Every finding on record at Country Club Ret Center I I I

Based on observation and interviews, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 70 of the 72 residents who received food from the facility kitchen. The facility identified two residents, Residents #14 and #70, who received no food from the kitchen. The facility census was 72.Findings include:Observations during the initial kitchen tour conducted on 02/10/26 between 8:31 A.M. and 8:53 A.M. with Assistant Dietary Manager (ADM) #223 revealed one opened and undated bag tortilla chips and three loaves of outdated bread. The ice machine had pink growth on the rims that came off when wiped with a paper towel. The oven knobs had accumulated grease and dirt. The shelf above the oven had a layer of grease and dust. The sanitizer buckets when tested did not meet the required chemical level for sanitizing surfaces. The wall next to the reach-in freezer had food splatters. Interview at the time of the observation with ADM #223 verified the above findings and stated the kitchen cleaned the ice machine monthly.

Based on observation, interview, record review, facility assessment review, and review of infection-Antibiotic (ATB) Surveillance logs and facility policy, the facility failed to have a designated infection preventionist (IP) who effectively monitored and implemented the facility's Infection Prevention and Control Program (IPCP). This had the potential to affect all 72 residents residing in the facility.Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 07/15/24 and a diagnosis of COVID-19 (Coronavirus, an infectious respiratory disease) dated 02/09/26. Review of physician orders for February 2026 identified an order for isolation airborne/droplet precautions (infection control measures to prevent the spread of germs using a mask, eye protection and proper hand hygiene) due to a positive test result for COVID-19 dated 02/09/26.Observation on 02/10/26 at 9:43 A.M. of Resident #69 revealed signage on the door for transmission-based precautions for COVID-19. The sign indicated isolation was in effect for Resident #69 from 02/09/26 until 02/19/26. The signage specified the wearing of at minimum eye, nose and mouth protection. The required personal protective equipment including masks, gowns and eye protection was in a bin outside the resident's room.Observation on 02/11/26 at 11:38 A.M. of CNA #289 revealed she delivered Resident #69's lunch into the resident's room. The CNA did not adhere to the required precautions by only wearing a surgical mask and gloves. She did not wear a gown, eye protection or an N95 respirator. Interview at the time of the observation with CNA #289 after exiting Resident #69's room confirmed the required precautions were not followed. 2. Review of Infection Log- ATB Surveillance log dated December 2025 revealed for the month of December 2025 there were 14 occurrences of residents ordered antibiotic use that did not meet McGeer's criteria (infection surveillance definitions for long term facilities for antibiotic use), and one occurrence for the month of December 2025 that was not marked if the ATB use met or did not meet McGeer's criteria. Review of January 2026 ATB surveillance revealed there was no log present only individual sheets labeled, McGeer Criteria for Infection Surveillance Checklists for each resident that was on an ATB for the month. There were 13 individual sheets that did not include the date the ATB was ordered, reason for the ATB, name of the ATB and/or if the ATB met criteria for ATB use. Review of Infection Log-ATB Surveillance log for February 2026 revealed there were five occurrences that were marked on the log that the ATB did not meet McGeer's criteria.3. Review of the medical record for Resident #32 revealed she was admitted on [DATE] with diagnoses of diabetes, cognitive communication deficit, dysphagia, congestive heart failure, chronic kidney disease stage four and obesity. There was no record Resident #32 was offered and/or received the pneumococcal vaccination.Interview on 02/12/2026 at 10:30 A.M. with DON confirmed the facility had no record that Resident #32 had received or had been offered the pneumococcal vaccine.4. Review of Nursing Home Infection Preventionist Training Course certificate dated 10/24/23 revealed the Director of Nursing (DON) had completed it. She was the only one with training at the facility. Review of Facility Assessment Tool dated 12/22/25 revealed under infection prevention and control included the identification and containment of infections, and prevention of infections. There was no other documentation identified in the facility assessment regarding the amount of time the IP was designated to work on infection control and/or any other specific responsibilities for the IP. Interview on 02/11/26 at 2:25 P.M. with the Director of Nursing (DON) revealed both she and the former Assistant Director of Nursing (ADON) #304 had shared the infection control preventionist responsibilities but the former ADON #304's last date of employment was 10/29/25. She tried to spend two to three hours per day on infection control but stated, yes I do wear many hats as she also verified, she had the responsibilities of the DON, as well as restorative nurse and infection control. She verified the December 2025 infection log had 14 occurrences of residents requiring antibiotic use that did not meet McGeer's criteria. She was asked what happened if an ATB did not meet the criteria and she stated she just put it on the log. She was asked if she contacted the physician to let them know that the ATB did not meet the criteria, and she stated she may mention it in general to a physician but that she did not contact the physician on each individual resident. She verified there was no documentation the physician was notified that the ATBs did not meet criteria for ATB use. She did not know she needed to, as she thought she just needed to put it on the log. She verified there was no log for January 2026 and that all the individual McGeer Criteria for Infection Surveillance Checklists did not include if the ATB met criteria or not. Then, she stated she might have it on the computer. She also verified several of the checklists were blank and included no signs and symptoms. She stated all the residents ordered ATBs in January 2026 most likely did not meet criteria which was why the individual sheets were blank. Interview on 02/12/26 at 1:26 P.M. with DON as she brought in an Infection Log-ATB Surveillance log dated January 2026 revealed on the log it stated all the ATBs met criteria. She also brought in new individual McGeer Criteria for Infection Surveillance Checklists for the individuals on ATBs in January 2026 that were no longer blank and/or had different items checked on the forms including that the ATB met criteria at the bottom. She revealed after talking to Corporate Nurse #800, she found out she had been doing the forms wrong as she thought for an ATB to meet criteria all the symptoms had to be in one sentence in a nursing note. She did not know she could look at different entries in the notes and/or records to determine if an ATB met the criteria. She verified she had redone the log and the forms on 02/11/26 after she was informed by Corporate Nurse #800 on how the process should go. She verified on February 2026 Infection Log-ATB Surveillance log there were five occurrences marked that the ATB did not meet criteria and that she had no documentation the physician was notified.Interview on 02/13/2026 11:12 AM with the Administrator verified there was nothing in the facility assessment regarding the amount of time the IP was designated to work on infection control. He verified after reviewing the infection control concerns identified during the survey of immunizations, wearing of appropriate personnel protective equipment into a COVID-19 room, and effective antibiotic stewardship program that since former ADON #304 left, it had been rough for the DON to keep up on infection control. Review of facility policy labeled, Antibiotic Stewardship dated 11/30/17 revealed the purpose of the policy was to meet the regulatory guidelines of ATB stewardship program and promote responsible utilization of ATBs. All residents with newly diagnosed infections utilizing ATBs were reviewed for appropriate utilization. The policy revealed residents without proof of infection symptoms prior to the initiation of an ATB were reviewed for ATB holiday, and/or a culture and sensitivity. The results of the testing and the recommendations for treatment were discussed with the physician to ensure ATBs were utilized in a responsible manner. Review of facility policy labeled, Infection Control Preventionist dated 8/25/23 revealed the purpose of the policy was to establish a process that investigates, monitors, identifies, controls, and surveys infections. The policy revealed when a resident was admitted or when a resident acquired an infection, the infection report was completed by the infection preventionist. The infection control preventionist encouraged the oversight of the environment, followed up on areas of concern, and educated staff. There was nothing in the policy regarding the infection control preventionist working at least part-time on infection control.

Based on observation, interview and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow transmission-based precautions for infection control. This affected one resident (#69) and had the potential to affect 12 residents on Certified Nursing Assistant (CNA) #289's assignment (#4, #13, #18, #22, #33, #37, #40, #41, #47, #53, #69 and #73). The facility census was 72.Findings include:Review of the medical record for Resident #69 revealed an admission date of 07/15/24 and a diagnosis of COVID-19 (Coronavirus, an infectious respiratory disease) dated 02/09/26. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. Review of physician orders for February 2026 identified an order for isolation airborne/droplet precautions (infection control measures to prevent the spread of germs using a mask, eye protection and proper hand hygiene) due to a positive test result for COVID-19 dated 02/09/26.Observation on 02/10/26 at 9:43 A.M. of Resident #69 revealed signage on the door for transmission-based precautions for COVID-19. The sign indicated isolation was in effect for Resident #69 from 02/09/26 until 02/19/26. The signage specified the wearing of at minimum eye, nose and mouth protection. The required personal protective equipment including masks, gowns and eye protection was in a bin outside the resident's room.Review of the nurses note dated 02/10/26 at 12:22 P.M. revealed Resident #69 was to continue isolation precautions due to COVID-19 diagnosis.Review of the Infection Note dated 02/11/26 at 5:29 P.M. revealed Resident #69 was to continue isolation precautions due to COVID-19 diagnosis.Observation on 02/11/26 at 11:38 A.M. of CNA #289 revealed she delivered Resident #69's lunch into the resident's room. The CNA did not adhere to the required precautions by only wearing a surgical mask and gloves. She did not wear a gown, eye protection or an N95 respirator. Interview at the time of the observation with CNA #289 after exiting Resident #69's room confirmed the required precautions were not followed. Interview on 02/11/26 at 1:46 P.M. with the DON verified the findings and stated CNA #289 was suspended for three days for not following the required COVID-19 precautions for Resident #69.Review of the CDC guidelines for viral respiratory pathogens in nursing homes dated 01/23/36 and located at https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html revealed to prevent the spread of COVID-19, apply appropriate transmission-based precautions. Healthcare personnel who enter the room of a resident with signs or symptoms of COVID-19 infection should adhere to standard precautions and use an N-95 or higher respirator, gown, gloves and eye protection.Review of the CDC guidelines for droplet precautions dated 01/16/20 and located at https://stacks.cdc.gov/view/cdc/134214 revealed droplet precautions included making sure eyes, nose and mouth were fully covered before room entry, removing face protection before room exit, and cleaning hands including before entering and when leaving the room.Review of the CDC guidelines for airborne precautions dated 07/24/19 and located at https://stacks.cdc.gov/view/cdc/134215 revealed airborne precautions included making sure to wear a fit-tested N-95 or higher-level respirator before room entry, removing the respirator after exiting the room and cleaning hands before entering and when leaving the room.Review of facility policy labeled, Novel Coronavirus Prevention, Response and Source Control, last revised 01/16/25 revealed to implement standard, contact and droplet precautions. Wear gloves, gowns, eye protection and a N-95 or equivalent or higher-level respirator upon entering the room and when caring for the resident.Review of facility policy labeled, Isolation Practices, last revised 03/06/20 revealed airborne precautions required use of respiratory protection and droplet precautions required a mask when working closely with the resident. Centers for Disease Control guidelines will be followed.

