Every finding on record at Country Court

Based on observations, resident and staff interviews, review of resident council minutes, and policy review, the facility failed to maintain a safe and sanitary environment. This affected five (Resident #11, #15, #40, #42, and #43) of 21 residents reviewed for physical environment. This had the potential to affect 16 residents who were identified by the facility as utilizing the Station One shower room. The facility census was 47.Findings include:1) Observation on 08/17/26 at 2:51 P.M. of Resident #42's ceiling to the left corner of the room revealed a gap between the wall and ceiling. Interview with Certified Nursing Assistant (CNA) #52 revealed the ceiling was leaking and they tried to repair it.Observation and interview on 08/20/26 at 10:00 A.M revealed Resident #15's room had a crack approximately one foot long in the ceiling near the wall at the foot of the resident's bed. The crack was encircled with a brown water like stain and had colors of purple and black at the opening of the crack. Resident #15 stated there was a leak at the crack but the staff keep an eye on it.Interview on 08/18/26 at 9:09 A.M. with Maintenance Director #300 revealed the ceilings have been leaking in spots, and repairs have been made. They got an estimate a year ago for a new roof but have not replaced the roof yet. They had one estimate completed for roof repairs and replacements from Roofing Company #1 dated July 2025. They have been aware of the damages since 2025.Interview and observations on 08/18/26 from 3:58 P.M. to 4:05 P.M. with Maintenance Director #300 verified the gap in the ceiling in Resident #42's room.Interview with Maintenance Worker (MW) #83 on 08/20/26 .at 10:06 A.M. confirmed the crack in Resident #15's ceiling. MW #83 stated it was water damage around the crack. MW #83 denied that the dark coloration was mold but did confirm there was an ongoing issue with the roof.Interview was conducted with the Administrator on 08/20/26 at 10:42 A.M. confirmed the facility had roof problems and was aware of water intrusion in some parts of the building. The Administrator stated that mold had not been identified or confirmed. AD #86 stated the facility had used a primer paint to resist mold build up, in some areas within the last two weeks as a precaution. The Administrator confirmed roofing companies had been to the facility to review the roofing project.2) Observation and interview on 08/17/26 at 2:09 P.M. with Resident #43 revealed the wallpaper below his window not adhering to the wall and held up with pushpins. Resident #43 stated the wallpaper was coming off, so the nurses put those there to hold it up.Observation and interview on 08/17/26 at 2:16 P.M with Resident #11 revealed the wall underneath the Packaged Terminal Air Conditioner, self-contained heating and cooling system (PTAC) unit revealed it was black with black, rotted wood. Interview with Resident #11 revealed the ceilings have been leaking throughout the facility.Observation and interview on 08/17/26 at 2:43 P.M. with Resident #40 revealed the windowsill was broken and there were holes in the wall behind her bed and along the lower left side of the wall. Resident #40 stated she wished they would repair it.Interview and observations on 08/18/26 from 3:58 P.M. to 4:05 P.M. with Maintenance Director #300 verified the room damages for the PTAC unit in Resident #11's room, the windowsill, holes in the wall in Resident #40's room, and the wallpaper in disrepair in Resident #43's room. 3) Review of the resident council meeting minutes dated 07/23/26 revealed a resident expressed concerns about possible black mold on the shower bench in the Station One shower room. The minutes revealed upon inspection, there was no black mold found. The discoloration observed was determined to be normal wear on the legs and feet of the shower bench.Observation and interview on 08/18/26 at 4:27 P.M. revealed the gray shower bench in the Station One shower room revealed there was black growth on the top of the rubber feet of the shower bench and also present on the metal legs connecting the bench to the rubber feet. This matter scratched off with pressure. Licensed Practical Nurse (LPN) #87 on 08/18/26 at 4:28 P.M. confirmed it was mold at the junction of the metal legs and rubber feet of the gray shower bench.Review of the facility's undated policy titled Safe Environment revealed the facility will provide a safe, functional, sanitary, and comfortable environment for residents.This deficiency represents non-compliance investigated under Complaint Number 3067986.

Based on observation and interviews with staff, the facility failed to ensure the washcloths used for resident care were not stained or discolored. This had the potential to affect all 48 residents in the facility.Findings Include: Observations conducted during the initial tour on 05/26/26 from 9:05 A.M. through 9:11 A.M. revealed all of the washcloths, 70 in total, in three of the linen closets were completely discolored/stained gray to dark brown.On 05/26/26 at 9:20 A.M. an interview with Certified Nursing Assistant (CNA) #106 revealed she did not know why all the washcloths in the linen closets were discolored and stained.Interview and observation of the laundry room on 05/26/26 at 9:35 A.M. with Laundry Staff #111 revealed a pile of unfolded stained/discolored washcloths on the top of the table and about a dozen white washcloths folded in the laundry cart to go out on the units. She stated the stained washcloths on the table in the pile were to be used for cleaning however the nursing staff would take the cleaning cloths and use them on the residents when they were not supposed to use them. Laundry Staff #111 went to the main linen storage closet and obtained more washcloths, took them out to the clean linen closets, gathered up all the discolored washcloths, and replaced them with the new ones.On 05/26/26 at 10:25 A.M. an interview with the Administrator revealed staff were not supposed to be using the discolored or stained washcloths on the residents they were for cleaning only.On 05/26/26 at 12:00 P.M. an interview with Certified Nursing Assistant #103 revealed the night shift must have placed the discolored washcloths in the linen closets. She verified she had been using them for morning care on the residents.

