes dated 12/20/20 at 11:53 A.M. revealed Resident #11 had trauma to her left thigh from a spilled beverage. Review of a progress note dated 12/20/20 at 12:10 P.M. revealed Resident #11's left thigh was assessed by the wound nurse and was noted to have open blisters and moderate amounts of drainage. Observation of Resident #11's wound on 12/23/20 at 7:37 A.M. with Registered Nurse (RN) #202 and the wound physician revealed a border dressing dated 12/22/20. RN #202 removed the dressing revealing a large reddened area that extended from the resident's left outer hip to her inner thigh. There were two areas that appeared to be open with a small amount of drainage that was also observed on the old bandage. The wound physician stated she would classify the wound as a second degree burn. Resident #11 did not appear to be in pain during the cleaning of the wound. Resident #11 was not interviewable. Interview with Assistant Activities Director (AAD) #402 on 12/23/20 at 9:47 A.M. revealed she had distributed hot chocolate to Resident #11 and had been informed of the temperature of the hot chocolate was 120 degrees Fahrenheit by Activities Director #401 prior to serving. AAD #402 further stated she entered Resident #11's room sometime after 3:00 P.M., the resident was sitting in a chair at her bedside and AAD #402 placed the cup of hot chocolate with a lid on it, on a table in front of the resident. After she placed the beverage on the table she proceeded to place a beverage on the bedside table of the roommate. When AAD #402 turned back around to exit the room she noticed Resident #402 had spilled the hot chocolate on her lap. The resident did not appear to be in distress. AAD #402 said State tested Nurse Aide (STNA) #305 was in the room and she believed STNA #305 would inform the nurse of the incident. AAD #402 did not report the incident and did not check the resident's skin after the hot chocolate was spilled. AAD #402 did not know if Resident #11 was safe to consume beverages or if the resident required assistance or supervision while consuming beverages. Interview with STNA #305 on 12/23/20 at 2:21 P.M. revealed he was present on the day Resident #11 [MEDICAL CONDITION] her left thigh. He stated he was walking down the hallway when he heard the resident yell OUCH. He saw the cup in the resident's lap, removed the cup and placed it on her table. STNA #305 was unsure of the exact time; however, he stated he had started his shift around 4:00 P.M. and it had occurred shortly after. He stated he had assisted the resident into the bathroom to change her pants and saw she had some red splotches on her leg. He stated he had informed the nurse who was on duty at the time. Review of the facility's undated policy titled Safety with Hot Beverages revealed residents were required to be screened for functional or cognitive impairments related to the risk of spilling beverages. The policy further stated the preferred temperatures of hot beverages was 135 degrees Fahrenheit. Review of policy titled Hot Beverages or Liquids dated 03/29/18 revealed residents were to be assessed on admission for the use of assistance in managing hot beverages. The assessment was to included cognitive and functional abilities. This deficiency substantiates Complaint Number OH 473.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility Criteria for COVID-19 Isolation policy, review of facility COVID-19 timeline documentation, observations and interviews with staff and residents, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 10/24/20 when the facility received notification of their first three COVID-19 positive cases, Licensed Practical Nurse (LPN) #812, State tested Nursing Assistant (STNA) #813 and STNA #814, whose last date of work prior to the COVID-19 [DIAGNOSES REDACTED].#16, #18, #29, #32, #47, #51, #55, #60, #66, #73, #113, #121 and #122) and the appropriate personal protective equipment (PPE) was not implemented while caring for these residents including gowns, gloves, N95 or higher respirator mask and goggles or face shields. The lack of effective infection control practices related to COVID 19 placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. In addition, interviews with staff and review of the COVID-19 timeline documentation revealed all residents were not immediately tested for COVID-19 on 10/24/20 when the first three staff were positive for COVID-19 constituting an outbreak. All of the residents were not tested until 10/26/20. The results came back on 10/28/20 and revealed 30 residents tested positive for COVID-19 including Residents #3, #6, #13, #16, #18, #19, #23, #29, #34, #49, #51, #55, #58, #63, #64, #67, #70, #73, #75, #77, #84, #86, #87, #97, #107, #110, #113, #114, #115, and #120. The facility indicated they were unable to do contact tracing due to the size of the outbreak. During facility testing on 10/28/20, two additional residents (Residents #43 and #93) also tested positive for COVID-19. A COVID-19 unit