Based on record review, interview, and review of facility policy and the antibiotic surveillance infection logs, the facility failed to maintain an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. This affected 25 residents (#1, #2, #3, #5, #10, #14, #15, #19, #28, #29, #32, #33, #34, #36, #37, #45, #46, #47, #48, #49, #50, #55, #56, #65 and #72) who were ordered antibiotics but did not meet McGeer's criteria (infection surveillance definitions for long term facilities for antibiotic use) during the months of December 2025, January 2026 and February 2026. The facility census was 72.Findings include: 1. Review of Infection Log-ATB (antibiotic) Surveillance log dated December 2025 revealed the form tracked residents that received ATBs and the form included unit, date, resident name, room number, sign and symptoms, site, if urinary tract infection (UTI) with or without catheter, culture/organism, ATB, isolation precautions if needed, symptoms present on admission, whether acquired in facility, and if it met McGeer's criteria. For the month of December 2025, there were 14 occurrences of residents with antibiotic use that did not meet McGeer's criteria, and one occurrence that was not marked if the ATB use met or did not meet McGeer's criteria. The log revealed the following: Resident #32 had an admission date of 01/03/24 and was ordered doxycycline on 12/03/25 for bilateral lower extremity cellulitis. The ATB did not meet the criteria for ATB use. Resident #28 had an admission date of 07/21/25 and was ordered doxycycline on 12/03/25 for cellulitis. The ATB did not meet the criteria for ATB use. Resident #2 had an admission date of 09/30/20 and was ordered Augmentin on 12/05/25 for a UTI, then on 12/08/25 ampicillin was ordered for a UTI. Both ATBs did not meet the criteria for ATB use. Resident #49 had an admission date of 04/12/03 and was ordered amoxicillin on 12/08/25 for a UTI. The ATB did not meet the criteria for ATB use. Resident #19 had an admission date of 03/12/25 and was ordered Augmentin on 12/08/25 for bacterial infection. The ATB did not meet the criteria for ATB use. Resident #33 had an admission date of 01/24/25 and was ordered Bactrim on 12/17/25 for a UTI. The ATB did not meet the criteria for ATB use. Resident #15 had an admission date of 09/30/23 and was ordered Augmentin on 12/19/25 for a UTI. The ATB did not meet the criteria for ATB use.Resident #72 had an admission date of 11/14/25 and was ordered Keflex on 12/19/25 for a his foot. The log did not state if it met criteria for ATB use or not. Resident #3 had an admission date of 05/09/25 and was ordered Macrobid on 12/20/25 for a UTI, then on 12/22/25 Levaquin was ordered for a UTI. Both ATBs did not meet the criteria for ATB use. Resident #10 had an admission date of 01/24/23 and was ordered doxycycline on 12/22/25 for an upper respiratory infection. The ATB did not meet the criteria for ATB use. Resident #34 had an admission date of 04/14/24 and was ordered Bactrim on 12/22/25 for a UTI. The ATB did not meet the criteria for ATB use. Resident #48 had an admission date of 07/16/25 and was ordered Keflex on 12/24/25 for her skin. The ATB did not meet the criteria for ATB use. Resident #55 had an admission date of 02/03/23 and was ordered Levaquin on 12/30/25 for a UTI. The ATB did not meet the criteria for ATB use. 2. Review of January 2026 ATB surveillance revealed there was no log present only individual sheets labeled, McGeer Criteria for Infection Surveillance Checklists, one for each resident that was on an ATB for the month. There were 13 individual sheets that did not include a date the ATB was ordered, reason for the ATB, name of the ATB and/or if the ATB met criteria for ATB use. The checklists revealed the following: Resident #5 had an admission date of 01/06/26 and was admitted on an ATB. The only thing marked on the checklist under influenza-like illness was that she had a new or increased cough. The checklist had no other information including whether it did or did not meet criteria for ATB use. Resident #14 had an admission date of 08/17/20. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use.Resident #50 had an admission date of 10/11/23. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use.Resident #49 had an admission date of 04/12/23. The checklist specified under influenza-like illness that he had a new or increased cough. At the bottom of the checklist, it noted congestion and it was not checked whether the ATB did or did not meet criteria for ATB use. Resident #36 had an admission date of 05/02/23. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use.Resident #19 had an admission date of 03/12/25. The checklist specified there was confusion and congestion. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use. Resident #29 had an admission date of 12/22/22. The checklist specified under influenza-like illness that he had a cough. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use.Resident #46 had an admission date of 01/01/26. The checklist specified under the pneumonia section that he had a chest x-ray, new or increased cough, and increased sputum production. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use. Resident #15 had an admission date of 09/30/23. The checklist specified under the pneumonia section that he had a chest x-ray, oxygen saturation level was below 94 percent, and had a change in lung abnormalities. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use. Resident #56 had an admission date of 01/17/26 and was admitted with an ear infection. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use. Resident #1 had an admission date of 12/16/25. The checklist specified under the influenza-like illness that he had a new or increased cough, and under the pneumonia section that he had a chest x-ray, new or increased sputum production, new or change in lung abnormalities, and acute functional decline. The checklist did include whether it did or did not meet criteria for ATB use. Resident #37 had an admission date of 10/03/24, and she had drainage from her ear. There was no other information regarding the ATB use including whether it did or did not meet criteria for ATB use. Resident #45 had an admission date of 01/19/26. The checklist specified under the section of UTI that she had acute pain, swelling or tenderness, and had a urine sample. The checklist did include whether it did or did not meet criteria for ATB use. 3. Review of Infection Log-ATB Surveillance log for February 2026 revealed there were five occurrences that were marked on the log that the ATB did not meet McGeer's criteria. The log revealed the following: Resident #10 had an admission date of 01/24/23 and was ordered Augmentin on 02/04/26 as preventative. The ATB did not meet the criteria for ATB use. Resident #47 had an admission date of 01/14/22 and was ordered Macrobid on 02/04/26 for a UTI. The ATB did not meet the criteria for ATB use. Resident #34 had an admission date of 04/14/24 and was ordered doxycycline on 02/09/26 for a cough. The ATB did not meet the criteria for ATB use. Resident #65 had an admission date of 11/26/25 and was ordered cipro and Macrobid on 02/09/26 for a UTI. The ATBs did not meet the criteria for ATB use. Interview on 02/11/26 at 2:25 P.M. with the Director of Nursing (DON) revealed both she and the former Assistant Director of Nursing (ADON) #304 had shared the infection control preventionist responsibilities but the former ADON #304's last date of employment was 10/29/25. She tried to spend two to three hours per day on infection control but stated, yes I do wear many hats as she also verified, she had the responsibilities of the DON, as well as restorative nurse and infection control. She verified the December 2025 infection log had 14 occurrences of residents requiring antibiotic use that did not meet McGeer's criteria. She was asked what happened if an ATB did not meet the criteria and she stated she just put it on the log. She was asked if she contacted the physician to let them know that the ATB did not meet the criteria, and she stated she may mention it in general to a physician but that she did not contact the physician on each individual resident. She verified there was no documentation the physician was notified that the ATBs did not meet criteria for ATB use. She did not know she needed to, as she thought she just needed to put it on the log. She verified there was no log for January 2026 and that all the individual McGeer Criteria for Infection Surveillance Checklists did not include if the ATB met criteria or not. Then, she stated she might have it on the computer. She also verified several of the checklists were blank and included no signs and symptoms. She stated all the residents ordered ATBs in January 2026 most likely did not meet criteria which was why the individual sheets were blank. Interview on 02/12/26 at 1:26 P.M. with DON as she brought in an Infection Log-ATB Surveillance log dated January 2026 revealed on the log it stated all the ATBs met criteria. She also brought in new individual McGeer Criteria for Infection Surveillance Checklists for the individuals on ATBs in January 2026 that were no longer blank and/or had different items checked on the forms including that the ATB met criteria at the bottom. She revealed after talking to Corporate Nurse #800, she found out she had been doing the forms wrong as she thought for an ATB to meet criteria all the symptoms had to be in one sentence in a nursing note. She did not know she could look at different entries in the notes and/or records to determine if an ATB met the criteria. She verified she had redone the log and the forms on 02/11/26 after she was informed by Corporate Nurse #800 on how the process should go. She verified on February 2026 Infection Log-ATB Surveillance log there were five occurrences marked that the ATB did not meet criteria and that she had no documentation the physician was notified.Review of facility policy labeled, Antibiotic Stewardship dated 11/30/17 revealed the purpose of the policy was to meet the regulatory guidelines of ATB stewardship program and promote responsible utilization of ATBs. All residents with newly diagnosed infections utilizing ATBs were reviewed for appropriate utilization. Residents without proof of infection symptoms prior to the initiation of an ATB would be reviewed for ATB holiday, and/or a culture and sensitivity. The results of the testing and the recommendations for treatment were discussed with the physician to ensure ATBs were utilized in a responsible manner.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain accurate and thorough documentation for Resident #2's wound assessments in the medical record. This affected one resident (#2) out of two residents reviewed for medical record accuracy with wounds documentation. The facility census was 72.Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/30/20 and his diagnoses included quadriplegia, muscle weakness, contractures, and abnormal posture. Review of care plan dated 04/11/25 revealed Resident #2 had pressure ulcers to his left ischium (region of hip bone) and right buttock. Interventions included scheduling wound clinic appointments, and treatment as ordered. There was nothing in the care plan regarding assessing or documenting his wounds at least weekly. Review of Weekly Wound Assessments in the medical record for Resident #2 revealed an assessment was completed 12/03/25, 12/10/25, 12/18/25, 12/26/25 and 01/14/26. There was no documentation a weekly wound assessment was completed from 12/26/25 to 01/14/26 (18 days) and from 01/14/26 to 02/03/26 (19 days) while seen at an outside wound clinic. Review of Wound Progress Note dated 12/16/25 completed by Wound Nurse Practitioner (WNP) #902 revealed Resident #2 was seen and his wounds were assessed. He continued to have left and right ischium pressure ulcers that were both classified as Stage 4 (full-thickness skin and tissue loss, exposing underlying tissue, muscle, tendon, ligament, cartilage or bone). Review of Weekly Wound Tracking Log dated from 12/19/25 to 01/28/26 revealed a log that contained multiple residents and for each resident it identified the following in regards to their wound: date of discovery; if the wound was in house acquired or not; stage of the wound; wound location; measurements; if the wound was improving or declining; and treatment orders and/or comments. The logs contained weekly documentation regarding Resident #2's pressure wounds to both his right and left ischium. Review of After Visit Summary dated 02/03/26 completed by WNP #901 revealed Resident #2 was seen in an outside wound clinic and his pressure ulcers to his left and right ischium were assessed and measured. Both wounds continued to be classified as Stage 4. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had intact cognition. He had impairment of both his upper and lower extremities. He was totally dependent on staff assistance with his activities of daily living (ADL) including turning left and right, transfers, toileting, hygiene, and showers. He had two Stage 4 pressure ulcers that were not present on admission. Observation of wound care on 02/11/26 at 11:25 A.M. completed by Program Nurse/Licensed Practical Nurse (LPN) #209, LPN #238, and Certified Nursing Assistant (CNA) #259 revealed Resident #2 had two Stage 4 pressure ulcers to his right and left ischium areas. Interview on 02/11/26 at 11:30 A.M. with Resident #2 revealed he used to go weekly to an outside wound clinic and see WNP #902, but she had retired so he was unable to see her any longer. He recently started going to another outside wound clinic and was seen by WNP #901 on 02/03/26.Interview on 02/12/26 at 6:45 A.M. with Program Nurse/LPN #209 revealed she followed the wounds at the facility. She verified Resident #2 was seen at an outside wound clinic weekly by WNP #902, but she was unable to see Resident #2 any longer. The last time Resident #2 saw WNP #902 was on 12/16/25. The facility was able to get Resident #2 into another outside wound clinic and he was seen by WNP #901 for his initial visit on 02/03/26. She verified that from 12/26/25 to 01/14/26 (18 days) and from 01/14/26 to 02/03/26 (19 days) there were no wound assessments in his medical record, and that wound assessments were to be completed at least weekly. She stated since the former Assistant Director of Nursing (ADON) #304 had left (10/29/25), she has had a hard time completing everything that now became her responsibility including wounds. She stated, I am one person cannot get to them, and it is a lot so yes measurements for him did not get done. Interview on 02/12/26 at 7:59 A.M. with Program Nurse/LPN #209 revealed she brought in weekly wound logs that she stated she submitted on a weekly basis to the facility corporate office and that Resident #2's measurements were on the log. She had forgotten she had assessed Resident #2's wounds weekly including measurements of the wounds and placed the information on the log. She verified the wound assessments were not documented into Resident #2's medical record and that the wound log was not part of his medical record as it contained multiple residents on the log. She revealed she did not have time to document his weekly wound assessments into his medical record. Review of facility policy labeled, Documentation of Wound dated 06/25/21 revealed wound assessments were documented upon admission, every seven days, and as needed if a resident or wound condition deteriorates. The following elements were documented as part of a complete wound assessment: type of wound, stage of wound, measurements, and description of wound. This deficiency represents non-compliance investigated under Complaint Number 2673147.

Based on interview, record review and review of facility policy, the facility failed to ensure Resident #32 was current with her pneumococcal vaccination and had no documentation she was offered the vaccine. This affected one resident (#32) out of six residents reviewed for immunizations. The facility census was 72.Findings include:Review of the medical record for Resident #32 revealed she was admitted on [DATE] with diagnoses of diabetes, cognitive communication deficit, dysphagia, congestive heart failure, chronic kidney disease stage four and obesity. Review of Annual MDS dated [DATE] revealed resident was cognitively intact. Resident #32 was not up to date regarding her pneumococcal vaccination and indicated she was not offered the vaccine. Interview on 02/12/2026 at 10:30 A.M. with DON confirmed the facility had no record that Resident #32 had received or had been offered the pneumococcal vaccine.Review of facility policy labeled, Influenza and Pneumococcal Vaccine last revised 01/20/20 revealed residents were assessed for pneumococcal vaccine status upon admission. Residents without proof of a previous pneumococcal vaccine received one dose per Centers for Disease Control and Prevention (CDC) guidelines if consent and physician's orders were obtained. Review of facility policy labeled, Influenza and Pneumococcal Disease Prevention dated 07/01/21 revealed residents were offered a pneumococcal vaccine in accordance with the CDC recommended immunization schedule.

Based on observation, interview, and facility policy review, the facility failed to ensure the environment remained free of accident hazards for residents who used the designated outdoor smoking area. The facility did not provide a safe environment for the disposal of smoking materials, resulting in potential fire hazard. This had the potential to affect all residents, employees, and visitors who use the facility smoking areas. The facility census was 72.Findings include:Observation of facility smoking areas on 11/05/25 at 10:45 A.M. revealed two large steel cigarette butt receptacles with the label butt cans that were overfilled and overflowing onto the pavement smoking area by the kitchen exit door. A large amount of cigarette butts were also present and scattered on the ground directly on top of a large amount dry leaves and debris. Interview with Director of Maintenance (DM) #539 on 11/05/25 at 10:45 A.M. confirmed overfilled cigarette butt receptacles as well as the cigarette butts on top of a large amount of dry leaves and debris. DM #539 agreed that it was a fire hazard and was going to empty the cans and remove cigarette butts.Review of the facility policy titled, Resident Smoking Policy, reviewed 01/08/25, revealed residents who smoke must use the facility designated outside area to smoke. Cigarette butts and matches used must be discarded in the appropriate receptacle.This deficiency is an incidental finding identified during the course of the complaint investigation.