Based on record review, interviews, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call emergency medical services (EMS) for a resident with advance directives for a Full Code (indication for healthcare providers to perform all possible life-saving measures in the event of a cardiac or respiratory arrest). This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death on [DATE] at 5:30 A.M. when Resident #50 was found unresponsive without vital signs and Licensed Practical Nurse (LPN) #79 and Registered Nurse (RN) #75 failed to initiate CPR or contact EMS. LPN #79 and RN #75 did not review Resident #50's code status and determined Resident #50 was deceased at 5:30 A.M. On [DATE] at 10:11 A.M., the Administrator and Registered Nurse (RN) #162 were notified Immediate Jeopardy began on [DATE] at 5:30 A.M. when Resident #50 was found unresponsive and without vital signs, and Licensed Practical Nurse (LPN) #79 and Registered Nurse (RN) #75 failed to initiate CPR or summon EMS services. The resident, who had advance directive for a Full Code was pronounced deceased at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions-On [DATE] at 9:05 A.M., the Medical Director #150 was notified of the incident. -On [DATE], the Director of Nursing (DON) completed a review of the event to determine potential areas of improvement as in when you determine the absence of vital signs to initiate CPR, and came up with a plan for educating nursing staff regarding the problem.-On [DATE] all licensed staff were in-serviced by the DON on the facility policy for identifying and responding appropriately to code status.-On [DATE], Corporate Registered Nurse (RN) #201 completed a whole house audit of all residents to verify code status, care plans and signed Do Not Resuscitate (DNR) forms were correctly documented in the health record as applicable. No concerns were identified. Audits were completed for all new admissions through [DATE].-LPN #79 was no longer employed at the facility. RN #75 received Code Status education on [DATE], which was related to the facility policy on identifying and responding appropriately to code status.-On [DATE], RN #162 audited the crash cart, and any expired equipment was removed and replaced with valid equipment by [DATE]. -On [DATE], the DON, RN #162, Corporate RN #201, and RN #191 began additional education of all nursing staff on the facility policy on advance directives, location of advanced directives, change of condition, notification of change, rounding protocols (every two hours and as needed if the resident's condition warrants) and immediate response when CPR is required. The education was provided to all nursing staff that were in-house and those not in-house received training via phone. All staff were educated by [DATE] except for those on vacation or leave. No nursing staff will be permitted to work until they receive the above education. Agency staff will review the above education prior to working a shift at the facility.-On [DATE], Business Office Manager #105 reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid. All certifications were valid and up to date.-Beginning on [DATE], the DON, Administrator and/or designee will conduct record review audits for all resident deaths going forward for at least the next three months to validate advanced directives were implemented appropriately. The QAPI committee will review the audits and determine if additional follow up is needed.-On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was completed to review the incident investigation, action plans, and applicable policies on CPR and advanced directives. Attendees included Administrator, DON, Corporate RN #201, RN #162, President #250. The Medical Director (Physician #150) provided input via phone. -On [DATE], the DON completed a comprehensive Root Cause Analysis and it was determined that the nurses did not implement CPR because the absence of vital signs was presumed to have occurred a considerable length of time prior. -On [DATE], the Administrator and DON were educated on investigating adverse events, including unexpected deaths, by Corporate Nurse #201. -Beginning on [DATE], the DON and/or designee will conduct Code Drills on alternating shifts to evaluate nurse competency with code procedures. Code drills will be completed three times weekly for four weeks, and then once a month for two months as directed by the QAPI committee.-Beginning on [DATE], the DON, Administrator and/or designee will conduct management rounds (observation and interview audits) throughout the facility on alternating shifts to validate the staff are meeting residents' needs in regard to their specific needs and concerns. Audits will be completed three times weekly for four weeks as directed by the QAPI committee. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of the medical record for Resident #50 revealed an admission date of [DATE]. Diagnoses included nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity. Review of physician orders for [DATE] revealed an advanced directive order for Full Code. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact.Review of the plan of care dated [DATE] revealed Resident #50 had a full code advanced directive with interventions to call nine-one-one (911) in the event the resident's heart stopped and start CPR if the resident was not breathing or had no pulse, and to start oxygen and or life-saving breaths via an artificial manual breathing unit (ambu) bag if the resident stopped breathing. It also included interventions to keep a copy of the resuscitation wishes in the medical record and to notify the Physician and family if the resident stopped breathing or her heart stopped.Review of the progress notes dated [DATE] at 5:30 A.M. by LPN #79 revealed during morning medication pass, Resident #50 was found nonresponsive with no communication. The nurse at the bedside noted the resident was cool to the touch and attempted to take vital signs. No blood pressure, pulse or respirations were identified. A second nurse (RN #75) verified Resident #50 had no heartbeat or breath sounds. A text message was sent to the Director of Nursing (DON) and Nurse Practitioner (NP) #225 and spouse were made aware. Review of the progress note dated [DATE] at 5:52 A.M. documented Resident #50 had expired.Review of the medical record found no evidence of any identified change in condition for Resident #50 prior to her death. The record also did not document CPR was initiated or EMS was contacted when Resident #50 was found unresponsive without vital signs. The record also did not document Resident #50 had been deceased for an extended period of time.During an interview on [DATE] at 10:19 A.M., Certified Nursing Assistant (CNA) #94 stated she worked night shift on [DATE] and stated an Agency CNA (CNA #103) working on another hall was not taking care of residents appropriately. She stated CNA #103 was sitting down at the desk or was difficult to find. She offered to help on a few occasions, and either was unable to locate CNA #103 or found him sitting and not providing care. She stated LPN #79 informed her of Resident #50 being found unresponsive and she was trying to find the nurse (RN #75) to confirm the lack of vital signs. At this time CNA #94 asked CNA #103 when he last saw her and he reported he saw her at [DATE] at 11:20 P.M. She stated CNA #103 had not worked since this incident. During an interview on [DATE] at 10:40 A.M., the DON stated Agency CNA #103 was the CNA working on night shift from [DATE] into [DATE] and he was Resident #50's assigned CNA. The DON reported she identified the facility staff did not check on Resident #50 timely and it was unknown how long Resident #50 was unresponsive before being found at 5:30 A.M. The DON confirmed staff should have performed CPR and called 911 for emergency services as Resident #50 was a full code. During an interview on [DATE] at 11:30 A.M., the DON again confirmed the nursing staff should have performed CPR on Resident #50. The DON also reported the assigned nurse working [DATE] only worked two more shifts and then left her employment after her shift on [DATE]. She confirmed an investigation was not completed. She said when she was alerted about Resident #50's death by phone on [DATE] around 7:00 A.M. she asked the nurse when she last saw the resident alive. LPN #79 informed her around 12:00 A.M. was her last observation of Resident #50 before she was found unresponsive at 5:30 A.M. and the nurse informed the DON she was unsure when Agency CNA #103 last cared for the resident prior to her death. The DON confirmed her expectation of staff checking on residents at least every two hours and laying eyes on residents to confirm safety. The DON confirmed if staff were unable to obtain vital signs on a resident, code status should be verified, and CPR should be initiated along with calling 911 for anyone unresponsive. The DON revealed she was unsure if 911 was contacted and stated she did not believe they were contacted. She confirmed Resident #50's body was sent directly from the facility to the funeral home. During an interview on [DATE] at 1:06 P.M., Funeral Home Staff #140 confirmed they had a copy of the death certificate which listed Resident #50's cause of death as sudden cardiac death and acute liver failure with the manner of death listed as natural and the date/time of death was [DATE] at 5:30 A.M. During an interview on [DATE] at 2:34 P.M., Physician #150 stated Resident #50 was very ill and was a newer admission to the facility. He was not informed of any changes in her condition leading up to her death and was informed by staff she had been found deceased . He reported staff did not perform any CPR or life-saving measures to his knowledge. He would expect staff to perform CPR if they observed her go unresponsive, but if she was found down for an unknown period of time, he would not have expected staff to perform CPR. He revealed the resident was found already deceased .During an interview on [DATE] at 11:00 A.M., the DON confirmed the facility had not completed an investigation for Resident #50's death and/or allegation of neglect due to lack of timely care. The DON stated she would begin an investigation on this date.During an interview on [DATE] at 1:55 P.M., Agency CNA #103 revealed the previous aide left her shift at 11:00 P.M. and that was when he assumed care for Resident #50. He stated Resident #50 had been on her call light all evening requesting incontinence care, a drink, and to be repositioned as she had reported being uncomfortable. He stated he had checked her last on [DATE] between midnight and 1:00 A.M. as she had stopped pressing the call light. CNA#103 revealed the resident appeared to be sleeping during this observation check. He acknowledged he did not check in with her again prior to Resident #50 being found unresponsive in her room at 5:30 A.M. Agency CNA #103 stated LPN #79 and RN #75 went into the room to assess her and check her vital signs after Resident #50 was found unresponsive and he revealed he stepped into the room as well, but the nurses were already in there and there was nothing for him to do. The nursing staff did not request his assistance and did not ask him to get any documentation or equipment related to Resident #50. He walked out of the room and went to care for other residents, and he did not really see Resident #50 and had no information on what she looked like or felt like upon finding her unresponsive. During an interview on [DATE] at 4:55 P.M., RN #75 stated she had never seen or cared for Resident #50 during her admission at the facility. LPN #79 came to her on [DATE] during morning medication administration and stated Resident #50 was found unresponsive, and she was unsure of the resident's code status and was unable to find it. RN #75 stated she went to Resident #50's room to check her vital signs and confirmed she did not check or verify the resident's code status and did not attempt to check the code status in the medical record. She confirmed CPR was not completed and 911was not contacted and she was unable to state why. She was asked to check the resident's vital signs and Resident #50 was lying on her side in bed. She used her stethoscope to check for vital signs and signs of life and did not move the resident during this assessment. RN #75 was unsure if Resident #50 was cold or stiff as she did not touch her or move her. She did not observe the bedside LPN #79 move the resident and was quickly in and out of the room because she was busy with medication pass. Resident #50 was grayish looking. LPN #79 was the one to call the doctor, the DON, and the family, and she was not around when the calls took place. She confirmed the nurse called time of death, then corrected herself stating the physician would have to call the time of death, but the nurse would put the time for the death certificate. LPN #79 mentioned Agency CNA #103 was making himself scarce during the shift and was hard to locate. RN #75 verified if a resident was a full code, CPR should be initiated and 911 should be contacted if they were found unresponsive without a heartbeat. RN #75 stated the outcome may have been different with more frequent monitoring or checks but revealed she was unsure if CPR would have been effective.During an interview on [DATE] at 4:15 P.M., the DON confirmed no staff had reported any signs that rigor mortis had set in when Resident #50 was found unresponsive on [DATE]. Review of the facility policy titled Additional Code status/Change in condition education points, dated [DATE], revealed when checking for code status's staff should check the active order profile first. The code status shall also be published onto the point of care dashboard for nurses. When a resident has a Code status of Do-Not Resuscitate Comfort Care (DNRCC) or DNRCC-Arrest (DNRCCA) the provider signed document shall be scanned into the medical record. In the absence of a signed DNR document, the resident shall be considered a Full Code. A resident who was Full Code shall have resuscitation attempts started immediately upon noting absence of vital signs. Resuscitation attempts shall be initiated regardless of temperature or lividity of the body. Staff shall promptly call 911, the provider assigned and the emergency contact for the resident. Staff must round at a minimum every two hours to check on residents for any possible changes in condition which include, but are not limited to change in breathing, new onset pain, altered mental status, vomiting, bleeding, fever, chills, sweating, or other abnormal changes from baseline. Changes must be promptly reported to the nurse, and the nurse will promptly assess the resident and report abnormal findings to the medical provider. Review of facility policy titled Code Status Education, dated [DATE], revealed Code status's included Full Code, DNRCC and DNRCCA. The Full Code status included all medical interventions including CPR, defibrillation, and artificial ventilation shall be performed to keep the resident alive. Any resident who was a Full Code shall have resuscitation attempts started immediately upon absence of vital signs. The code status can be revoked or changed by the resident or representative at any time. Residents without a designated signed DNR shall be considered a Full Code. In Ohio, CPR must continue until trained medical professionals take over, the patients is resuscitated, or a valid DNR order is presented. This deficiency represents non-compliance investigated under Complaint Number 2983896.