was implemented on 10/28/20 and the 32 COVID-19 positive residents were moved to the unit. Additional testing on 10/29/20, 10/30/20, 10/31/20, 11/01/20 and 11/02/20 revealed an additional 49 residents tested positive for COVID-19 (Residents #4, #7, #8, #9, #10, #11, #12, #15, #17, #20, #22, #24, #26, #27, #28, #31, #33, #35, #40, #44, #45, #46, #47, #50, #52, #56, #57, #59, #65, #69, #71, #72, #76, #78, #79, #83, #85, #89, #91, #92, #94, #98, #103, #104, #111, #118, #123, #124, #125) bringing the total to 81 residents who were positive for COVID-19. The facility census was 118. Additional COVID-19 testing from 10/28/20 to 11/03/20 of facility staff revealed the Administrator and Scheduler #816 tested positive on 10/28/20; Registered Nurse (RN) #827, LPN #828 and LPN #829 tested positive on 10/29/20; Occupational Therapist (OT) #830 tested positive on 10/30/20; and Admissions #831 and STNA #834 tested positive on 11/02/20. Observations and interviews on 11/03/20 with STNA #809, STNA #810 and Maintenance #815 confirmed the staff were not donning isolation gowns over their clothing, were not changing their N95 respirator masks or covering them with a surgical mask to be discarded between residents and were not wearing gloves while in contact with the residents who were placed in transmission droplet precautions on the yellow quarantine unit. This had the potential to affect all other residents residing on the yellow quarantine unit. On 11/03/20 at 4:19 P.M., the Director of Nursing (DON) was notified the Immediate Jeopardy began on 10/24/20 when the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when entering resident rooms who were placed in droplet transmission-based precautions on the yellow quarantine unit and failed to complete prompt testing of all residents upon identification of COVID-19 positive staff members. The Immediate Jeopardy was removed on 11/04/20 when the facility implemented the following corrective actions: · On 11/03/20 at 8:30 A.M., Regional Director of Operations #819 educated the DON regarding appropriate COVID-19 testing for outbreaks, the appropriate PPE usage by staff and monitoring and auditing of staff for appropriate PPE use during resident care. · On 11/03/20 at 8:30 A.M., the DON and LPN #817 began inservicing staff regarding proper PPE usage in quarantined areas including two RNs, one LPN, two STNAs, one certified nursing assistant (CNA), one hospitality aide, one activity director, one activity assistant, one human resources (HR) manager, one physical therapist (PT), the maintenance director and the social worker. · On 11/03/20 by 7:10 P.M., all additional staff were re-educated on appropriate PPE usage by LPN #817 and Human Resources Manager (HR) #820. · On 11/03/20 at 3:00 P.M., an additional 37 residents who were previously negative for COVID-19 were re-tested by RN #818 and LPN #821. Seven residents tested positive including Residents #1, #39, #54, #68, #80, #81 and #95. The facility will continue at least weekly testing of negative residents until no additional residents test positive for 14 days. · COVID-19 testing of employees continues weekly and as needed when there are symptomatic employees. Additional facility staff were tested between 10/28/20 and 11/03/20. The Administrator and Scheduler #816 tested positive for COVID-19 on 10/28/20. RN #827, LPN #828 and LPN #829 tested positive for COVID-19 on 10/29/20. Occupational Therapist (OT) #830 tested positive on 10/30/20 and Admissions #831 and STNA #834 tested positive on 11/02/20. · Starting on 11/03/20, the two halls of the yellow quarantine unit will be monitored by assigned staff per the DON/Designee during the three meal times to ensure proper staff use of PPE including gowns, N95 respirator mask, surgical mask, gloves and face shield or goggles are used, seven days a week for two weeks and as needed thereafter. The facility has two units currently, the red COVID-19 positive unit and the yellow quarantine unit. · Starting on 11/03/20, the DON or designee will complete random observations for proper staff use of PPE on the yellow quarantine unit, daily for a week for two weeks and as needed thereafter. · The DON or designee will continue to audit the monitoring of residents on the yellow quarantine unit for signs and symptoms via the COVID-19 assessment, daily for two weeks and as needed thereafter. · On 11/03/20 at 5:10 P.M., the Medical Director was updated on the identified infection control concerns with no further recommendations at that time. · Regional Director of Operations #819 will educate the Administrator on proper COVID-19 testing during outbreaks, appropriate PPE usage, and monitoring and auditing of these areas on 11/09/20 at 8:30 A.M. when she returns to work. · All findings will be submitted to QAPI committee, including the Medical Director, the Administrator, the DON and all department heads on 11/04/20 and then be reviewed monthly and as needed. · Interviews on 11/04/20 from 9:45 A.M. to 