Based on observation, interview, record review, facility policy review, review of the memorandum from the Department of Health & Human Services, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to implement and utilize required enhanced barrier precautions (EBP) for Residents #35, #36, #163, #170 and #172, and use appropriate standards of practice with use of gloves during catheter care and tracheostomy care for Residents #36 and #170. This affected five residents (#35, #36, #163, #170 and #172) and had the potential to affect all 68 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included dysphagia (difficulty swallowing), dementia and gastrostomy status. Physician orders effective May 2024 included enteral feeding 16 hours daily via gastrostomy tube. Observation and interview on 05/06/24 at 9:40 A.M. with Resident #35 indicated an enteral tube feeding was used. There was no EBP posted and no PPE (personal protective equipment) available at the room entrance. 2. Review of the medical record for Resident #170 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of supraglottis, emphysema, and tracheostomy status. Physician orders effective May 2024 included tracheostomy care daily and as needed. Observation on 05/06/24 at 10:54 A.M. of Resident #170 revealed a tracheostomy was in place. There was no EBP posted and no PPE available at the room entrance. Observation on 05/08/24 at 7:53 A.M. with RN #258 of tracheostomy care for Resident #170 revealed Registered Nurse (RN) #258 entered the room wearing gloves without donning a gown and then completed tracheostomy care without wearing the required gown for EBP. Interview at the time of the observation with RN #258 verified a gown was not worn as required. Further observation Observation on 05/08/24 at 7:53 A.M. with RN #258 of tracheostomy care for Resident #170 revealed RN #258 removed the soiled tracheostomy dressing and inner cannula using gloved hands then removed the gloves and used hand sanitizer. RN #258 then donned sterile gloves and using the right hand and a sterile cotton tipped applicator moistened with normal saline, cleansed around the tracheostomy opening and discarded the applicator. RN #258 then picked up sterile gauze saturated with normal saline and cleansed around the base of the tracheostomy tube. Using both gloved hands, RN #258 pulled the gauze underneath the flange and around the base of the tube for cleansing then disposed of the soiled gauze. Using the gloved hands now soiled, RN #258 picked up the sterile disposable cannula with the right hand making contact with the tip of the cannula and the upper portion of the sterile tube and inserted it into Resident #170's tracheostomy tube. Then using the same soiled gloved hands picked up a clean tracheostomy collar and applied it around Resident #170's neck. Interview at the time of the observation with RN #258 verified the above observation and confirmed the soiled gloves were not changed prior to touching and inserting the sterile cannula. 3. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included obstructive and reflux uropathy, chronic kidney disease stage 2 mild, and benign prostatic hyperplasia. Physician orders effective May 2024 included urinary catheter care every shift. Observation and interview on 05/06/24 at 11:36 A.M. with Resident #36 indicated a urinary catheter was used. There was no EBP posted and no PPE available at the room entrance. Observation on 05/07/24 at 2:20 P.M. with State tested Nursing Assistant (STNA) #264 and ADON #232 of urinary catheter care for Resident #36 revealed STNA #264 while wearing gloves and a gown performed urinary catheter care which included handling of Resident #36's genitals and washing and drying the urinary catheter site. STNA #264 then emptied the urinary catheter drainage bag. While wearing the soiled gloves worn during the care, STNA #264 assisted Resident #36 to stand, pulled up Resident #264's brief and pants, pulled down the shirt, and completed a transfer from the commode to the wheelchair. The soiled gloves contacted multiple body areas while providing assistance. Upon completion, STNA #264 removed the soiled gloves. Interview at the time of the observation with STNA #264 verified the above observation and indicated the soiled gloves should have been removed after the procedure and prior to assisting Resident #36 with dressing and a transfer. 4. Review of the medical record for Resident #172 revealed an admitted [DATE]. Diagnoses included peritoneal abscess and diverticulosis. Physician orders effective May 2024 included flush the wound drain every shift, antibiotic therapy intravenously four times daily, and change the PICC line dressing weekly. Observation and interview on 05/06/24 at 12:06 P.M. with Resident #172 indicated a left upper arm PICC (peripherally inserted central catheter) used for antibiotic therapy and a wound drain was in place. There was no EBP posted and no PPE available at the room entrance. Observation on 05/08/24 at 11:21 A.M. with RN #201 of intravenous medication administration through a PICC line for Resident #172. RN #201 entered the room wearing gloves without donning a gown and then completed the intravenous medication administration via the PICC line without wearing the required gown for EBP. Interview at the time of the observation with RN #201 verified a gown was not worn as required. 5. Review of the medical record for Resident #163 revealed an admitted [DATE]. Diagnoses included osteomyelitis left ankle and foot and diabetes mellitus type 2. Physician orders effective May 2024 and progress notes from April 2024 to May 2024 indicated antibiotic therapy intravenously twice daily via right upper arm PICC line. Observation and interview on 05/06/24 at 1:46 P.M. with Resident #163 indicated a right upper arm PICC was used for antibiotic therapy. There was no EBP posted and no PPE available at the room entrance. Observations on 05/06/24 at 5:10 P.M. revealed EBPs remained not posted with no PPE available at the room entrances for Residents #35, #36, #163, #170 and #172. Interviews on 05/06/24 at 5:11 P.M. with Licensed Practical Nurse (LPN) #286 and Registered Nurse (RN) #281 verified there were no EBPs in place for Residents #35, #36, #163, #170 and #172. RN #281 indicated EBP training was completed in the previous month and was planned to be started on the next day, 05/07/24. Interviews on 05/06/24 at 5:18 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) #232 confirmed the facility had no EBPs in place yet and the plan was to begin on the next day, 05/07/24. EBP orders were in the process of being put in place on this date, 05/06/24, and then the supplies were to be put out on the next morning of 05/07/24. The facility had some issues with supplies being on back order so it took a while to enough into the facility. Interview on 05/06/24 at 5:20 P.M. with Corporate Nurse (CN) #289 confirmed EBPs were planned to begin on the next day, 05/07/24. There was an issue with supplies being available, and staff training was completed in April 2024. Originally there was a planned start date of 05/01/24 but they were unable to start it then. CN #289 indicated being aware of the memorandum from the Department of Health and Human Services for initiating EBPs but was uncertain about the required effective date. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24. Review of facility policy for EBP which was untitled and undated revealed EBP involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient.

Based on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of abuse for Resident #52. This affected one resident (Resident #52) of one reviewed for abuse and had the potential to affect all 68 residents residing in the facility. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type 2, need for assistance with personal care and neuromuscular dysfunction of bladder. The quarterly Minimum Data Set (MDS) assessment completed 04/08/24 indicated Resident #52 had moderate cognitive impairment. Review of Resident #52's nursing progress note by Licensed Practical Nurse (LPN) #211 dated 03/01/24 at 5:13 P.M. revealed staff reported Resident #52's spouse smacked her in the face, so the two were separated for the night. Interview on 05/07/24 at 9:38 A.M. with Resident #52 and Resident #52's spouse revealed the spouse lived in the adjoining assisted living facility and visited Resident #52 daily and usually all day long. The two had arguments but the spouse denied ever laying a hand on Resident #52 or details of the incident on 03/01/24. Resident #52 was unable to recall the incident on 03/01/24. Interview on 05/08/24 at 8:13 A.M. with Registered Nurse (RN) #258 stated Resident #52's spouse visited daily from the adjoining facility and were known to fight with each other frequently. There were times when staff had to separate them but denied knowledge of the 03/01/24 incident. Interview on 05/09/24 at 7:26 A.M. with LPN #211 confirmed on 03/01/24, another staff member who LPN #211 could not remember the name, reported an incident had occurred in the adjoining assisted living facility dining room area. Both Resident #52 and the spouse were visiting each other in the adjoining facility dining room when staff reportedly saw the spouse slap Resident #52 across the face, then Resident #52 supposedly tried to throw a bowl back at him. LPN #211 denied reporting the incident to the facility's Administrator or any other staff member because she assumed the adjoining facility's staff took care of it. However, LPN #211 stated she made sure the two stayed separated for the night on 03/01/24. Interview on 05/09/24 at 9:22 A.M. with Administrator confirmed no knowledge of the incident on 03/01/24 with Resident #52 and verified an abuse investigation was not completed due to the lack of staff reporting it to Administrator. Interview on 05/09/24 at 3:54 P.M. with Administrator and Assistant Director of Nursing (ADON) #232 revealed ADON #232 was present in the facility on 03/01/24, received a report of the incident from the adjoining assisted living facility's staff member, Hospitality Companion Aide (HCA) #292 so ADON #232 completed a facility incident report. This incident report was provided to the surveyor with a facility copy of Self-Reported Incident (SRI) instructions on abuse. A marking was made on the instruction sheet to highlight Examples from CMS (Centers for Medicare & Medicaid Services) of issues that do not need reported: Resident to resident altercations that do not result in physical injury, mental anguish, and/or pain. Review of the facility incident report dated 03/01/24 at 6:00 P.M. which was provided by ADON #232 indicated an incident occurred in the location of the apartment dining room (of the adjoining assisted living facility) which involved Resident #52 and Resident #52's husband (who lived in the adjoining assisted living facility). The incident report indicated an apartment aide (from the adjoining facility) reported Resident #52's husband smacked Resident #52 in the back of the head after Resident #52 threw a bowel of food at him. A skin assessment of Resident #52 resulted in no injury. Resident #52 stated the husband was following girls and fooling around, so she got mad and he got mad. As part of the incident report a nurse progress note which was obtained from the adjoining assisted living facility's medical record for Resident #52's spouse. It was dated 03/01/24 at 5:06 P.M., authored by LPN #293, a nurse employed by the adjoining facility, and indicated a companion aide reported Resident #52's spouse was physically fighting with Resident #52. The spouse hit Resident #52, who then attempted to hit back with a bowl from dinner. The incident report further recorded the two were separated and the spouse was instructed not to visit Resident #52 until the next day. There was also a history of arguments between the two. Continued interview on 05/09/24 at 3:54 P.M. with Administrator and ADON #232 confirmed ADON #232 did not report the incident to Administrator as required for abuse prevention. ADON #232 indicated a belief the incident was resident to resident despite the fact the spouse did not live in the same facility as Resident #52. The Administrator conferred and stated that although the two individuals lived in separate facilities, the two facilities were adjoined so staff responded to the incident as if it was one facility and being resident to resident. Review of facility policy, Abuse, revised 01/31/20 revealed staff should report all incident/allegations immediately to the Administrator or designee per regulations. The Administrator should be notified by informing him/her in person, calling via telephone, or sending an email or text message. The Administrator or designee will notify the survey agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If a third party (including family members) have abused, exploited, mistreated, neglected, or misappropriated property from a resident, the Administrator will determine an appropriate response up and including notifying the appropriate legal authorities and permanently banning the individual from the premises.

Based on observation, interview, record review, and facility policy review, the facility failed to provide individualized and sufficient care to manage edema for Resident #24. This affected one resident (#24) of one resident reviewed for edema. The facility census was 68. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type 2, congestive heart failure, chronic severe kidney disease and essential primary hypertension. Review of the progress note for admitted d 01/03/24 revealed Resident #24 had edema at a grade of plus two pitting in both ankles and feet. Review of the Admission and Medicare 5-day MDS (Minimum Data Set) assessment completed 01/10/24 indicated no cognitive impairment. The plan of care initiated on 01/18/24 revealed cardiac impairment and potential for fluid volume excess. Interventions included observing edema and reporting to physician as needed. Review of the physician orders, medication administration record (MAR), treatment administration record (TAR) and nursing progress notes for January 2024 to February 2024 revealed there was an order for Bumex (a diuretic) 1 milligram (mg) daily for edema which started 11/15/23 (during a previous facility admission) which was discontinued on 01/03/24 at the time of the current facility admission. There was no additional evidence for the care, monitoring and management of Resident #24's edema after admission. Review of the physician progress note dated 03/09/24 revealed the physician examined Resident #24 who complained of chronic pitting leg edema. The physician documented will use loop diuretics with monitoring renal profile. The leg (specific location(s) not described) had edema at a grade of plus three pitting. Review of the physician orders, MAR, TAR, and nursing progress notes from March 2024 to April 2024 revealed on 03/09/24 spironolactone (a diuretic) was ordered and administered for two days. There was no additional evidence for the care, monitoring and management of Resident #24's edema. Review of the physician progress note dated 05/02/24 revealed the physician examined Resident #24 and documented massive chronic edema with need to try to reduce amlodipine (medication for hypertension), add chlorthalidone (a diuretic), and monitor blood pressure and kidney profile. Review of the physician orders, MAR, TAR, and nursing progress notes for May 2024 revealed there were no medication changes made, and no additional evidence for the care, monitoring and management of Resident #24's edema. Interview on 05/07/24 at 9:51 A.M. with Resident #24 who complained of being frustrated with the swelling in both legs because it was hard to get any shoes on the feet, and although she was able to still walk it was getting more difficult. Resident #24 stated prior to admission she took 40 mg of a diuretic (could not remember the name) daily and at times took 80 mg when it was bad, but since being at the facility nothing is being done. Resident #24 talked to the physician each time when examined and it is said something will be done but nothing yet. The physician said once a stronger diuretic was needed but Resident #24 indicated not being aware of receiving any medication to address the edema. Observation at the time of the interview revealed Resident #24 was reclined in a chair. Both lower legs, particularly the ankles, had gross edema. Some of the skin appeared shiny and tight. Velcro foot coverings covered the feet and were snug. Interview on 05/08/24 at 7:24 A.M. with Registered Nurse (RN) #258 confirmed Resident #24 had edema in both legs since admission and was not on a diuretic. RN #258 indicated Resident #24's legs were not routinely monitored and was not aware of Resident #24 making any complaints related to the edema. Interview on 05/08/24 at 2:09 P.M. with Assistant Director of Nursing (ADON) #232 verified the above findings and confirmed the facts were accurate. ADON #232 indicated for the physician visit on 05/02/24, the physician did not communicate a plan of care or orders to nursing, so it just did not get done. ADON #232 also reported seeing Resident #24 prior to the interview and confirmed the gross edema was present. Review of the facility policy, Resident Condition Changes, revised 04/01/23 revealed the nurse will implement all new physician's orders immediately and if unable to implement order will contact the physician immediately for direction as to how to proceed. This conversation will be documented in nurses' notes.