Based on observation of facility crash cart (a mobile cart utilized in emergency situations that contains emergency medications and equipment), review of the crash cart binder, interview, and review of facility policy, the facility failed to maintain emergency patient care medications and equipment in safe operating condition. This had the potential to affect all residents. The census was 48.Findings Include:Observation of the facility crash cart on [DATE] at 3:47 P.M. revealed the following expired items: suction machine with a sticker indicating the next inspection was due on 02/2026, five packets of iodine with an expiration date of 02/2025, one bottle of aspirin with an expiration date of 08/2025, one biohazard spill kit with an expiration date [DATE], 11 airway tubes with expiration dates of [DATE], one suction tip with a use by year of 2024, suction tubing with use by year of 2024, small bore extension kits with expiration years of 2025, one central line dressing kit with an expiration year of 2023, and a heat pack with an expiration date of 08/2025. During observation of crash cart, an interview with the Director of Nursing (DON) confirmed that the suction machine was past due for the next inspection and confirmed the above listed expired supplies. The DON stated that she believed the expiration dates were the manufacturing dates. The DON stated that the facility completed monthly checks of the contents of the crash cart. The DON stated that she kept a binder with a checklist of all the equipment that was supposed to be housed on the crash cart.Review of the crash cart binder revealed three crash cart checklists dated [DATE], [DATE] and February 2025. Review of the crash cart checklist dated [DATE] revealed check marks documented for all equipment on the checklist. No expiration dates were noted on the crash cart checklist.On [DATE] at 8:56 A.M. a policy for crash cart maintenance was requested from Office Manager #105. Interview with Office Manager #105 on [DATE] at 9:43 A.M. confirmed that the facility had no policy regarding the crash cart, crash cart audits, or crash cart maintenance.Review of the undated facility policy titled Crash Cart Audit Policy and Procedure revealed the facility will ensure that all crash carts are maintained in a state of readiness at all times. The policy stated that any missing, expired, or damaged items will be replaced promptly and that a trained staff member will maintain a running inventory of expiration dates for all applicable crash cart supplies. The trained staff member will monitor upcoming expiration dates routinely and identify items that are nearing expiration.

Based on closed record review, review of self reported incidents (SRI), staff interview, and policy review, facility failed to ensure a concern of resident neglect was reported to the State agency. This affected one resident (#50) of three reviewed for resident death. The facility census was 48. Findings include:Review of the medical record for Resident #50 revealed an admission date of [DATE]. Diagnoses included nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition.Review of the plan of care dated [DATE] revealed Resident #50 had a full code advanced directive with interventions to call nine-one-one (911) in the event the resident's heart stopped and start Cardiopulmonary Resuscitation (CPR) if the resident was not breathing or had no pulse, and to start oxygen and or life-saving breaths via an artificial manual breathing unit (ambu) bag if the resident stopped breathing. It also included interventions to keep a copy of the resuscitation wishes in the medical record and to notify the physician and family if the resident stopped breathing or her heart stopped. Review of the care plan dated [DATE] revealed Resident #50 was at risk for alteration in skin integrity related to diabetes, incontinence, self mobility problems and long term use of steroids with interventions to be turned and repositioned every two hours. Review progress notes dated [DATE] at 5:30 A.M. from Licensed Practical Nurse (LPN) #79 revealed during morning medication pass, Resident #50 was found to be nonresponsive with no communication. The nurse at bedside noted the resident to be cool to touch and attempted to take vital signs. No blood pressure, pulse or respirations were identified. A second nurse (Registered Nurse (RN) #75) verified. No heartbeat or breath sounds were noted. A text message was sent to the Director of Nursing (DON) and the Nurse Practitioner #225 and spouse were made aware. Review of the medical record found no evidence of any identified change in condition for Resident #50 prior to her death and documentation did not state the last time resident was checked on and last seen or cared for.Review of the Self-Reported Incidents located on the Enhanced Information Dissemination Collection (a database used to report information, including facility self-reportable incidents, directly to the state survey agency) revealed no self-reported incidents were generated by the facility notifying the State agency of an allegation of neglect related to Resident #50's death.Interview on [DATE] at 10:19 A.M. with Certified Nursing Assistant (CNA) #94 revealed she worked night shift on [DATE] and stated an Agency Aide working on another hall was not taking care of residents appropriately. She revealed the CNA was sitting down at the desk or missing frequently and was difficult to find. She reported she offered to help on a few occasions, and either was unable to locate the CNA or found him sitting and not providing care. She revealed LPN #79 informed her of Resident #50 being found unresponsive and she was trying to find the nurse (RN #75) to confirm the lack of vital signs. At this time CNA #94 asked the assigned CNA when he last saw her and he reported [DATE] at 11:20 P.M. She stated that CNA had not worked since this incident. Interview on [DATE] at 10:40 A.M. and 11:30 A.M. with the Director of Nursing (DON) revealed Agency CNA #103 was the CNA working on night shift from [DATE] into [DATE]. She confirmed Agency CNA #103 was Resident #50's assigned CNA. The DON reported she identified the facility staff did not check on Resident #50 timely and it was unknown how long Resident #50 was unresponsive before being found at 5:30 A.M. She revealed when she was alerted by phone on [DATE] around 7:00 A.M. she asked the nurse when she last saw resident alive and LPN #79 informed her around 12:00 midnight was her last observation of Resident #50 before she was found unresponsive at 5:30 A.M. and the nurse informed the DON she was unsure when CNA #103 last cared for the resident prior to her death. The DON confirmed facility staff did not follow up to confirm with CNA #103 about the last time he saw her alive and well. The DON confirmed her expectation of staff checking on residents at least every two hours and laying eyes on residents to confirm safety. The DON confirmed Resident #50 was not cared for and checked on in a timely manner. Interview on [DATE] at 11:49 A.M. with Hospitality Aide (HA) #98 revealed she had worked part of the shift with CNA #103 and reported he was not tending to resident's needs and was not following up timely with requests for resident care. She reported concerns related to lack of care and monitoring and the residents' unforeseen death. Interview on [DATE] at 6:40 A.M. with CNA #131 and CNA #135 revealed they worked night shift and confirmed the facility expectation for residents to be observed and checked on every one to two hours, including on the night shift. Interview on [DATE] at 11:00 A.M. with the DON confirmed the facility had not placed Agency CNA #103 on the do not return list from his agency, but reported he would not be returning. She also verified the investigation had not been completed for Resident #50's death and/or allegation of neglect due to lack of timely care. The DON stated she would begin an investigation on this date.Interview on [DATE] at 1:55 P.M. with Agency CNA #103 revealed the previous aide left her shift at 11:00 P.M. and that was when he assumed care for Resident #50. He revealed Resident #50 had been on her call light all evening requesting incontinence care, a drink, and to be repositioned as she had reported being uncomfortable. He revealed he had checked her last on [DATE] between midnight and 1:00 A.M. as she had stopped pressing the call light. CNA revealed the resident appeared to be sleeping during this observation check. He acknowledged he did not check in with her again prior to Resident #50 being found unresponsive in her room at 5:30 A.M. CNA #103 revealed LPN #79 and RN #75 went into the room to assess her and check her vital signs after Resident #50 was found unresponsive and he revealed he stepped into the room as well, but the nurses were already in there and there was nothing for him to do. Interview on [DATE] at 4:55 P.M. with RN #75 revealed LPN #79 came to her on [DATE] during morning medication administration and stated Resident #50 was found unresponsive. RN #75 reported LPN #79 had mentioned CNA #103 was making himself scarce during the shift and was hard to locate. She stated the outcome may have been different with more frequent monitoring or checks.Interviews on [DATE] at 2:00 P.M. and at 4:15 P.M. with the DON acknowledged not checking on a resident for an extended period of time would be considered neglect and the DON confirmed no self-reported incident (SRI) had been initiated and reported to the State agency related the Resident #50's care the night of her death. Review of the undated facility policy titled Policy and Procedure on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property revealed Policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries from an unknown source. Additionally, the facility should immediately report all such allegations to the administrator and/or designee. The administrator/designate will report the allegations to the State agency. Mistreatment of a resident is defined as inappropriate treatment or exploitation of a resident. Neglect was defined as the willful failure of the facility, its employees, or the facility service providers, to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, this policy notes in response to allegations of abuse, neglect, exploitation, or mistreatment, the administrator and/or designee of the facility will report to the State agency in accordance with state law and they also must have evidence that the alleged violations are thoroughly investigated and they must report the results of all investigations to the administrator and/or his designated representative and to the other officials in accordance with state law including the State survey agency within five working days of the incident.This deficiency represents an example of continued noncompliance from the survey dated [DATE].