10:03 A.M. confirmed STNA #809, STNA #824, LPN #817, RN #807, RN #818, Activity Leader #825 and Secretary #826 were inserviced on appropriate infection control measures. Although the Immediate Jeopardy was removed on 11/04/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: The facility had two separate units and both units consisted of four halls. The first unit currently identified as the red COVID-19 unit which was blocked off from the main building by plastic barriers. The second unit was currently identified as the yellow quarantine unit. Interview on 11/02/20 at 6:52 A.M. with the DON confirmed the facility had an outbreak of COVID-19 beginning with staff testing positive and then many residents. The DON said Local Health Department Employee (LHD) #806 was contacted on 10/28/20 for guidance on contact tracing of the infected employees and guidance of current infection control procedures to be followed for the safety of the residents. Interview on 11/02/20 at 12:12 P.M. with LHD #806 indicated the facility could not determine the source of the COVID-19 infection because the infection had already progressed to many residents and indicated there was a break in infection control. Interview on 11/02/20 at 3:35 P.M. with the Medical Director indicated he could not determine the reason COVID-19 was spreading between residents in the building. Observation on 11/03/20 at 8:09 A.M. on the yellow quarantine unit of STNA #809 revealed she carried Resident #41's breakfast meal tray into the resident's room wearing only a N95 respirator mask and goggles. She was not wearing gloves, an isolation gown or a surgical mask over her N95 respirator mask. She assisted the resident to set-up her meal tray by removing the lids and adjusting the tray table over the bed. STNA #809 washed her hands and exited the room. She was not observed to change her N95 respirator mask upon exiting the room. Observation of the resident's door revealed signage indicating the resident was in droplet transmission-based precautions. Interview on 11/03/20 at 8:11 A.M. with STNA #809 indicated she was not required to wear an isolation gown to deliver meal trays to the resident. Observation on 11/03/20 at 8:12 A.M. on the yellow quarantine unit with STNA #810 revealed she went into Resident #81's resident room delivering the resident's breakfast tray while wearing a N95 respirator mask and goggles. She sanitized her hands and exited the room. She was not wearing an isolation gown, gloves or a surgical mask over her N95 respirator mask. STNA #810 was not observed to change her N95 respirator mask upon leaving Resident #81's room and she continued delivering meal trays into other resident rooms. Observation of the resident's door revealed signage indicating the resident was in droplet transmission-based precautions. Interview on 11/03/20 at 8:14 A.M. with STNA #810 verified she did not wear an isolation gown. She said she was supposed to wear an isolation gown over her clothing when entering resident rooms in droplet transmission-based precautions. Interview on 11/03/20 at 8:29 A.M. with the DON confirmed staff should don an isolation gown, goggles, gloves and N95 respirator mask when entering resident rooms who were in quarantine. Observation on 11/03/20 at 11:16 A.M. with the DON of the yellow quarantine unit revealed Maintenance #815 was in Resident #37's resident room, which had a sign to indicate the resident was in droplet precautions. He was observed removing the side assist bar (grab bar) from the resident's bed. Maintenance #815 had on goggles, gloves and an N95 respirator mask but no isolation gown or clothing protector to protect his clothing against cross contamination. He was not wearing a surgical mask over his N95 respirator mask. Maintenance #815 was observed exiting Resident #37's room with the grab bar in his hands but was not observed to change his N95 respirator mask at the time of the observation. He carried the uncovered grab bar down the hall through the double doors and off the quarantine unit to the maintenance office. Interview on 11/03/20 at 11:17 A.M. with Maintenance #815 confirmed he did not use an isolation gown/clothing protector to protect his clothing against cross contamination while consulting with the resident about an air mattress and removing the grab bar from the resident's bed. He indicated he used hand sanitizer before he exited Resident #37's room. An additional interview on 11/03/20 at 1:25 P.M. with the DON confirmed LPN #812, STNA #813 and STNA #814 were tested for COVID-19 on 10/21/20 and the facility obtained the results of the testing on 10/24/20. All three staff members tested positive and worked on the quarantine unit. LPN #812 last worked on 10/19/20, STNA #813 last worked on 10/19/20 and STNA #814 last worked on 10/22/20. Further interview with the DON confirmed all residents were not tested for COVID-19 until 10/26/20. The facility obtained the results of the testing on 10/28/20 and at