Based on observation, interview, and record review, the facility failed to provide tracheostomy care for Resident #170. This affected one resident (#170) of one resident reviewed for tracheostomy care. The facility census was 68. Findings include: Review of the medical record for Resident #170 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of supraglottis, emphysema, diabetes mellitus type 2, and tracheostomy status. The baseline care plan undated for admission on 05/02/24 indicated tracheostomy and oxygen saturation checks as needed. Review of Resident #170's physician orders for May 2024 revealed an order dated 05/05/24 for trach care daily and every 24 hours PRN (as needed) for tracheostomy. There were no orders for any tracheostomy related care including oxygenation monitoring, suctioning, dressing changes, or cannula changes at the time of admission or thereafter until the order for trach care daily was started on 05/05/24. No other tracheostomy related orders were in place. Review of the medication administration record for May 2024 revealed no tracheostomy related care was completed. Review of the treatment administration record for May 2024 revealed tracheostomy care daily and PRN was not provided until 05/06/24. Other than the trach care provided on 05/06/24, there was no evidence of any tracheostomy related care provided after admission. Review of the nursing progress note for admission assessment dated [DATE] indicated Resident #170 had no cognitive impairment and trach care was provided. A nursing progress note dated 05/05/24 indicated the tracheostomy dressing and ties were changed. There was no additional evidence in the progress notes of any tracheostomy related care being provided. Interview on 05/08/24 at 7:50 A.M. with Resident #170 using a writing method to communicate complained of tracheostomy care not being completed daily since admission. Resident #170 indicated having to remind the staff to give care for the tracheostomy including changing the dressing. Resident #170 stated some nurses do it and some do not. Observation at the time of the interview revealed tracheostomy supplies and a suctioning machine was present in the room. Interview on 05/08/24 at 7:53 A.M. with Registered Nurse (RN) #258 reported after Resident #170 was admitted there was an issue with availability of supplies such as a shipment was received with the wrong sized disposable cannulas but it was now resolved. Interview on 05/08/24 at 9:46 A.M. with Director of Nursing (DON) and Corporate Nurse #289 verified the above findings.

Based on record review and staff interview, and the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days or had a determined stop date. This affected three residents (#51, #28 and #48 ) of five reviewed for unnecessary medications. The facility census was 68. Findings include: 1. Resident #28 was admitted on [DATE]. Medical diagnoses included major depression, type two diabetes, anxiety, dysphasia, muscle weakness, assistance with personal care, difficulty walking, and dementia. Review of the facility electric medical record Minimum Data Set ( MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview of Mental Status ( BIMS) revealed a score of 04 out of 15 indicating severe cognitive impairment. Review of the facility electric medical record Plan of Care dated 04/22/24 revealed Resident # 28 would have no episodes of inappropriate behaviors. Interventions included administer medications as ordered, approach resident in a slow manner, bring Resident #28 to a quiet environment as needed, document behaviors, observations of environment and situation for possible cause of behaviors, observe Resident #28 for pain, provide diversional activities such as ambulation, food , drink, toileting and small group activities. Provide verbal support as needed, psychological consult, and redirect as possible. Review of electric medical record physician orders dated 05/08/24 revealed an order for Lorazepam oral tablet one milligram ( mg) , given by mouth two times a day for anxiety and agitation. Start date was 05/08/24 and end date was indefinite. Review of electric medical record physician order start date 02/27/24 and end date was indefinite for Lorazepam oral tablet one milligram give by mouth every twelve hours as needed for anxiety was discontinued 05/08/24. Review of electric medical record physician order dated 05/08/24 revealed a new order for Lorazepam oral tablet one milligram given by mouth every twelve hours for anxiety was started 05/08/24 and end date was indefinite. Review of the electronic medical record Pharmacist Medication Regimen Review dated 04/20/24 revealed a report of irregularities was provided to the Director of Nursing and prescriber. The facility could not locate the note to Attending Physician document dated 04/20/24. Review of electronic medical record Medication Administration Record dated May 2024 revealed Lorazepam oral tablet one milligram by mouth was provide as needed every twelve hours : once on 05/01/24 at 4:06 P.M., twice on 05/02/24 at 9:59 A.M. and 9:40 P.M., once on 05/03/24 at 7:30 P.M., 05/04/24 at 4:15 P.M. ,05/05/24 at 8:42 P.M., 05/06/24 10:15 A.M. , and twice on 05/07/24 at 5:42 A.M. and 9:07 P.M. Review of electric medical record Medication Administration Record dated April 2024 revealed Lorazepam oral tablet one milligram provide every twelve hours as needed for anxiety was provided by mouth once on 04/03/24 at 4:25 P.M., 04/06/24 at 4:49 P.M., 04/07/24 at 4:35 P.M., 04/08/24 at 5:32 P.M. , 04/10/24 at 9:08 A.M., 04/14/24 at 10:47 A.M., 04/21/24 at 10:29 A.M. , 04/22/24 at 4:31 P.M. , 04/23/24 at 4:31 P.M., 04/24/24 at 9:07 A.M., 04/28/24 at 9:16 A.M., 04/29/24 at 5:54 P.M. and 04/30/24 6:24 P.M. Review of electronic medical record Medication Administration Record dated March 2024 revealed Lorazepam oral tablet one milligram give every twelve hours as needed for anxiety was provided once on 03/01/24 at 9:29 A.M., 03/03/24 at 7:38 A.M., 03/06/24 at 8:16 A.M., twice on 03/07/24 at 7:23 A.M. and 7:53 P.M., once on 03/10/24 at 7:30 A.M., twice on 03/11/24, once on 03/13/24 at 12:00 P.M. , 03/14/24 at 5:00 P.M., 03/15/24 at 6:38 P.M. , 03/16/24 at 4:43 P.M., 03/17/24 at 10:15 A.M., 03/27/24 at 7:26 A.M., 03/28/24 at 10:00 A.M., 03/29/24 at 9:36 A.M., 03/30/24 at 8:59 A.M. and 03/31/24 at 9:32 A.M 2. Resident #51 was admitted to the facility on [DATE]. Medical diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, anxiety, depression, muscle weakness, hypertension, congestive heart failure, cerebral palsy, insomnia, constipation. Review of electric medical record Minimum Data Set ( MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #51 had a Brief Interview Mental Status ( BIMS) revealed a score of 14 out of 15 indicating cognition was intact. No verbal or physical behaviors were exhibited. Review of facility electric medical record Plan of Care dated 04/11/24 revealed Resident #51 had potential for feelings of sadness, emptiness, anxiety, and depression. Interventions included Resident #51 to accept care and medication as prescribed, discuss feeling about placement, encourage loved ones to keep contact, encourage resident to attend group activities, , praise and reward for demonstration of desired mood and behavior, provided one on one as needed. Review of electronic medical record physician order start date of 02/07/24 and end date was indefinite of hydroxyzine HCL 25 milligrams by mouth four times a day for anxiety related to depression. Review of electronic medical record physician order start date of 03/25/24 and end date was indefinite for hydroxyzine Pamoate ( antianxiety) oral capsule by mouth every twelve hours as needed for anxiety. Review of the facility Note to Attending Physician document dated 03/25/24 from the pharmacist #290 revealed Resident #51 had an order for both Hydroxyzine HCL 25 milligrams and Hydroxyzine Pamoaye 25 milligrams every twelve hours as needed for anxiety. The pharmacist stated in order to avoid duplication of therapy please consider discontinuing one. Further review of the Note to Attending Physician document dated 03/25/24 revealed Advanced Practitioner Registered Nurse #291 responded on 04/08/24 and disagreed with the recommendation. The Advanced Practitioner Registered Nurse declined to change treatment because it was a necessary treatment. Review of the facility medical record Medication Administration Record dated April 2024 revealed as needed hydroxyzine Pamoate oral capsule was provided by mouth the night of 04/23/24, twice a day on 04/24/23, 04/25/23, 04/26/23, 04/27/24, 04/28/24, 04/29/24 and 04/30/24 the time medication was given was not documented. Interview with the Assistant Director of Nursing on 05/09/24 at 10:55 A.M. revealed the Advanced Practice Registered Nurse #291 declined to change Resident #51 as needed Hydroxyzine Pamoave 25 milligram every twelve hours as needed for anxiety with any stop date as indicated. 37097 3. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included diabetes, muscle weakness, need for assistance with personal care, difficulty in walking, other abnormalities of gait and walking, cognitive communication deficit, other specified disorders of bone density and structure, chronic kidney disease, osteoarthritis, encephalopathy, and a history of falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #48, dated 04/05/24, revealed impaired cognition. The assessment identified the resident had received insulin and antianxiety medication. Review of physician orders for Resident #48 revealed medication orders including Lorazepam Tablet 1 mg by mouth every 12 hours as needed for anxiety and agitation started 04/08/24 with no stop date. Review of the Pharmacy Recommendation dated 03/25/24 revealed the pharmacist had informed the physician Resident #48 had an as needed (PRN) order for Lorazepam and that PRN orders for Anxiolytics, Antidepressants, and Sedative/Hypnotics medications were to be limited to 14 days. If PRN use was extended, the medical record must contain documented rationale for use and a determined duration. Review of the Medication Administration Records (MAR) for Resident #48 for April 2024 revealed Lorazepam Tablet 1 mg had been given eight times. Review of the MAR for May 2024 revealed Lorazepam Tablet 1 mg had been given twice. Interview on 05/08/24 at 2:30 P.M. with ADON #232 verified the order for Lorazepam did not have a stop date.

Based on record review and interview the facility failed to accurately document the resident's diagnoses to justify use of ordered medications. This affected one resident (#48) of five residents reviewed for medications. Facility census was 68. Findings Include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included diabetes, muscle weakness, need for assistance with personal care, difficulty in walking, other abnormalities of gait and walking, cognitive communication deficit, other specified disorders of bone density and structure, chronic kidney disease, osteoarthritis, encephalopathy, and a history of falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #48, dated 04/05/24, revealed impaired cognition. Review of physician orders for Resident #48 revealed medication orders including the following which did not have corresponding diagnosis: Atorvastatin Calcium Oral Tablet 40 MG. for cholesterol dated 12/14/23. Amitiza Oral. 24 MCG. for irritable bowel syndrome dated 12/14/23. Levothyroxine Sodium Oral Tablet 25 MCG. for hypothyroidism dated 12/14/23. Tizanidine HCl Oral Tablet 2 MG. for spasms dated 01/18/24. Buspirone HCl Oral Tablet 10 MG. for anxiety dated 03/15/24. Lorazepam Tablet 1 MG. for anxiety and agitation dated 04/08/24. Interview on 05/08/24 at 2:30 P.M. with Assistant Director of Nursing (ADON) #232 verified there were not diagnosis listed that justified all medications orders.