Based on closed record review, review of facility self reported incidents (SRI), staff interview, and policy review, facility failed to ensure a concern of resident neglect was thoroughly investigated. This affected one resident (#50) of three reviewed for resident death. The facility census was 48. Findings include:Review of the medical record for Resident #50 revealed an admission date of [DATE]. Diagnoses included nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition.Review of the plan of care dated [DATE] revealed Resident #50 had a full code advanced directive with interventions to call nine-one-one (911) in the event the resident's heart stopped and start Cardiopulmonary Resuscitation (CPR) if the resident was not breathing or had no pulse, and to start oxygen and or life-saving breaths via an artificial manual breathing unit (ambu) bag if the resident stopped breathing. It also included interventions to keep a copy of the resuscitation wishes in the medical record and to notify the Physician and family if the resident stopped breathing or her heart stopped. Review of the care plan dated [DATE] revealed Resident #50 was at risk for alteration in skin integrity related to diabetes, incontinence, self mobility problems and long term use of steroids with interventions to be turned and repositioned every two hours. Review progress notes dated [DATE] at 5:30 A.M. from Licensed Practical Nurse (LPN) #79 revealed during morning medication pass, Resident #50 was found to be nonresponsive with no communication. The nurse at bedside noted the resident to be cool to touch and attempted to take vital signs. No blood pressure, pulse or respirations were identified. A second nurse (Registered Nurse (RN) #75) verified. No heartbeat or breath sounds were noted. A text message was sent to the Director of Nursing (DON) and the Nurse Practitioner #225 and spouse were made aware. Review of the medical record found no evidence of any identified change in condition for Resident #50 prior to her death and documentation did not state the last time resident was checked on and last seen or cared for.Review of facility investigation documents and Self-Reported Incidents located on the Enhanced Information Dissemination Collection (a database used to report information, including facility self-reportable incidents, directly to the state survey agency) revealed no documented evidence of an investigation into Resident #50's death or neglect.Interview on [DATE] at 10:19 A.M. with Certified Nursing Assistant (CNA) #94 revealed she worked night shift on [DATE] and stated an Agency Aide working on another hall was not taking care of residents appropriately. She revealed the CNA was sitting down at the desk or missing frequently and was difficult to find. She reported she offered to help on a few occasions, and either was unable to locate the CNA or found him sitting and not providing care. She revealed LPN #79 informed her of Resident #50 being found unresponsive and she was trying to find the nurse (RN #75) to confirm the lack of vital signs. At this time, CNA #94 asked the assigned CNA when he last saw her and he reported [DATE] at 11:20 P.M. Interview on [DATE] at 10:40 A.M. and 11:30 A.M. with the Director of Nursing (DON) revealed an Agency CNA #103 was the CNA working on night shift from [DATE] into [DATE]. She confirmed Agency CNA #103 was Resident #50's assigned CNA. The DON reported she identified the facility staff did not check on Resident #50 timely and it was unknown how long Resident #50 was unresponsive before being found at 5:30 A.M. The DON confirmed an investigation was not completed. She revealed when she was alerted by phone on [DATE] around 7:00 A.M. she asked the nurse when she last saw resident alive and LPN #79 informed her around 12:00 midnight was her last observation of Resident #50 before she was found unresponsive at 5:30 A.M. and the nurse informed the DON she was unsure when CNA #103 last cared for the resident prior to her death. The DON confirmed facility staff did not follow up to confirm with CNA #103 about the last time he saw her alive and well. The DON confirmed her expectation of staff checking on residents at least every two hours and laying eyes on residents to confirm safety. The DON confirmed Resident #50 was not cared for and checked on in a timely manner. Interview on [DATE] at 11:49 A.M. with Hospitality Aide (HA) #98 revealed she had worked part of the shift with CNA #103 and reported he was not tending to resident's needs and was not following up timely with requests for resident care. She reported concerns related to lack of care and monitoring and the residents' unforeseen death. Interview on [DATE] at 11:00 A.M. with the DON confirmed the facility had not placed Agency CNA #103 on the do not return list from his agency, but reported he would not be returning. She also verified the investigation had not been completed for Resident #50's death and/or allegation of neglect due to lack of timely care. The DON stated she would begin an investigation on this date.Interview on [DATE] at 1:55 P.M. with Agency CNA #103 revealed the previous aide left her shift at 11:00 P.M. and that was when he assumed care for Resident #50. He revealed Resident #50 had been on her call light all evening requesting incontinence care, a drink, and to be repositioned as she had reported being uncomfortable. He revealed he had checked her last on [DATE] between midnight and 1:00 A.M. as she had stopped pressing the call light. CNA #103 revealed the resident appeared to be sleeping during this observation check. He acknowledged he did not check in with her again prior to Resident #50 being found unresponsive in her room at 5:30 A.M. CNA #103 revealed LPN #79 and RN #75 went into the room to assess her and check her vital signs after Resident #50 was found unresponsive and he revealed he stepped into the room as well, but the nurses were already in there and there was nothing for him to do. Interview on [DATE] at 4:55 P.M. with RN #75 revealed LPN #79 came to her on [DATE] during morning medication administration and stated Resident #50 was found unresponsive. RN #75 reported LPN #79 had mentioned CNA #103 was making himself scarce during the shift and was hard to locate. She stated the outcome may have been different with more frequent monitoring or checks.Interviews on [DATE] at 2:00 P.M. and at 4:15 P.M. with the DON acknowledged not checking on a resident for an extended period of time would be considered neglect.Review of the undated facility policy titled Policy and Procedure on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property revealed Policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries from an unknown source. Additionally, the facility should immediately report all such allegations to the administrator and/or designee. Mistreatment of a resident is defined as inappropriate treatment or exploitation of a resident. Neglect was defined as the willful failure of the facility, its employees, or the facility service providers, to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, this policy notes in response to allegations of abuse, neglect, exploitation, or mistreatment, the administrator and/or designee of the facility will report to the State agency in accordance with state law and they also must have evidence that the alleged violations are thoroughly investigated and they must report the results of all investigations to the administrator and/or his designated representative and to the other officials in accordance with state law including the State survey agency within five working days of the incident.This deficiency represents an example of continued noncompliance from the survey dated [DATE].