that time, 30 residents tested positive for COVID-19 including Residents #3, #6, #13, #16, #18, #19, #23, #29, #34, #49, #51, #55, #58, #63, #64, #67, #70, #73, #75, #77, #84, #86, #87, #97, #107, #110, #113, #114, #115, and #120. Two additional residents (Residents #43 and #93) tested positive for COVID-19 on 10/28/20. The yellow quarantine unit was moved to the C and D units and the red COVID-19 unit was implemented on the A and B units. Testing on 10/29/20, 10/30/20, 10/31/20, 11/01/20 and 11/02/20 revealed an additional 49 residents tested positive for COVID-19 (Residents #4, #7, #8, #9, #10, #11, #12, #15, #17, #20, #22, #24, #26, #27, #28, #31, #33, #35, #40, #44, #45, #46, #47, #50, #52, #56, #57, #59, #65, #69, #71, #72, #76, #78, #79, #83, #85, #89, #91, #92, #94, #98, #103, #104, #111, #118, #123, #124, #125) bringing the total to 81 residents. There were 118 residents residing in the facility. The DON verified all other residents who were not COVID-19 positive were placed in droplet quarantine precautions. The DON also verified staff testing for COVID-19 from 10/28/20 to 11/03/20 determined the Administrator and Scheduler #816 tested positive on 10/28/20; RN #827, LPN #828 and LPN #829 tested positive on 10/29/20; Occupational Therapist (OT) #830 tested positive on 10/30/20; Admissions #831 and STNA #834 tested positive on 11/02/20. Interview on 11/03/20 at 3:05 P.M. with LPN #812 confirmed she worked on the yellow quarantine unit. She said she was not required to wear an isolation gown on the yellow quarantine unit prior to the outbreak of COVID-19 in the facility unless she physically touched the resident. LPN #812 confirmed she administered medications and answered call lights without using an isolation gown and did not change her N95 respirator mask between residents or cover her N95 respirator mask with a surgical mask and discard the surgical mask between residents. Interview on 11/03/20 at 3:19 P.M. with STNA #814 indicated the facility directed them to don an isolation gown on the yellow quarantine unit prior to the identification of COVID-19 in the building when they were providing personal care to the resident but not for serving meals, to answer call lights etc. STNA #814 also confirmed she did not change her N95 respirator mask or cover the mask with a surgical mask and discard the surgical mask between residents. A second interview on 11/04/20 at 10:22 A.M. with Maintenance #815 verified he did not don a surgical mask over his N95 respirator mask prior to entering Resident #37's room and did not replace the N95 respirator mask when exiting the resident's room. He confirmed he took Resident #37's grab bar from her room, off the unit, and to the maintenance office. Interview on 11/04/20 at 11:48 A.M. with the DON confirmed 13 residents (Residents #16, #18, #29, #32, #47, #51, #55, #60, #66, #73, #113, #121 and #122) resided on the quarantine unit on 10/22/20, prior to the outbreak. The DON indicated she initially instructed her staff to don an isolation gown if providing hands-on resident care to those residents who resided on the yellow quarantine prior to the outbreak. She said isolation gowns were not required when dropping off meal trays, medication pass or answering call lights. The procedure was revised to include using an isolation gown, gloves, goggles or face shield and N95 respirator mask when entering/exiting resident rooms when the COVID-19 outbreak was identified on 10/24/20. Review of the Centers for Disease Control (CDC) guidelines titled Infection Control for Nursing Homes updated 06/25/20 confirmed because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCPs is newly identified in the facility. Health Care Providers (HCP) should wear an N95 or higher-level respirator mask, eye protection, gloves and gown when caring for new admissions and readmissions. If the residents remain afebrile for fourteen days after their admission, they may be transferred out of the observation area to the main facility. Review of the CDC guidance Optimizing N95 Respirator Supplies dated 06/28/20 confirmed HCP can consider using a face shield or facemask over the respirator to reduce/prevent contamination of the N95 respirator mask. Review of the facility Criteria for COVID-19 Isolation policy reviewed 08/04/20 confirmed the at risk for COVID-19 unit would be used for residents who may be at risk for developing COVID-9, such as new admits, residents who have been exposed, but not showing signs and symptoms, etc. The process for the at risk unit would include identifying the unit as a yellow unit and full PPE would be used while working on the unit. Full PPE consists of an N95 respirator mask, gloves, gown and eye covers. A surgical mask would be placed over the N95 respirator mask upon entering a resident room. Surgical mask, gowns and gloves must be changed out between residents. This deficiency substantiates Master Complaint Number OH 079 and Complaint Numbers OH 937, OH 895, and OH 861.