Based on observation, interview, record review, and facility policy review the facility failed to ensure Resident #51's medications were administered properly. This affected one resident (#51) of the 24 residents (#3, #4, #5, #6, #7, #13, #16, #18, #22, #23, #24, #25, #26, #27, #29, #34, #36, #37, #39, #47, #48, #51, #55, and #56) who reside on the 400 unit. The facility census is 58. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, insomnia, osteoarthritis, peripheral vascular disease, and hypertension. Review of physician's orders dated 01/21/23 for Resident #51 revealed an order for Eliquis (anticoagulant) 5 milligrams (mg) two times a day; an order for Verapamil HCL ER (blood pressure medication) 180 mg daily; Tylenol 325 mg give two tablets every six hours as needed for pain; and Metoprolol (blood pressure medication) 12.5 mg twice a day. Review of the care plan dated 04/24/23 for Resident #51 revealed she had impaired cognition. Interventions included administering medications as ordered and observing a decline in cognition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had moderate cognitive impairment. Resident #51 required extensive two-person physical assistance for bed mobility and toilet use; extensive one-person physical assistance for transfers, dressing, and personal hygiene; and supervision with set-up help only for eating. Review of the facility Medication Administration Record (MAR) for Resident #51 revealed she was administered Tylenol, Metoprolol, Eliquis, and Verapamil on 05/15/23 at 8:00 A.M. Observation on 05/15/23 at 11:39 A.M. of Resident #51 revealed her lying in bed sleeping. Her bedside tray was halfway across the bed and on the edge closest to her was a pill cup with five pills inside. Interview during the observation with Resident #51 revealed she did not know what they were and why they were there. Interview on 05/15/23 at 11:42 A.M. with Registered Nurse (RN) #502 confirmed she gave those pills to Resident #51 on 05/15/23 at 8:00 A.M. RN #502 was unsure of what medication was in the cup. RN #502 discarded the medications and then administered the 8:00 A.M. pills to Resident #51. RN #502 could not confirm that Resident #51 had even taken any medications that morning. RN #502 reported she did not stay with Resident #51 to ensure she had taken the medications before she documented them as administered. Interview on 05/15/23 at 12:00 P.M. with the Director of Nursing (DON) confirmed nurses must make sure the residents swallow all their pills or refuse them before they document that the pills were administered. Review of the facility policy titled Administration Procedures for all Medications, effective 07/01/21, revealed all medication storage areas are locked at all times unless in use and under direct observation of the medication nurse/aide. Once medications are removed from the package or container, unused or partial doses should be disposed of in accordance with the medication destruction policy.

Based on interviews, record review, documented staff statements, and facility policy review, the facility failed to ensure the physician and family were notified timely of Resident #50's fall which resulted in a fracture on 12/08/22. This affected one resident (#50) of three residents reviewed for falls. The census was 62. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included difficulty walking, abnormalities of gait, muscle weakness, cognitive communication deficit, need for assistance with personal care, pain in right knee, arthritis, overactive bladder, history of falling, and dizziness and giddiness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderately impaired cognition. Resident #50 required extensive one staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #50 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the progress note dated 12/09/22 at 10:14 A.M. revealed Resident #50 complained of left rib pain and all over pain to her son and was transferred to the local emergency room for evaluation. Review of the physician progress note dated 12/14/22 revealed Resident #50 was diagnosed with post left multiple rib fractures with pain of the eighth and ninth ribs. Interview on 03/29/23 at 5:10 P.M. with Regional Nurse #582 verified there was no incident report or investigation completed for Resident #50's rib fractures, and the only documentation in the medical record was the progress notes. Regional Nurse #582 stated Resident #50 reported that the evening before going to the hospital she was trying to put her nightgown on and fell forward out of her wheelchair. When asked if anyone helped her off the floor she did not respond or indicate reporting it to any staff. Regional Nurse #582 confirmed an investigation was started. Interview on 03/30/23 at 8:06 A.M. with Regional Nurse #582 revealed staff was aware Resident #50 fell prior to the resulting fractures on 12/09/23, and the facility was collecting documents to complete the fall investigation. Regional Nurse #582 identified Registered Nurse (RN) #537 who was on assignment when the fall occurred and despite being confronted by administrative staff through a text message to complete the necessary documentation, failed to do so and ultimately it was not again addressed. Review of the hospital documentation dated 12/09/22 at 11:49 A.M. revealed left eighth and ninth rib fractures. Treatment instructions were provided to the son which included monitoring closely for signs of pneumonia and administering acetaminophen (analgesic) as needed for pain. Review of the printed text message dated December 9th (year not printed), at 2:30 P.M. to RN #537 from the Director of Nursing revealed questioning for forgotten documentation of a fall on the previous night for Resident #50 as the resident was sent out with a fractured rib. RN #537 responded with Ok. Review of the progress note dated 12/10/22 at 4:01 A.M. by RN #537 for Resident #50 revealed an entry of . Interview on 03/30/23 at 8:55 A.M. with Assistant Director of Nursing (ADON) #532 confirmed RN #537 and State tested Nursing Assistant (STNA) #529 reported Resident #50 fell but verified there was no documentation including an incident report and an investigation related to the fall. ADON #532 was the manager on duty the weekend of the incident and talked with Resident #50's family and recalled the incident on 12/08/22 around 6:30 P.M. ADON #532 indicated Licensed Practical Nurse (LPN) #578 who was assigned on 12/09/22 stated receiving in report from RN #537 that Resident #50 fell and then Resident #50's son called and reported Resident #50 was having rib pain so LPN #578 transferred her to the local emergency room for evaluation. ADON #532 verified nurses were required to document all falls, including filling out a report. Telephone interview on 03/30/23 at 11:24 A.M. with RN #537 stated on 12/08/22 between 7:30 P.M. and 8:00 P.M. Resident #50 fell while attempting to get out of a recliner chair and was sitting on its leg rest. An assessment revealed no injury or pain so both RN #537 and STNA #529, one on each side and arm in arm, assisted Resident #50 in scooting back onto the chair seat, then to a standing position, and then to ambulate to the bed using a walker. Resident #50 did not complain throughout the night or during personal care. RN #537 indicated a belief the documentation was completed but now all that could be found was an entry with a period in it. RN #537 confirmed the physician and family were not contacted and informed of the fall, investigation forms were not completed, and interventions were not put into place. Interview on 03/30/23 at 11:42 A.M. with ADON #532, Regional Nurse #582, and the Director of Nursing verified there was no fall investigation completed or fall interventions put into place by RN #537 after Resident #50's fall on 12/08/22. Interview on 03/30/23 at 1:44 P.M. with LPN #578 verified Resident #50 was transferred to the local emergency room because of complaint of rib pain. LPN #578 denied remembering what was received in report from RN #537 but knew Resident #50 fell because the nursing assistants talked to her about the fall the night before. LPN #578 denied remembering talking with Resident #50's family but stated the physician was aware which was how Resident #50 was able to be transferred. Review of the documented statement by RN #537, dated 03/31/23, revealed on 12/08/22 around 8:00 P.M. Resident #50 was observed sitting upright on the mechanical reclining chair footrest with her legs out in front of her and arms down at her sides. Resident #50 stated she was trying to get out of the recliner and the remote control did not work to lower the leg rest so she scooted down to get out of the chair which resulted in tipping the recliner and the footrest to the floor with Resident #50 sitting on top of it. Resident #50 denied pain and hitting her head. After assessment of the upper and lower extremities all were within normal limits. Resident #50 with assistance of STNA (unnamed) was raised to the seat of the recliner. The power chord of the recliner was found to be unplugged and the remote began to work again. Resident #50 was raised to a standing positioning using the mechanical recliner and with two staff assistance and a walker ambulated to bed. Resident #50 was educated to use the call bell for assistance with transfers. The physician was not notified due to no significant abnormal findings and Resident #50 had no complaints of pain. Resident #50 was alert and in a good mood, and there were no other incidents for the remainder of the shift. Review of the documented statement by STNA #529 dated 04/03/23 revealed on 12/08/23 Resident #50 was observed sitting on the footrest of the lift recliner. The nurse (unnamed) was informed and assessed Resident #50 who stated the chair remote did not work so she scooted down onto the footrest to get out of the chair, causing the chair to tilt. The footrest landed on the floor with Resident #50 sitting on top with legs out in front of her, and with the assistance of Resident #50 and the nurse, lifted her back into the chair. Resident #50 had no complaints of pain. After inspecting the chair, it was found to be unplugged so it was plugged back in, and Resident #50 was ambulated to the bed with assistance. Interview on 04/03/23 at 1:01 P.M. with ADON #532 verified RN #537 should have called the physician and family after Resident #50 fell on [DATE] regardless of injury because it was the facility's policy. ADON #532 stated there were some families who had designated not to receive phone calls during night hours which were designated on the medical chart but Resident #50 was not one of them. Review of the facility policy, Falls Policy and Procedures, revised 05/21/18, revealed when a fall occurs the licensed nurse shall assess the resident's condition, complete the incident report, the falls investigation, implement immediate safety approaches if identifiable until the interdisciplinary team (falls committee) can meet to review the fall and implement interventions to the plan of care, document the incident in the medical record and post fall assessment, and notification of physician and responsible party. Review of the facility policy, Resident Condition Changes/COVID Notification, revised 05/20/20, revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition, an assessment will be made by the nurse prior to the phone call so that nurse is prepared to discuss condition change, a condition change includes an accident, the nurse will also notify resident' responsible party of condition change, if resident is responsible for self that is the person who should be notified documentation will be completed in nurses notes, the nurse will implement all new physician's order immediately, the nurse will document condition change and physician/responsible party contact information in nurses notes, the nurse will report resident changes and new orders to oncoming nurse. This deficiency represents non-compliance investigated under Complaint Number OH00141550.