Based on record review, observation, interviews, and review of facility policy, the facility failed to report an allegation of an injury of unknown origin to the State Survey Agency as required. This affected one (Resident #49) of three residents reviewed for abuse. The facility census was 48.|Findings include: Review of the medical record for Resident #49 revealed an admission date of 02/03/17 with diagnoses including Alzheimer's Disease with late onset, protein calorie malnutrition, major depressive disorder and chronic kidney disease.Review of Resident #49's care plan last revised on 07/15/24 revealed the resident had difficulty integrating information during conversation due to cognitive problems and she was extensive/dependent for all care. Interventions included monitor for skin concerns during care. Report all found.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with eating and bed mobility and dependent on staff for showering/bathing, hygiene, and transfers.Review of facility incident report dated 02/26/26, revealed a bruise to Resident #49's right cheek. The incident report indicated daughter in reporting seeing light purple bruising to right cheek. No nature of incident was indicated in the report. Further review of the incident report, completed by the DON revealed the area could have been a line created if her right cheek had rested on a side rail during incontinence care. Interviews conducted with staff members revealed no evidence of Resident #49's face coming in contact with the bed rail.Further review of the medical record revealed no mention of the bruise to the resident's right cheek. No skin assessment was completed on 02/26/26, after the area was identified.Review of the February 2026 incident/accident log revealed no documentation of the resident's bruising to her right cheek. Review of the Self-Reported Incidents located on the Enhanced Information Dissemination Collection (a database used to report information, including facility self-reportable incidents, directly to the state survey agency) for February 2026 through March 2026 revealed no self-reported incidents were generated by the facility related to Resident #49 and the discoloration to her right cheek.On 03/18/26 at 10:18 A.M. Resident #49 was observed lying in bed. No areas of discoloration were noted to the resident's right cheek.Interview on 03/18/26 at 1:30 P.M. with Family member #160 revealed she visited Resident #49 on 02/26/26. Upon entering the room, a staff member was assisting Resident #49 with lunch and Family member #160 noticed a bruise on Resident #49's right cheek. She stated she took a picture then spoke to Registered Nurse (RN) #102, who stated to the family member it appeared to be an age spot. The Director of Nursing (DON) came to assess the area and stated to the family member the area could have been caused by the bedrail during care. The DON told Family member #160 she would perform an investigation and provide staff education for Resident #49 to require two staff members for all care.Interview on 03/19/26 at 9:46 A.M. with RN #102 revealed she was working the day Resident #49's daughter came in and stated she saw a bruise on Resident #49's face. The area was discolored, and the RN reported it to the DON. The RN denied noticing the area earlier in the day. Interview on 03/19/26 at 9:54 A.M. with Family member #170 revealed the DON had contacted her on 02/26/26 regarding the potential bruise and she would perform an investigation, but no information was provided how the facility planned to prevent further incidents.Interview on 03/19/26 at 3:00 P.M. with the DON verified no self-reported incident (SRI) was submitted by the facility related to the discoloration/bruise noted to the resident's right cheek as an allegation of an injury of unknown origin.Review of facility policy titled Abuse policy, last revised 04/12, revealed Investigation will be completed by social services and/or Director of Nurses, and Ohio Department of Health will be notified within 24 hours and investigation completed by five days.This deficiency represents non-compliance investigated under Complaint Number 2733229.

Based on observation, medical record review, facility policy review, and interview, the facility failed to complete a thorough investigation following an allegation of an injury of unknown origin. This affected one (#49) of three residents reviewed for abuse. The facility census was 48.Findings include: Review of the medical record for Resident #49 revealed an admission date of 02/03/17 with diagnoses including Alzheimer's Disease with late onset, protein calorie malnutrition, major depressive disorder and chronic kidney disease.Review of Resident #49's care plan last revised on 07/15/24 revealed the resident had difficulty integrating information during conversation due to cognitive problems and she was extensive/dependent for all care. Interventions included monitor for skin concerns during care. Report all found.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with eating and bed mobility and dependent on staff for showering/bathing, hygiene, and transfers.Review of facility incident report dated 02/26/26, revealed a bruise to Resident #49's right cheek. The incident report indicated daughter in reporting seeing light purple bruising to right cheek. No nature of incident was indicated in the report. Further review of the incident report, completed by the DON revealed the area could have been a line created if her right cheek had rested on a side rail during incontinence care. Interviews conducted with staff members revealed no evidence of Resident #49's face coming in contact with the bed rail. Further review of the information provided by the facility revealed Certified Nursing Assistant (CNA) #116, #117, #119, #120, #121, #122 and #123's interviews did not indicate dates or times of their interviews; CNA #358's witness statement (conducted via phone by the Director of Nursing) did not contain her last name or title; and no physical assessments for abuse were conducted of non-interviewable residents to ensure no other residents were affected.Review of the facility's incident/accident log revealed no evidence of a bruise to Resident #49's cheek.Further review of the medical record revealed no mention of the bruise to the resident's right cheek. No skin assessment was completed on 02/26/26, after the area was identified.On 03/18/26 at 10:18 A.M. Resident #49 was observed lying in bed. No areas of discoloration were noted to the resident's right cheek.Interview on 03/18/26 at 1:30 P.M. with Family member #160 revealed she visited Resident #49 on 02/26/26. Upon entering the room, a staff member was assisting Resident #49 with lunch and Family member #160 noticed a bruise on Resident #49's right cheek. She stated she took a picture then spoke to Registered Nurse (RN) #102, who stated to the family member it appeared to be an age spot. The Director of Nursing (DON) came to assess the area and stated to the family member the area could have been caused by the bedrail during care. The DON told Family member #160 she would perform an investigation and provide staff education for Resident #49 to require two staff members for all care.Interview on 03/19/26 at 9:46 A.M. with RN #102 revealed she was working the day Resident #49's daughter came in and stated she saw a bruise on Resident #49's face. The area was discolored, and the RN reported it to the DON. The RN denied noticing the area earlier in the day. Interview on 03/19/26 at 9:54 A.M. with Family member #170 revealed the DON had contacted her on 02/26/26 regarding the potential bruise and she would perform an investigation, but no information was provided how the facility planned to prevent further incidents.Interview on 03/19/26 at 3:00 P.M. with the DON verified the incident report provided by the facility was the full investigation, no other residents were assessed for injuries, no written education was provided to staff for further prevention of re-occurrence, and no documentation was in Resident #49's medical record related to the discoloration/bruise noted to the resident's right cheek. Review of facility policy titled Abuse policy, last revised 04/12, revealed all investigations of abuse will be thoroughly investigated. Request written statements from all persons involved in reporting, witnessing and intervening in abuse situations. All statements must be returned to the DON office within 24 hours. Investigation will be completed by social services and/or Director of Nurses. This deficiency represents non-compliance investigated under Complaint Number 2733229.

Based on record review, review of facility policy and interviews, the facility failed to ensure showers were provided to dependent residents as scheduled and/or per plan of care. This affected two residents (Resident #38 and #49) of three residents reviewed for activities of daily living. The census was 48.Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 01/06/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, tremors, anxiety disorder, and major depressive disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13. The resident was assessed to require assistance with all activities of daily living (ADL's).Review of Resident #38's care plan last revised on 02/11/26 revealed resident required assistance with bathing, hygiene and dressing. Interventions included shower days were Mondays and Fridays.Review of the shower schedule provided by the facility revealed Resident #38's shower days were scheduled Mondays and Fridays.Review of the shower sheets revealed Resident #38 received showers on 01/09/26, 02/06/26, 02/09/26, 02/20/26, 02/23/26 and 03/06/26.Review of the Certified Nursing Assistant (CNA) Point of Care (POC) revealed no evidence Resident #38 received showers since her admission to the facility.Interview on 03/18/26 at 10:24 A.M. with Resident #38 revealed she did not get her showers as scheduled. She reported she was lucky getting one once a week and stated it upset her that she didn't get her two showers per week as planned on Mondays and Fridays.Interview on 03/23/26 at 11:30 A.M. with the Director of Nursing (DON) verified the missing shower documentation for Resident #38. The DON verified showers are to be provided to the residents as care planned, requested and as needed unless refusals are documented. 2. Review of the medical record for Resident #49 revealed an admission date of 02/03/17 with diagnoses including Alzheimer's Disease with late onset, protein calorie malnutrition, major depressive disorder and chronic kidney disease.Review of Resident #49's care plan last revised on 07/15/24 revealed resident required increased assistance with care. Interventions included resident is totally/nearly dependent on staff for bathing, hygiene, and dressing.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. The resident was assessed to require substantial/maximal assistance with eating and bed mobility and dependent on staff for showering/bathing, hygiene, and transfers.Review of the shower schedule provided by the facility revealed Resident #49's shower days were scheduled on Tuesdays and Saturdays.Review of shower documentation revealed no shower being provided on 01/06/26, 01/13/26, 01/17/26, 01/24/26, 01/27/26, and 01/31/26, 02/10/26, 02/17/26, 02/21/26, 02/24/26, 02/28/26 and 03/03/26.Review of the nurse progress notes revealed no documentation to support the resident's refusal of her showers or the facility's attempt again later.Interview on 03/18/26 at 1:30 P.M. with Resident #49's daughter stated the staff tell her the resident refuses showers but the resident doesn't speak and the daughter was confused as to how the resident would refuse her showers. The daughter stated the resident needed showered her planned two times a week to maintain hygiene. Interview on 03/23/26 at 11:30 A.M. with the DON verified the missing shower documentation Resident #49. The DON verified showers are to be provided to the residents as care planned, requested and as needed unless refusals are documented. Review of facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities, not dated, revealed It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each residents preferences, choices, values and beliefs.This deficiency represents non-compliance investigated under Complaint Number 2733229.

Based on record review, observation, interview, and policy review the facility failed to ensure meal intakes were documented to ensure residents maintained appropriate nutritional parameters to prevent potential weight loss and meet nutritional needs. This affected three residents (Resident #44, #49 and #53) of three residents reviewed for nutrition. The facility census was 48.|Findings include: 1. Review of the medical record for Resident #44, revealed an initial admission date of 11/22/23 and a readmission date of 10/31/25 with diagnoses including Huntington's disease, dysphagia, abnormal weight loss, bipolar disorder and adult failure to thrive.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed to require dependent on staff for eating, toileting hygiene, shower/bathing, all ADLs, bed mobility, and transfers.Review of Resident #44's care plan last revised on 03/05/26 revealed resident is at nutrition risk, risk for altered fluid maintenance/dehydration risk for significant weight loss, related to Huntington's disease, anemia, anxiety, history of abnormal weight loss. She consumes less than 75% of diet at times, uses mechanically altered diet, needs assistance with meals, Low body mass index (BMI), and abnormal labs. Interventions included monitoring percentages of meals consumed and documenting each meal.Review of the resident's meal percentage for January 2026 revealed no documented meal percentage intakes for 01/02/26, 01/08/26, 01/26/26, 01/27/26 for dinner; 01/09/26 for breakfast and 01/13/26 for lunch and dinner.Review of the resident's meal percentages for February 2026 revealed no documented meal percentage intakes for 02/04/26, 02/05/26, 02/06/26, 02/10/26, 02/17/26, 02/19/26 for dinner; 02/11/26 for lunch and dinner; 02/20/26 for breakfast and lunch; 02/21/26 for breakfast, lunch and dinner and 02/22/26 for lunch and dinner. Review of the resident's meal percentages for March 2026 revealed no documented meal percentage intakes for 03/04/26, 03/08/26, 03/10/26 and 03/17/26 for dinner; 03/05/26 for breakfast, lunch and dinner and 03/06/26 for breakfast.Interview on 03/19/26 at 9:58 A.M with Certified Nursing Assistant (CNA) #122 revealed meal intakes are recorded after the meal is complete and she does not leave her shift until her documentation is completed.Interview on 03/23/26 at 11:30 A.M. with the Director of Nursing (DON), revealed the aides are expected to do charting daily, including the meal percentages. The DON verified meal percentages are used to monitor a resident's nutritional status.2. Review of the medical record for Resident #49 revealed an admission date of 02/03/17 with diagnoses including Alzheimer's Disease with late onset, protein calorie malnutrition, major depressive disorder and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. The resident was assessed to require substantial/maximal assistance with eating and bed mobility and dependent on staff for showering/bathing, hygiene, and transfers.Review of Resident #49's care plan last revised on 12/31/25 revealed resident is at malnutrition risk, altered fluid maintenance /dehydration, and significant weight loss related to diagnoses of malnutrition, Alzheimer's disease, chronic kidney disease stage two, anxiety, dementia with delusions, depression, needs assistance with meals, and use of mechanically altered diet. Interventions included monitoring percentages of meals consumed and document each meal.Review of the resident's meal percentage for January 2026 revealed no documented meal percentage intakes for 01/02/26 for breakfast.Review of the resident's meal percentages for February 2026 revealed no documented meal percentage intakes for 02/04/26, 02/11/26, 02/16/26, and 02/17/26 for dinner; 02/19/26 for breakfast and dinner and 02/22/26 and 02/24/26 for lunch and dinner.Review of the resident's meal percentages for March 2026 revealed no documented meal percentage intakes for 03/08/26 for dinner.Interview on 03/19/26 at 9:58 A.M with CNA #122 revealed meal intakes are recorded after the meal is complete and she does not leave her shift until her documentation is complete.Interview on 03/23/26 at 11:30 A.M. with the Director of Nursing (DON), revealed the aides are expected to do charting daily, including the meal percentages. The DON verified meal percentages are used to monitor a resident's nutritional status.3. Review of the medical record for Resident #53, revealed an admission date of 06/29/24 with diagnoses including non-traumatic subdural hemorrhage, visual hallucinations, Down syndrome, chronic pain syndrome, and left foot drop. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. The resident was assessed to require dependent on eating, all ADL's and transfers.Review of Resident #53's care plan last revised on 12/31/25 revealed resident is at malnutrition risk, altered fluid maintenance /dehydration, and significant weight loss related to diagnoses of seizure-like activity, Down syndrome, consumes less than 75% of meals and needs assistance with meals. Interventions included monitoring percentages of meals consumed and document each meal.Review of the resident's meal percentage for January 2026 revealed no documented meal percentage intakes for 01/02/26, 01/09/26, 01/23/26, 01/26/26 and 01/27/26 for dinner and 01/08/26 for lunch and dinner.Review of the resident's meal percentages for February 2026 revealed no documented meal percentage intakes for 02/04/26, 02/05/26, 02/06/26, 02/18/26, 02/23/26, and 02/24/26 for dinner; 02/10/26, 02/21/26, and 02/22/26 for breakfast, lunch and dinner; 02/11/26, 02/17/26 and 02/19/26 for breakfast and dinner and 02/20/26 for breakfast and lunch.Review of the resident's meal percentages for March 2026 revealed no documented meal percentage intakes for 03/04/26 for breakfast and dinner; 03/08/26 and 03/10/26 for dinner and 03/17/26 for breakfast, lunch and dinner.Interview on 03/19/26 at 9:58 A.M with CNA #122 revealed meal intakes are recorded after the meal is complete and she does not leave her shift until her documentation is complete.Interview on 03/23/26 at 11:30 A.M. with the Director of Nursing (DON), revealed the aides are expected to do charting daily, including the meal percentages. The DON verified meal percentages are used to monitor a resident's nutritional status.Review of facility policy titled Nutrition Documentation Overview, not dated, revealed Nutrition documentation shall be completed on all residents in accordance with state and federal regulations and meet standards of practice.This deficiency represents non-compliance investigated under Complaint Number 2733229.