Based on interviews, record review, documented staff statements, and facility policy review, the facility failed to ensure a fall was documented, investigated, fall interventions were implemented, and the care plan was updated for Resident #50. This affected one resident (#50) of three residents reviewed for falls. The census was 62. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included difficulty walking, abnormalities of gait, muscle weakness, cognitive communication deficit, need for assistance with personal care, pain in right knee, arthritis, overactive bladder, history of falling, and dizziness and giddiness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderately impaired cognition. Resident #50 required extensive one staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #50 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the progress note dated 12/09/22 at 10:14 A.M. revealed Resident #50 complained of left rib pain and all over pain to her son and was transferred to the local emergency room for evaluation. Review of the physician progress note dated 12/14/22 revealed Resident #50 was diagnosed with post left multiple rib fractures with pain of the eighth and ninth ribs. Interview on 03/29/23 at 5:10 P.M. with Regional Nurse #582 verified there was no incident report or investigation completed for Resident #50's rib fractures, and the only documentation in the medical record was the progress notes. Regional Nurse #582 stated Resident #50 reported that the evening before going to the hospital she was trying to put her nightgown on and fell forward out of her wheelchair. When asked if anyone helped her off the floor she did not respond or indicate reporting it to any staff. Regional Nurse #582 confirmed an investigation was started. Interview on 03/30/23 at 8:06 A.M. with Regional Nurse #582 revealed staff was aware Resident #50 fell prior to the resulting fractures on 12/09/23, and the facility was collecting documents to complete the fall investigation. Regional Nurse #582 identified Registered Nurse (RN) #537 who was on assignment when the fall occurred and despite being confronted by administrative staff through a text message to complete the necessary documentation, failed to do so and ultimately it was not again addressed. Review of the hospital documentation dated 12/09/22 at 11:49 A.M. revealed left eighth and ninth rib fractures. Treatment instructions were provided to the son which included monitoring closely for signs of pneumonia and administering acetaminophen (analgesic) as needed for pain. Review of the printed text message dated December 9th (year not printed), at 2:30 P.M. to RN #537 from the Director of Nursing revealed questioning for forgotten documentation of a fall on the previous night for Resident #50 as the resident was sent out with a fractured rib. RN #537 responded with Ok. Review of the progress note dated 12/10/22 at 4:01 A.M. by RN #537 for Resident #50 revealed an entry of . Interview on 03/30/23 at 8:55 A.M. with Assistant Director of Nursing (ADON) #532 confirmed RN #537 and State tested Nursing Assistant (STNA) #529 reported Resident #50 fell but verified there was no documentation including an incident report and an investigation related to the fall. ADON #532 was the manager on duty the weekend of the incident and talked with Resident #50's family and recalled the incident on 12/08/22 around 6:30 P.M. ADON #532 indicated Licensed Practical Nurse (LPN) #578 who was assigned on 12/09/22 stated receiving in report from RN #537 that Resident #50 fell and then Resident #50's son called and reported Resident #50 was having rib pain so LPN #578 transferred her to the local emergency room for evaluation. ADON #532 verified nurses were required to document all falls, including filling out a report, and initiate interventions. ADON #532 stated if nurses did not complete the necessary paperwork it might fall through the cracks as in this case. Review of the plan of care for falls last revised on 09/14/22 revealed Resident #50 was at risk for falls and injury related to a history of falls, weakness, arthritis, macular degeneration, dizziness, pain in the right knee, muscle weakness, difficulty walking and other abnormalities of gait. Interventions included one person assistance with transfers and gait with walker; increase assistance as needed; keep bed in low position; staff to anticipate needs; therapy to evaluate and treat as ordered; put call light within resident reach; encourage resident to come to the multipurpose room for closer supervision; and encourage non-skid, gripper socks when shoes are off. There were no additional interventions added or revisions made after Resident #50's fall with resulting fracture on 12/08/22. Review of the plan of care for pain last revised on 08/23/22 revealed Resident #50 had potential for alteration in comfort related to arthritis, right knee pain, a history of falls, and an overactive bladder. Interventions included to administer medications as ordered and per resident preference or request; assist resident with repositioning as needed; attempt alternate relief measures, i.e., a back rub, relaxation, reposition, exercise, or music prior to medications; encourage resident to report pain early prior to becoming severe; and observe for any signs or symptoms of pain. There were no additional interventions added or revisions made after Resident #50's fall with resulting fracture on 12/08/22. Interview on 03/30/23 at 10:28 A.M. with MDS Nurse #530 stated being unaware of Resident #50's fall with rib fractures on 12/08/22 and confirmed Resident #50's care plan for falls and pain was not revised or updated after 12/08/22. Telephone interview on 03/30/23 at 11:24 A.M. with RN #537 stated on 12/08/22 between 7:30 P.M. and 8:00 P.M. Resident #50 fell while attempting to get out of a recliner chair and was sitting on its leg rest. An assessment revealed no injury or pain so both RN #537 and STNA #529, one on each side and arm in arm, assisted Resident #50 in scooting back onto the chair seat, then to a standing position, and then to ambulate to the bed using a walker. Resident #50 did not complain throughout the night or during personal care. RN #537 indicated a belief the documentation was completed but now all that could be found was an entry with a period in it. RN #537 confirmed the physician and family were not contacted and informed of the fall, investigation forms were not completed, and interventions were not put in place. Interview on 03/30/23 at 11:42 A.M. with ADON #532, Regional Nurse #582, and the Director of Nursing verified there was no fall investigation completed or fall interventions put into place by RN #537 after Resident #50's fall on 12/08/22. Interview on 03/30/23 at 1:44 P.M. with LPN #578 verified Resident #50 was transferred to the local emergency room because of complaint of rib pain. LPN #578 denied remembering what was received in report from RN #537 but knew Resident #50 fell because the nursing assistants talked to her about the fall the night before. LPN #578 denied remembering talking with Resident #50's family but stated the physician was aware which was how Resident #50 was able to be transferred. Review of the documented statement by RN #537, dated 03/31/23, revealed on 12/08/22 around 8:00 P.M. Resident #50 was observed sitting upright on the mechanical reclining chair footrest with her legs out in front of her and arms down at her sides. Resident #50 stated she was trying to get out of the recliner and the remote control did not work to lower the leg rest so she scooted down to get out of the chair which resulted in tipping the recliner and the footrest to the floor with Resident #50 sitting on top of it. Resident #50 denied pain and hitting her head. After assessment of the upper and lower extremities all were within normal limits. Resident #50 with assistance of STNA (unnamed) was raised to the seat of the recliner. The power chord of the recliner was found to be unplugged and the remote began to work again. Resident #50 was raised to a standing positioning using the mechanical recliner and with two staff assistance and a walker ambulated to bed. Resident #50 was educated to use the call bell for assistance with transfers. The physician was not notified due to no significant abnormal findings and Resident #50 had no complaints of pain. Resident #50 was alert and in a good mood, and there were no other incidents for the remainder of the shift. Review of the documented statement by STNA #529 dated 04/03/23 revealed on 12/08/23 Resident #50 was observed sitting on the footrest of the lift recliner. The nurse (unnamed) was informed and assessed Resident #50 who stated the chair remote did not work so she scooted down onto the footrest to get out of the chair, causing the chair to tilt. The footrest landed on the floor with Resident #50 sitting on top with legs out in front of her, and with the assistance of Resident #50 and the nurse, lifted her back into the chair. Resident #50 had no complaints of pain. After inspecting the chair, it was found to be unplugged so it was plugged back in, and Resident #50 was ambulated to the bed with assistance. Interview on 04/03/23 at 1:01 P.M. with ADON #532 verified RN #537 should have called the physician and family after Resident #50 fell on [DATE] regardless of injury because it was the facility's policy. ADON #532 stated there were some families who had designated not to receive phone calls during night hours which were designated on the medical chart but Resident #50 was not one of them. Review of the facility policy, Falls Policy and Procedures, revised 05/21/18, revealed the falls care plan will be reviewed at least quarterly and as needed by the interdisciplinary team/falls committee and updated; when a fall occurs the licensed nurse shall assess the resident's condition, complete the incident report, the falls investigation, implement immediate safety approaches if identifiable until the interdisciplinary team (falls committee) can meet to review the fall and implement interventions to the plan of care, document the incident in the medical record and post fall assessment, and notification of physician and responsible party. Review of the facility policy, Resident Condition Changes/COVID Notification, revised 05/20/20, revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition, an assessment will be made by the nurse prior to the phone call so that nurse is prepared to discuss condition change, a condition change includes an accident, the nurse will also notify resident' responsible party of condition change, if resident is responsible for self that is the person who should be notified documentation will be completed in nurses notes, the nurse will implement all new physician's order immediately, the nurse will document condition change and physician/responsible party contact information in nurses notes, the nurse will report resident changes and new orders to oncoming nurse. This deficiency represents non-compliance investigated under Complaint Number OH00141550.

Based on interview, record review, and facility policy review the facility failed to ensure facility temperatures of common areas and resident rooms were monitored and documented during a power outage. This had the potential to affect all residents residing in the facility. The census was 62. Findings include: Interview on 03/29/23 at 11:53 A.M. of Licensed Practical Nurse (LPN) #509 revealed she was working at the facility when the power went out on 03/25/23. LPN #509 stated the power flickered on and off a couple times before going out, and the generator turned on, flickered and then the power went out. LPN #509 stated Maintenance Director (MD) #517 was called, he lived close to the facility, arrived timely and was able to get the generator to work. LPN #509 stated she thought from the time the generator went out until it came back on was approximately a half hour. LPN #509 indicated when the power was out oxygen concentrators, air mattresses, computers were all plugged into the emergency outlets, and portable oxygen tanks were used. LPN #509 stated residents were on every 15-minute checks while the power was out. LPN #509 indicated she left the facility around 7:00 P.M. and she did not work again until 03/27/23 and the power was restored. Interview on 03/29/23 at 12:00 P.M. of Registered Nurse (RN) #556 revealed the facility had a power outage on 03/25/23 due to severe weather. RN #556 stated the power was out for about 16 hours from around 3:00 P.M. on 03/25/23 through 03/26/23 at around 9:00 A.M. RN #556 stated the call light system and facility phones did not work and no management staff were in the facility during the outage. RN #556 stated on 03/25/23 at 3:00 P.M. the emergency generator did not work for about a half hour when the power went out. RN #556 stated on 03/26/23 at around 6:30 or 7:00 A.M. it was 65 degrees in the facility when he looked at the indoor thermometer in the common area, and residents were complaining they were very cold, especially on the skilled nursing unit. RN #556 stated he started calling families to let them know the facility was not sure when the power would come back on and asked them if they wanted to take residents home until the power was restored. RN #556 indicated residents were checked at least every half hour, and oxygen and air mattresses were plugged into the emergency outlets in the halls. RN #556 stated the emergency generator did not work for about a half hour when the power first went out on 03/25/23 at 3:00 P.M. Interview on 03/29/23 at 12:35 P.M. of MD #517 revealed the weather got bad very quickly, and the power was out throughout the entire area the facility was in. MD #517 stated the power flickered on and off for about ten minutes, then went out entirely. MD #517 stated the generator started but because the power flickered multiple times the generator had an issue and did not work for a few minutes. MD #517 indicated he arrived at the facility in about ten minutes because he lived close and had the generator running within minutes of his arrival. MD #517 stated he walked around to make sure everything was alright, and the staff had enough extension cords and batteries. MD #517 stated he checked the water, and it was ok, and the corridor lights were working. MD #517 indicated the extension cords were plugged into emergency outlets in the hallway and were used for air mattresses and oxygen concentrators. MD #517 stated heat was supplied to the residents during the power outage through a central duct located in the ceilings of the halls of each nursing unit and branches from the central duct led into each resident room and supplied some heat. MD #517 stated on 03/25/23 at 8:00 P.M. the temperature was 71 degrees Fahrenheit. MD #517 stated RN #556 told him the temperature was around 66 degrees Fahrenheit in the skilled nursing unit and around 70 degrees Fahrenheit in the long-term nursing unit on the morning of 03/26/23. MD #517 stated there was no log with temperatures documented throughout the power outage of the common areas and resident rooms. MD #517 stated if the facility phones were not working, he was not aware of it, and his communication with the staff was via his cell phone. Interview on 03/29/23 at 3:42 P.M. of the Administrator revealed severe weather on 03/25/23 caused the facility to have a power outage. The Administrator stated MD #517 was in the facility timely and supplied flashlights, extension cords, and assisted with plugging oxygen concentrators into emergency outlets. The Administrator indicated the electric company was contacted and the facility was told power would not be restored until 03/27/23, but power was restored on 03/26/23 around 8:30 A.M. The Administrator stated he did not come to the facility to assist staff during the power outage because he was out of town. The Administrator stated the furnaces were working, just not at full power, and he was told by RN #556 the temperature in the facility was 69 degrees Fahrenheit. The Administrator stated residents liked their rooms very warm and a temperature of 69 was freezing for them. The Administrator stated residents were given blankets and hot tea. The Administrator confirmed temperatures were not monitored during the power outage in resident rooms and the common areas. The Administrator stated monitoring the temperatures was a good idea if there was enough staff and resources, and it was a matter of priority. Interviews on 03/29/23 between 2:50 P.M. and 3:05 P.M. of Resident's #20, #41 and #50 revealed it was very cold in the facility when the power was out. Interview on 03/30/23 at 3:46 P.M. with the Director of Nursing (DON) revealed she worked on 03/24/23 from 10:00 P.M. until 03/25/23 around 3:00 P.M. and was home sleeping when the power went out in the facility. When she learned about the power outage, she returned to work on 03/26/23 around 7:45 A.M. and assisted staff to provide care for the residents. Record review did not reveal evidence temperatures in the facility common areas and resident rooms were monitored during the power outage on 03/25/23 at 3:00 P.M. through 03/26/23 at 8:30 A.M. Review of the undated facility policy titled Exceeding Maximum and Minimum Temperature included the policy of the facility was to provide comfortable and safe temperature levels. The temperature of the facility should be maintained between 71- and 81-degrees Fahrenheit. Any temperature outside of this range required specific interventions to avoid potential negative impact on the resident's wellbeing. Should the air conditioning or heating system fail, specific monitoring and safety measures should be activated. Environmental temperatures were monitored by the assigned person every one to four hours throughout the facility. This deficiency represents non-compliance investigated under Complaint Number OH00141475 and OH00141550.

Based on observation, interview, record review and policy review, the facility failed to ensure proper personal protective equipment (PPE) was donned and/or doffed prior to entering and exiting Resident #31's room who was on isolation related to potential Covid-19. This had the potential to affect all 65 residents residing at the facility. Findings include: Review of the medical record for Resident #31 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 12/23/20 revealed Resident #31 was at risk for acquiring Covid-19 related to potential exposure of an asymptomatic Covid-19 carrier. Interventions included assist resident with handwashing as needed, provide meals in the resident's room, and remind the resident and assist if needed to keep an approximate six-foot distance from other residents when in the common area. The care plan did not include any intervention regarding transmission-based precautions or isolation. Review of the physician's orders [REDACTED].#31 had an order for [REDACTED]. Observation on 12/29/20 on 9:12 A.M. revealed Resident #31 had a green sign on the wall outside his room that read This Room Was Under a 14-Day Isolation Period that started on 12/23/20 and with an end date on the sign reading as 01/06/20. The sign revealed in order to enter Resident #31's room staff must have on a mask, goggles, gown and gloves. Observation on 12/29/20 at 9:55 A.M. of Housekeeper #606 revealed she entered Resident #31's room wearing the same N95 mask, goggles, and gown that she had previously been wearing on the unit. Housekeeper #606 applied gloves prior to entering Resident #31's room. Observation revealed Housekeeper #606 cleansed Resident #31's bathroom, emptied his garbage and wiped off his bedside table. Housekeeper #606 removed her gloves and then proceeded to exit Resident #31's room pushing the housekeeping cart towards the next room. Interview on 12/29/20 at 9:58 A.M. with Housekeeper #606 revealed she wears the same goggles, N95 and gown into all the rooms on the unit even for Resident #31. Housekeeper #606 verified Resident #31 had a green sign outside his room indicating he was on a 14-day isolation, but she revealed she was not aware she was to do anything different for that room. She verified she did not change her N95 mask, clean her goggles, or change her gown upon exiting Resident #31's room. She revealed she was not trained to change her PPE upon exiting a room for a resident on isolation. She revealed she was not instructed to clean the isolation rooms at the end of the day as she revealed she went in order room by room down the hallway. She proceeded after the interview to continue to enter the next room, room [ROOM NUMBER], with the same PPE on. Interview on 12/29/20 at 10:09 A.M. with the Director of Nursing and Housekeeper #606 revealed Housekeeper #606 verified she had cleaned the room of Resident #31 who was on isolation. She verified she had not changed her gown, mask, or changed or cleansed her goggles after exiting Resident #31's room and proceeded into room [ROOM NUMBER] with the same PPE. The Director of Nursing verified Resident #31 was on droplet precautions, and Housekeeper #606 should have changed her gown, N95 mask, and cleansed her goggles upon exiting Resident #31's room and should not have proceeded to the next room wearing the same PPE. Review of facility policy labeled, 14-Day Preventative Isolation, dated 09/10/20, revealed all residents who were admitted to the hospital and return were placed in a 14- day preventative transmission-based precaution isolation. The facility was to assume new admits and readmits were exposed to Covid-19. The policy revealed the resident would be placed in isolation for 14-days in a private room, therapy was to be completed in their room and at the end of the day after all other residents were treated, staff who entered the room were to wear eye protection, gloves, gowns and masks, and housekeeping was to clean the isolation room last. Review of undated facility procedure per Center of Disease Control labeled, How to Safely Remove PPE revealed remove all PPE before exiting the patient room except a respirator if worn. The procedure revealed the respirator was to be removed after leaving the patient room and closing the door. This deficiency substantiates Complaint Number OH 951.