Based on observation, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The census was 53. Finds Included: Observation on 02/18/25 at 8:37 A.M. of the kitchen with the Dietary Manager #300 revealed serving pans of various sizes were being stored wet. There were six serving pans stacked on the shelf that were still wet. Interview on 02/18/25 at 8:40 A.M. with the Dietary Manager #300 verified after serving dishes are washed they have to be air dried completely before being stacked and put away. Review of the facility policy Cleaning Dishes/Dish Machine, dated 2023 revealed dishes should be air dried on the dish racks, not dried with towels. Dishes are to be inspected for cleanliness and dryness and put dishes away. Dishes should not be nested unless they are completely dry.

Based on observation, water management plan review and interview, the facility failed to maintain a comprehensive water management plan and utilize appropriate disinfectants to prevent the spread of communicable disease. This had the potential to affect all residents who reside in the facility. The facility census was 53. Findings include: 1. Review of the undated Water Management Plan revealed it was not descriptive of the facility. The plan did not detail limits or control measures. The Water Management Plan excluded the basement and fixtures such as the backflow prevention device in the Water Management Plan flow diagrams. Review of the empty room water temperature checks revealed the water temperature checks were not completed in January, March, and April of 2024. Interview on 02/20/25 at 3:15 P.M. with the Administrator revealed the Water Management Plan is a template and in development. The Administrator revealed he would have it completed in the next month. The Administrator also revealed the minimum water temperature they test for is not indicated in the Water Management Plan. The Administrator revealed the basement floor plan is not included in the Water Management Plan flow diagrams. The Administrator confirmed that empty room water checks were missed in some months last year. Review of the Worksheet to Identify Buildings at Increased Risk for Legionella Growth and Spread dated 09/26/24 revealed the facility water safety plan or Legionella prevention program was in progress. 42015 2. Observation on 02/20/25 at 2:20 P.M. revealed Housekeeper #337 cleaning a resident's room. The resident was in isolation for Clostridium Difficile (C-diff) (a very contagious infection that causes diarrhea and inflammation of the colon). Observed on the housekeeping cart was several cleaning supplies. Interview on 02/20/25 at 2:22 P.M. with Housekeeper #337 stated she was trained to use Clorox Clean-Up Disinfectant with Bleach to clean resident rooms with C. diff. Observation of the bottle efficacy label did not list C. diff as a bacteria that it was effective against. Interview on 02/20/25 at 3:15 P.M. with Housekeeping Supervisor #240 confirmed she investigated the product and it does not kill the bacteria C. Diff. She reported it had been awhile since they had a case but when they did she instructed staff members to use bleach or the Clorox Clean-Up Disinfectant with Bleach. She verified she would need to retrain staff and order additional cleaning supplies that will kill the bacteria. Interview on 02/20/25 at 3:20 P.M. with Registered Nurse #254, who identified herself as the infection control nurse, verified the facility did not have an outbreak of C. diff. She stated the facility would retrain the housekeeping staff on appropriate cleaning agents to use that will be effective against killing the bacteria.