Based on record review and interview the facility failed to ensure advance directives for Resident #43 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#43) of one resident reviewed for advance directives. The facility census was 62. Findings included: Review of medical record for Resident #43 with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of nursing notes dated [DATE] at 12:52 P.M. completed per Licensed Practical Nurse (LPN) #[AGE]0 revealed Resident #43 was admitted to the facility on [DATE] and Resident #43's power of attorney signed for Resident #43 to be a Do Not Resuscitate Comfort Care (DNRCC). Resident #43 Primary Care Physician (PCP) #[AGE]1 was notified, and the family was awaiting on the physician's arrival. Review of form labeled, DNR Comfort Care located in Resident #43's chart revealed Resident #43's authorized representative signed but did not date requesting Resident #43 to be a DNRCC. Resident #43's Primary Care Physician (PCP) #[AGE]1 signed the DNRCC form and dated the form 01/16/20. The form indicated the following DNR protocol was effective immediately. Review of admission Medicare five-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #43 had impaired cognition. Review of care plan for Resident #43 dated 01/29/20 revealed Resident #43 was a full code. Intervention included review code status quarterly and as needed. Review of physician orders [REDACTED].#43 did not have a code status listed on his physician orders. Interview on 02/26/20 at 10:52 A.M. with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #[AGE]2 revealed when a code status was not listed on the physician orders [REDACTED]. RN/ ADON #[AGE]2 verified PCP #[AGE]1 signed Resident #43's DNR comfort care form to have Resident #43 a DNR Comfort Care (DNRCC) on 01/16/20. She verified the facility did not change Resident #43's code status in his physician orders [REDACTED]. Review of facility policy labeled, Advance Directives dated 11/21/16 revealed the purpose of the policy was to recognize the resident's right to establish individual advance directives. The facility revealed the resident's right to determine a DNR or full code status would be honored. The facility would offer information about the DNR decision at the time of admission.

Based on review of the medical record, a facility Self- Reported Incident (SRI) to the State Agency, police report, facility policy and interview with staff, the facility failed to ensure Resident #5 was free from physical abuse by a staff member. This affected one resident (Resident #5) of three residents reviewed for abuse. The facility census was 58. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE]. She was discharged to the hospital for psychiatric admission on 11/10/19 and currently remains on bed-hold in the hospital. [DIAGNOSES REDACTED]. Review of care plan dated 1/20/17 revealed Resident #5 had impaired cognition related to dementia with behavioral disturbances. Interventions included approach the resident in a quiet manner, re-orient the resident as able, staff to anticipate the resident's needs, and staff to explain all procedures and treatments to the resident. Review of care plan dated 01/20/17 revealed Resident #5 needed assistance from staff to meet her activities of daily living needs due to cognitive deficit, shortness of breath, and signs of depression. Interventions included she was a one person assist for activities of daily living, transfers, and wheelchair mobility and required assistance with dressing. Review of care plan dated 11/27/18 revealed Resident #5 had inappropriate behaviors related to wandering in and out of others rooms, taking items that did not belong to her, hitting and kicking staff and residents, refusing to take medications, spitting, scratching, pinching, and grabbing at staff, yelling and screaming at staff and other residents, using abusive language, and rejected hands on care at times. Resident #5 had a [DIAGNOSES REDACTED]. Interventions included approach the resident in a slow calm manner, provide diversional activities, provide support and encouragement, and allow the resident to make choices about her daily care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/22/19, revealed Resident #5 had impaired cognition. The resident required extensive assist of one person with bed mobility and transfers. She required extensive assist of two persons with toileting and dressing. She was able to ambulate in her room but required extensive assist of two persons. She had physical behaviors four to six days of the seven-day assessment reference period, verbal behaviors one to three days of the seven-day assessment reference period, rejection of care one to three days and wandering behaviors one to three days of the seven-day assessment reference period. She was frequently incontinent of urine and bowel. Review of the facility SRI with a tracking number of 8 and a date of discovery of 10/28/19 revealed the facility substantiated physical abuse of Resident #5 by facility staff, STNA #602. The effect on Resident #5 revealed she was upset. The SRI revealed on 10/28/19 at 6:45 [NAME]M. STNA #603 reported to the Director of Nursing that STNA #602 smacked Resident #5 on the mouth and face during direct care. The Director of Nursing reported to the Administrator who arrived at the facility at 6:55 [NAME]M. Resident #5 was assessed, and no apparent injuries had been noticed. The STNA #602 was removed from service, and the Administrator interviewed and suspended STNA #602 until further notice. STNA #603 was interviewed and stated she and STNA #602 were trying to change Resident #5 but she became combative. STNA #603 revealed Resident #5 spit in STNA #602's face, and STNA #602 smacked Resident #5 in the mouth. Resident #5 then called STNA #602 a (expletive) and spit in STNA's #602's face again, and STNA #602 smacked the residents face a second time. On 10/28/19 at 8:15 [NAME]M. the Administrator interviewed Resident #5 and she was calm, quiet and had no complaints of pain or discomfort. She had no recollection of the incident as her last Brief Interview for Mental Status (BIMS) score was a two on her last MDS dated [DATE]. Resident #5's family and physician were notified of the incident. The police were notified, and a police report #19- was filed on 10/28/19 at 10:34 [NAME]M. The facility investigated and substantiated the physical abuse allegation. STNA #602 was terminated, and the incident was reported to the Ohio Board of Nursing. Review of witness statement per STNA #603 revealed on 10/28/19 at 6:30 [NAME]M. STNA #602 came over the walkie talkie asking if any third shift employees were done with their work so she could have a walkie talkie. STNA #603 revealed she was finishing up with Resident #5 and stated over the walkie talkie she could come get her walkie talkie. STNA #602 came into the room and started helping STNA #603 with Resident #5. Resident #5 became combative at this point and her pants were around her ankles. STNA #603 revealed they had to act quickly to prevent falls and transferred her to her recliner. STNA #603 revealed Resident #5 then spit on STNA #602's face. STNA #602 smacked Resident #5 in the mouth and then Resident #5 called STNA #602 a (expletive) and spit on STNA #602's face again. STNA #603 revealed STNA #602 smacked Resident #5 in the face a second time. Review of witness statement per STNA #602 revealed on 10/28/19 she was in helping STNA #603 with Resident #5, and Resident #5 was scratching and hitting at both of them. She revealed she took her hands and tried to hold down Resident #5's hands, and then Resident #5 was wailing her arms and she revealed she was also wailing her arms. She revealed Resident #5 spit in her face twice and she told the Resident #5 not to spit as it was nasty. Review of the local law enforcement report #19- dated 10/29/19 at 12:59 P.M. revealed Police Officer #615 was called by the Administrator to the facility on [DATE] at 10:34 [NAME]M. for a report of an assault to a resident. The report revealed upon arrival he met with the Administrator and he showed Police Officer #615 the two employees witness statements. The report revealed STNA's #602 and #603 were assisting Resident #5, and she was not being cooperative. Resident #5 spit on STNA #602, and STNA #602 used the back of her hand and hit Resident #5 near her mouth. The report revealed Resident #5 spit at STNA #602 again, and the STNA #602 struck her again. The report revealed the Administrator only wanted a report on filed at this time. The report revealed Police Officer #615 did not meet with Resident #5 as the Administrator advised the resident had no visible injuries. Review of daily skilled nursing note per Assessment Nurse Licensed Practical Nurse (LPN) #605 dated 10/28/19 at 11:42 [NAME]M. revealed Resident #5's vital signs were within normal limits, and she had no injury noted to her body. Her Primary Care Physician was contacted regarding the incident this morning and recommended no new orders. Interview on 11/20/19 at 8:29 [NAME]M. with STNA #603 revealed she had attempted to give Resident #5 a shower earlier in the morning around 5:00 [NAME]M., but Resident #5 refused as she was being combative. She revealed at approximately 6:20 [NAME]M. she and another STNA went to provide Resident #5 with incontinence care and get Resident #5 up out of bed. She revealed Resident #5 was calm during this period. She revealed the other STNA left the room as Resident #5 was being cooperative with care. She revealed approximately 6:30 [NAME]M. STNA #602 came over the walkie- talkie asking if any third shift staff was done and leaving so she could use their walkie talkie. STNA #603 revealed she stated she was almost done with Resident #5's care and STNA #602 could use her walkie talkie. STNA #602 came into Resident #5's room, and Resident #5 started to become combative when trying to pull up her pants and transfer her to the chair. STNA #603 revealed they sat her in the chair, and Resident #5 spit in STNA #602's face. STNA #602 backhanded her hitting her in the right side of her face and mouth. STNA #603 stated Resident #5 then called STNA #603 a (expletive), and the resident and spit in STNA #602's face again. STNA #603 revealed STNA #602 immediately backhanded Resident #5 again across the right side of her face and mouth. STNA #603 stated both times the STNA #602 back handed Resident #5 she stated, they were pretty damn hard as it left her cheek looking beat red like she had been outside in the cold for a long period of time. STNA #603 revealed she was in shock and it was difficult to react as she never witnessed someone abuse a resident, and she had a hard time speaking and reacting. STNA #603 revealed she went to another STNA, STNA #616, and they went outside and called the Director of Nursing to report the incident. Interview on 11/20/19 at 10:51 [NAME]M. with LPN #604 revealed she was one of the nurses coming on duty at approximately 6:45 [NAME]M. as the Director of Nursing called her and asked her to remove the STNA #602 from the floor. She revealed STNA #603 then went into a room and explained the incident to her. She revealed she did not assess or see Resident #5 until later that day as she had relayed the information of what happened to Resident #5's nurse, LPN #608, and she was going to assess her. Interview on 11/20/19 at 11:40 [NAME]M. with LPN #608 revealed on 10 28/19 she was about ten minutes late to work. She revealed LPN #604 gave her report on the incident that had occurred, and she did not assess Resident #5 until about 7:30 [NAME]M. after receiving report. She revealed on assessment she did not see any redness or injury at that time. Interview on 11/20/19 at 12:55 P.M. with LPN Assessment Nurse #611 revealed she arrived at the facility at 8:00 [NAME]M. and completed the Skin and Wound Total Body Skin Assessment on Resident #5 shortly after she came in at 8:00 [NAME]M. and revealed no signs of injury. Interview on 11/20/19 at 5:30 P.M. with the Corporate Director of Nursing # 617 verified the incident occurred at 6:40 [NAME]M., and a nurse did not assess Resident #5 until 7:30 [NAME]M. after the incident for injury. Review of facility policy titled, Abuse, dated 10/01/18, revealed the facility failed to ensure residents had the right to be free from abuse, neglect, exploitation, and misappropriation of their property. The definition of abuse was defining per their policy as willful infliction of injury unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse. This deficiency substantiates Self-Reported Incident Investigation Control Number OH 262.

Based on closed record review and interview the facility failed to implement an effective pain management program for Resident #1, who received Hospice services for [MEDICAL CONDITION]. Actual harm occurred on 08/20/19 when the facility did not have pain medication available for Resident #1 as ordered by the physician resulting in Resident #1 experiencing increased pain. Resident #1 was moaning out help me, rubbing and holding her abdomen with a pain level assessed by Hospice as a six on a scale of one to ten with ten being the most severe pain when Hospice arrived to the facility. This affected one resident (#1) of three residents reviewed for pain. Findings include: Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] and passed away at the facility on 08/21/19. The resident had [DIAGNOSES REDACTED]. Review of the care plan dated 07/25/19 revealed Resident #1 had a potential for alteration in comfort related to [MEDICAL CONDITION] with spastic [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Interventions included administer medications as ordered, assist resident with repositioning, consult physician as needed, observe resident for any sign and symptoms of pain, observe resident for nonverbal signs of pain including facial grimacing, restlessness, and grabbing effected areas. Review of a Pain Assessment (3.0) completed by Licensed Practical Nurse (LPN) #600 dated 08/13/19 revealed Resident #1 was able to be interviewed and denied any pain. Record review revealed no additional pain assessments were completed for Resident #1 after 08/13/19. Review of a Medicare Five Day Minimum Data Set (MDS) 3.0 assessment, dated 08/18/19 revealed a Brief Interview for Mental Status (BIMS) score of a 13 reflecting Resident #1 was cognitively intact. The assessment revealed the resident had occasional mild pain present and received pain medications. Review of a nursing progress note, dated 08/19/19 at 3:49 P.M. and written by Registered Nurse (RN) #602 revealed Hospice RN and Spiritual care was in to meet with Resident #1's daughter. RN #602 revealed Resident #1 signed all paperwork to initiate Hospice services and new orders were received at this time. Review of a Hospice skilled nursing visit note dated 08/19/19 at 5:30 P.M. completed by Hospice RN #601 revealed Resident #1 was admitted to Hospice services on 08/19/19 with a terminal [DIAGNOSES REDACTED]. Resident co-morbidities included malignant neoplasm of the ovary and malignant ascites. Resident #1 was found to have a significant pelvic mass that had infiltrated and upon biopsy the family was notified of the poor prognosis and family agreed with Hospice services. Hospice RN #601 revealed she contacted Resident #1's Primary Care Physician (PCP) #603 and orders were received to discontinue all medications and comfort care medications orders were received. Medication orders were written for the facility and care was collaborated with Registered Nurse #602 who verbalized understanding of medications and stated she (RN #602) would get the medications ordered from pharmacy. PCP #603 stated he would give verbal authorization for medication to pharmacy. Resident #1's daughter was updated per Hospice RN #601. Review of physician's orders [REDACTED].#603 ordered [MEDICATION NAME] (concentrate) solution 20 milligram (mg) per milliliter (ml), give five milligrams by mouth every three hours as needed for pain and [MEDICATION NAME] (anti-anxiety) 0.5 milligram tablet give one tablet by mouth every six hours as needed for anxiety. Review of Controlled Drug Receipt/ Record/ Disposition Form for Resident #1 for [MEDICATION NAME] Concentration 20 milligrams per milliliter for Resident #1 revealed RN #605 signed out [MEDICATION NAME] 0.25 mg on 08/20/19 at 2:15 P.M., [MEDICATION NAME] 0.25 mg on 08/20/19 at 2:30 P.M. (as an order was received to increase to 0.5 mg every hour as needed for pain), [MEDICATION NAME] 0.5 mg on 08/20/19 at 4:00 P.M. and [MEDICATION NAME] 0.5 mg on 08/20/19 at 5:30 P.M Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the documentation entered on 08/20/19 for dayshift revealed RN #605 documented Resident #1's pain level a four out of ten. Review of the nursing notes, dated 08/20/19 from 6:00 [NAME]M. to 7:00 P.M. revealed no documentation of Resident #1's pain, pain interventions provided, pain medications given to Resident #1, or any change in condition regarding pain documented. Review of a hospice visit note, dated 08/20/19 at 12:10 P.M. and completed by Hospice RN #604 revealed upon entering Resident #1's room the resident was observed in bed with Resident #1's daughter at the bedside. Resident #1 was moaning saying help me. Resident #1 was anxious and a Face, Legs, Activity, Cry, Consolibility (FLACC) pain scale was completed per Hospice RN #604 which assessed the resident's pain level to be a six out of ten on the pain scale. Hospice RN #604 revealed she notified the facility nurse (RN #605) and asked if she had given anything to Resident #1 for pain. RN #605 revealed the medications ([MEDICATION NAME] and [MEDICATION NAME]) had not come in from pharmacy. Hospice RN #604 revealed she contacted the pharmacy who stated they did not receive the prescription from PCP #603. PCP #603 was contacted by Hospice RN #604 who stated he would call in authorization for medications. Hospice RN #604 filled out authorization to pull from the facility starter kit to be approved by pharmacy and medications- [MEDICATION NAME] and [MEDICATION NAME] were given. Hospice RN completed the FLACC scale after pain medications were given and Resident #1's pain remained a six out of ten and she continued to reach out. PCP #603 was notified the pain medications were not effective and ordered an increase in [MEDICATION NAME] to one milligram every hour as needed, and [MEDICATION NAME] ten milligrams every one hour as needed. Hospice RN #604 notified facility RN #605 of the new orders and extensive education was provided to RN #605 regarding medication administration needed to be given in timely manner. Hospice RN #604 and Resident #1's daughter repositioned Resident #1 and provided incontinence care. Hospice RN #604 continued education with facility staff to ensure medication administration was given at appropriate times. Interview on 10/07/19 at 11:09 [NAME]M. with Resident #1's daughter revealed a family member arrived at the facility on 08/20/19 approximately 12:00 P.M. and called her as her mom was screaming out help me and appeared in pain as she was rubbing and holding her abdomen. Resident #1's daughter arrived at the facility shortly after and revealed Resident #1 continued yelling out help me, with facial grimacing and holding her abdomen. She revealed Hospice RN #604 was present at the facility and revealed the facility did not have the [MEDICATION NAME] or the [MEDICATION NAME] available per the physician orders [REDACTED]. Resident #1's daughter revealed staff had stated she had been yelling out most the morning. Resident #1's daughter revealed she had never seen her mother in so much pain. She revealed Hospice RN #604 assisted in getting medications but there was an approximate two-hour delay in giving Resident #1 pain medications from the time she arrived at the facility. Resident #1's daughter revealed facility RN #605 who was assigned to care for Resident #1 did not come in and assess Resident #1's pain level prior or after she provided her medication. She revealed Resident #1 continued to be in pain after she had given the pain medication and Resident #1's order allowed Resident #1 to receive pain medication every hour, but RN #605 did not come in and assess the effectiveness of the pain medication and RN #605 delayed administering Resident #1's pain medication every hour even after Hospice nurse #604 continued to try to get RN #605 to give Resident #1's pain medication timely. Interview on 10/07/19 at 11:35 P.M. with Hospice RN #604 revealed on 08/19/19 Hospice services were initiated for Resident #1 and they received orders from PCP #603 for [MEDICATION NAME] and [MEDICATION NAME] for comfort. She revealed Hospice discussed the plan of care with RN #602 and she stated she would order the medication from pharmacy on 08/19/19. Hospice RN #604 revealed she received a call from the Hospice state tested nursing assistant (STNA), who was at the facility providing care on 08/20/19 at approximately 11:30 [NAME]M. concerned about Resident #1's pain as she was yelling out, moaning and holding her abdomen. Hospice RN #604 arrived immediately to the facility and assessed Resident #1. She revealed Resident #1 was in pain by signs of moaning, moving her head back and forth, yelling out help me and rubbing and holding her abdomen. Hospice RN #604 assessed Resident #1 and determined her pain level was a six out of ten on the pain scale. Hospice RN #604 asked the facility nurse, RN #605, if she administered Resident #1 any pain medication. She revealed RN #605 verified she had not administered any pain medication as she did not have any of the medications in from pharmacy. She revealed RN #605 had stated she had not attempted to call the physician or pharmacist regarding Resident #1's pain. Hospice RN #604 contacted the pharmacist, physician and filled out an authorization to pull from the facilities authorization emergency starter. Hospice RN #604 revealed Resident #1 received the medications at approximately 2:30 P.M. and felt there was a significant delay and Resident #1 was in continuous pain during this time frame. Hospice RN #604 revealed Resident #1 was ordered to have her [MEDICATION NAME] every hour due to the continuous pain and after the hour she went to locate RN #605 as Resident #1 continued to have pain at a six out of ten on the pain scale. Hospice RN #604 revealed RN #605 stated she was completing glucometer checks and would be in after. Hospice RN #604 revealed she was concerned because Resident #1 continued to be in pain, and she was trying to get her pain under control, but RN #605 was not administering Resident #1's pain medication every hour as it needed to be. She revealed she followed RN #605 educating her on the importance of timely pain medication and RN #605 stated to Hospice RN #604 that she knew how to do her job. Hospice RN #604 revealed she was concerned because RN #605 did not come in and assess Resident #1's pain after the pain medication was administered to monitor effectiveness and did not come in when Resident #1 was able to have more pain medication and administer timely as each time she had to go look for RN #605 and then RN #605 did not come in timely with the medication. She revealed she continuously had to educate RN #605 the importance of pain management with timely medication administration. She revealed she felt Resident #1's pain management was delayed because of RN #605's lack of assessing and timely administration. Hospice RN #604 revealed she notified the Assistant Director of Nursing (ADON) #606 of her concerns as the Administrator and Director of Nursing were not in the building. Interview on 10/07/19 at 2:17 P.M. with the Director of Nursing (DON) verified RN #605 did not document any of the medications she administered Resident #1 on the Medication Administration Record [REDACTED]. She verified RN #605 documented in the MAR indicated [REDACTED]. The DON verified there was no documentation regarding Resident #1's pain per RN #605 on 08/20/19. Interview on 10/07/19 at 3:15 P.M. with Licensed Practical Nurse (LPN) Assessment Nurse #607 revealed she completed the pain assessments at the facility and assessed residents for pain and assessed each resident to determine effective non-medication interventions and if their medication regimen was effective. She verified after review RN #605 did not complete the documentation for Resident #1's pain assessment on 08/20/19 correctly. She verified RN #605 documented Resident #1's pain was a four but did not continue to document where the computer system would prompt where the pain was located and what interventions were attempted. She revealed RN #605 should have documented the pain level and effectiveness of any interventions implemented including assessing after a pain medication was administered to determine effectiveness. Review of hospice contract titled, Nursing Facility Agreement between the Hospice provider and the facility dated 08/27/13 revealed the facility shall provide facility services to Hospice patients which included ensuring the patient was kept comfortable. Review of facility policy titled Pain Management Program, dated 06/12/17 revealed the facility goal was to identify, assess, manage, and treat resident's pain. The facility would on an individual basis, assess every shift as the nurse used a one through ten numeric scale or the Wong-Baker faces pain scale to determine intensity. The nurse would document the specific verbal or nonverbal reports of pain prior to administering as needed pain medication. The facility policy did not include monitoring for effectiveness of the pain medication and documenting. This deficiency substantiates Complaint Number OH 346.

Based on observation, record review, resident and staff interviews the facility failed to ensure sufficient staff assisted and supervised one resident (Resident #31) during toileting to prevent a fall that resulted in injury. Actual harm occurred when Resident #31 sustained bilateral knee fractures and bilateral ankle fractures following lack of the proper number of staff assistance from the wheelchair to the commode. This affected one of four residents reviewed for accidents. The facility identified 53 residents requiring assistance of one or two staff members for toileting. The facility census was 57. Findings included: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] from the assisted living unit of the facility with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #31 was assessed to need two plus person physical assist for transfers, toileting, sit to stand and surface to surface transfers. Resident #31 was assessed to not be steady without staff to assist for stabilization. Resident #31 was assessed to have bilateral lower extremity impairment. Resident #31 was cognitively intact, alert and oriented to person, place, and time. Review of therapy notes dated 04/03/15 and 04/09/15 revealed resident and staff were educated on continued participation on stand pivot transfer and to provide standby assist for functional transfers including sit to stand from motorized wheelchair in bathroom using grab bars and stand pivot transfer to toilet requiring verbal cues for safe technique. An incident report dated 04/30/15 revealed at 12:15 P.M., Resident #31 was lowered to the floor in the bathroom. Review of the progress note dated 04/30/15 at 6:04 P.M. indicated at 12:15 P.M., Resident #31 was lowered to the floor in the bathroom due to inability to transfer and becoming weak in the knees. Resident #31 complained of bilateral knee and ankle pain. The physician was notified and ordered x-rays. At 6:27 P.M., Resident #31 demanded to go to the hospital. At 11:46 P.M., Resident #31 was admitted to the hospital with [REDACTED]. There was no evidence in the clinical record of an assessment at the time of the fall or any details describing the incident of how and what happened. On 06/04/15 at 12:30 P.M., Resident #31 was interviewed. She verified that at the time of the fall, she did not have help from staff. Resident #31 reported I went into the bathroom with my power wheelchair and the nurse was behind the wheelchair and she could not help me when I fell . The nurse cried and felt bad that she could not reach me. Resident #31 stated she now has to have a urinary catheter as she is not able to bear weight to go to the bathroom. On 06/04/15 at 12:45 P.M. Licensed Practical Nurse (LPN) #400 was interviewed. LPN #400 was with Resident #31 at the time of the incident. LPN #400 stated Resident #31 propelled her power wheelchair into the bathroom and I was behind the power wheelchair and could not really reach her as she fell forward as she stood up. On 06/04/15 at 4:15 P.M., the therapy director (TD) was interviewed. The TD verified that Resident #31 has needed hands on assistance for a long time and cannot stand without help. The TD stated staff should have entered the bathroom first then had Resident #31 enter the bathroom in her power wheelchair to enable staff to provide stand by assistance, verbal cues, and supervision during transfers to the commode. On 06/05/15 at 10:13 A.M., the director of nursing (DON) verified therapy had trained staff for stand by assist and supervision when toileting Resident #31. The DON reported she re-interviewed LPN #400 on 06/05/15 who confirmed she was not next to Resident #31 but was behind the wheelchair which would not have allowed visual supervision of foot placement or stand by assistance. The DON reported that LPN #400 explained that because she was behind the power wheelchair, she could not assist in lowering Resident #31 to the ground when she fell forward onto her knees.