Based on record review, staff interview, resident interviews and policy review the facility failed to provide showers per resident preference. This affected six of six residents (Resident #19, #21, #26, #30, #43, and #47) reviewed for showers. The census was 53. Findings Include: 1. Review of the medical record for Resident #47 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the right dominant side and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact and under the area of preferences Resident #47 indicated it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's cognition, according to subsequent MDS Assessments, has remained intact. Review of the care plan dated 06/07/24 revealed Resident #47 required assistance for bathing related to physical limitation and weakness. Interventions included bathing (required) one person and is totally dependent on bathing, prefers showers and ensure hair is washed and nails are manicured on bathing day. Review of the progress notes from 01/21/25 through 02/19/25 revealed no documentation regarding the resident refusing showers. Review of the task tab in the medical record revealed Resident #47 received bathing needs with one assistance on Monday and Thursday on evening shift. Review of the shower log from 01/21/25 through 02/18/25 revealed Resident #47 received bed baths on 01/21/25, 01/22/25, 01/25/25, 01/26/25, 01/27/25, 01/29/25, 01/31/25, 02/03/25, 02/04/25, 02/06/25, 02/08/25, 02/09/25, 02/13/25, 02/14/25, 02/16/25, 02/17/25, 02/18/25. No showers were given. Interview on 02/18/25 at 12:47 P.M. with Resident #47 revealed he does not receive a shower. Resident #47 stated he would like a shower at least once a week. The staff will wash him up but he does not get a shower. Interview on 02/19/25 at 3:00 P.M. with the Director of Nursing (DON) verified Resident #47 did not receive showers according to Resident #47's preference. Residents should be receiving showers at least twice a week. The DON verified Resident #47 had not received a shower in the last 30 days. 2 Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnosis included chronic kidney disease stage 3, atrial fibrillation and muscle weakness. Review of the admission MDS dated [DATE] revealed Resident #30 had intact cognition. Under preferences revealed choosing between a tub bath, shower, bed bath or sponge bath is very important. Review of the plan of care dated 12/30/24 revealed Resident #30 had an activity of daily living (ADL's) performance deficit. requiring assistance with bathing, hygiene and dressing. Interventions included staff to set up equipment and assist as needed for bathing, dressing and hygiene. Review of the task tab in the medical records revealed Resident #30's bathing needs were on Tuesday and Friday, on evening shift with one assist of staff. Review of the progress notes from 11/30/24 revealed no progress note on refusing showers. Review of the shower log from 01/21/25 through 02/19/25 revealed Resident #30 received bed baths on 01/21/25, 01/22/25, 01/25/25, 01/26/25, 01/27/25, 01/29/25, 01/31/25, 02/04/25, 02/06/25, 02/0825, 02/09/25, 02/13/25, 02/14/25, 02/17/25 and 02/18/25. Resident #30 received a shower once on 02/07/25. Interview on 02/18/25 at 1:04 P.M. with Resident #30 revealed he is not getting showers like he wants, once or twice a week would be nice. Staff will wash him but that is all and they want to come in at 10:30 P.M. to give him a bath and that is too late. Interview on 02/19/25 at 3:00 P.M. with the DON verified Resident #30 did not receive showers according to Resident #30's preference. Residents should be receiving showers at least twice a week. The DON verified Resident #30 only received a shower once in the last month. 3 Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnosis included anxiety, dementia and chronic obstructive pulmonary disease. Review of the annual MDS dated [DATE] revealed Resident #26 had intact cognition. Under preferences Resident #26 showed it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the care plan dated 06/17/24 revealed Resident #26 required assistance for bathing related to impaired mobility and weakness. Interventions included one assist for bathing. prefer showers and ensure hair is washed and nails are manicured on bathing day. Review of the shower log from 01/21/25 through 02/19/25 revealed a bed bath on 01/21/25, 01/22/25, 01/23/25, 01/26/25, 01/27/25, 01/28/25, 01/31/25, 02/04/25, 02/05/25, 02/06/25, 02/08/25, 02/09/25, 02/10/25, 02/12/25, 02/13/25, 02/14/25, 02/17/25 and 02/18/25. Showers were given on 01/22/25, 01/29/25 and 02/12/25. Shower /bath skin sheet for 01/22/25 and 01/29/25 skin check completed. Interview on 02/18/25 at 1:17 P.M. with Resident #26 revealed she gets a shower at night and would like to receive a shower at least once a week. Resident #26 stated she asked for her showers to be moved to days and this has not happened. Interview on 02/19/25 at 3:00 P.M. with the DON verified Resident #26 did not receive showers according to Resident #26's preference and some residents should be receiving showers at least twice a week. The DON verified Resident #26 received three showers in the last 30 days. 47569 4. Review of Resident #19's medical record revealed an admitted [DATE] with diagnoses including but not limited to hemiplegia on the left side, anxiety, depression and history of stroke. Resident #19 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. Resident #19 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, bathing/showering and personal hygiene tasks related to left side weakness and hemiplegia. Review of Resident #19's ADL care plan dated 01/03/24 revealed Resident #19 required staff assistance for bathing, personal hygiene, shaving, dressing and toileting with intervention marked as bathing with shower days on Monday and Fridays during evening shift. Review of Resident #19's of Annual [NAME] Data Set (MDS) dated [DATE] revealed Section F - Preferences for Routine and Activities revealed for Resident #19 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #19's assistance level for showering marked as maximum assistance from staff with personal hygiene assistance marked as supervision assistance by staff. Review of Resident #19's Point of Care (POC) task documentation dated 01/25/25 to 02/17/25 revealed there were no showers being completed during the timeframe; bed baths were marked as being completed instead and there were no refusals marked. Further review of Resident #19's shower sheets dated 01/17/25, 01/20/25, 01/24/25, 01/28/25, 01/31/25, 02/10/25, and 02/07/25 revealed bed baths were completed on these dates. An interview on 02/18/25 at 12:10 P.M. with Resident #19 revealed he had not been receiving regular showers on Monday and Friday nights. Resident #19 stated he preferred to have showers two times a week and not bed baths. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #19 was not receiving showers as he preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. 5. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #21 had moderately impaired cognition and required assistance with completion of ADL tasks including transfers, bathing/showering, and personal hygiene. Review of Resident #21's ADL care plan dated 10/21/24 revealed Resident #21 received assistance with bathing/showering with preferred showers marked as Sunday and Thursday's during evening shift. Review of Resident #21's quarterly MDS dated [DATE] revealed Section F - Preferences for Routine and Activities revealed for Resident #21 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #21's assistance level for showering and personal hygiene marked as supervision assistance from staff. Review of Resident #21's POC shower/bathing documentation dated 01/25/25 to 02/17/25 revealed showers being received on 01/25/25 and 02/08/25, bed baths being received on 01/23/25, 01/24/25, 01/31/25, 02/03/25, 02/07/25, 02/09/25, 02/21/25, 02/13/25, 02/14/25 and 02/17/25, and not applicable (NA) being marked on 01/26/25, 01/29/25, and 02/02/25. Interview on 02/18/25 at 10:55 A.M. with Resident #21 revealed their last shower was received on Saturday 02/08/25. Resident #21 stated, at best, he may get one shower a week and sometimes there is no shower offered, only a bed bath. Resident #21 preferred to have two showers per week. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #21 was not receiving showers as he preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. 6. Review of Resident #43's medical record revealed an admitted [DATE] with the following diagnoses including but not limited to weakness, anxiety, major depression, and high blood pressure. Resident #43 was cognitively intact dated 12/13/24. Resident #43 required assistance from staff to complete ADL tasks including bathing/showers and personal hygiene. Review of Resident #43's admission MDS dated [DATE] revealed the resident was cognitively intact and required assistance from staff to complete ADL tasks including bathing/showers and personal hygiene. Section F - Preferences for Routine and Activities revealed for Resident #43 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #43's assistance level for showering and personal hygiene marked as partial to moderate assistance from staff. Review of Resident #43's ADL care plan revision date 02/01/25 revealed assistance with bathing/showering as an intervention, there were no preferences documented for Resident #43. Review of Resident #43's POC task documentation dated 01/25/5 to 02/17/25 revealed Resident #43's preference for shower days as being on Mondays and Thursdays during day shift. There was a shower marked as being completed on 01/25/25 and a tub bath as being completed on 01/26/25. The rest of the dates were marked as having a bed bath being completed. Interview on 02/18/25 at 10:53 A.M. with Resident #43 revealed she had only been receiving a shower or bed bath once a week and would prefer to have two showers per week. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #43 was not receiving showers as she preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. Review of the facility's policy titled, Personal Hygiene, Bathing and Showering of the Residents undated revealed, Nursing facilities shall provide residents with the opportunity for bathing per the resident's preference. The resident, the family, or an alternate decision maker shall have the opportunity to choose a type of bathing method that is preferred. In addition, the resident has an opportunity to express how often they would like to bath as well as what time of the day they prefer (am, pm). Review of the facility policy Personal Cleanliness/hygiene, dated 02/19/25 revealed personal cleanliness/ hygiene is the foundation for health and wellness. The nursing facilities shall provide residents with the opportunity for bathing per the resident's preference. personal hygiene, bathing and showering of the residents.

Based on medical record review, observations, interviews, and facility policy review the facility failed to ensure fall/safety measures were in place for a high fall risk resident. This deficient practice affected one resident (Resident #19) of four residents reviewed for accidents and hazards. The facility census was 53. Findings Include: Review of Resident #19's medical record revealed admitted [DATE] with diagnoses including but not limited to Parkinson's Disease, hemiplegia on the left side, anxiety, depression and history of stroke. Review of Resident #19's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. Resident #19 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, bathing/showering and personal hygiene tasks related to left side weakness and hemiplegia. Review of Section J - Health Conditions revealed two or more falls were marked as occurring since admission. Review of Resident #19's fall risk assessment dated [DATE] revealed Resident #19 score was 16 which placed him in a high risk category for falls. Review of Resident #19's self mobility care plan revised date 01/13/25 revealed fall interventions including but not limited to pad alarm to wheelchair and bed to alert (staff) of unassisted transfers, a mirror and table outside of the bathroom, and appropriate footwear in place. Review of Resident #19's signed physician orders revealed an order dated 01/14/25 for a pad alarm to the wheelchair to notify staff of unassisted transfers, every day and night shift. There was no order for the pad alarm to be used in Resident #19's bed. Review of Resident #19's Treatment Administration Record (TAR) dated 01/15/25 to 02/19/25 revealed completion of monitoring the pad alarm to Resident #19's wheelchair seat during both day and night shifts. An observation on 02/18/25 at 12:11 P.M. revealed Resident #19 was in his room, seated in his wheelchair. There was a pad alarm located on the bed but no pad alarm in the wheelchair. An observation on 02/19/25 at 11:32 A.M. revealed Resident #19 was self propelling in the wheelchair in the hallway, and there was no pad alarm in the wheelchair. An observation on 02/19/25 5:21 P.M. revealed Resident #19 was in the dining room, sitting in the wheelchair at the table waiting for the supper meal. There was no pad alarm in the wheelchair. An interview on 02/19/25 at 5:23 P.M. with Certified Nursing Assistant (CNA) #315 confirmed there was no pad alarm in Resident #19's wheelchair. CNA #315 shared they thought the pad alarm was only for the resident's bed. An interview on 02/19/25 at 5:25 P.M. with the Assistant Director of Nursing (ADON) verified the pad alarm for Resident #19 should be in both the wheelchair and the bed to alert staff of Resident #19's attempted unassisted transfers. Review of the facility's policy titled, Fall Prevention and Management Policy and Procedure revised 04/2021 revealed, The Interdisciplinary Team (IDT) will review the investigation of the fall and the preventative intervention that was put into place. The results of the review will be documented on the Post Incident Evaluation and the approved intervention will be placed on the resident's comprehensive plan of care and added to the tasks on the resident's Point of Care Kardex.

Based on medical record review, interview, and facility policy review the facility failed to implement indwelling urinary catheter care orders. This deficient practice affected one resident (Resident #21) of two residents reviewed for urinary catheter care. The facility census was 53. Findings Include: Review of Resident #21's medical record revealed admitted [DATE] with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Review of Resident #21's urinary catheter care plan dated 06/02/23 revealed Resident #21 had a suprapubic indwelling urinary catheter with interventions including catheter care every shift. Review of Resident #21's signed physician orders revealed an order dated 01/01/25 to change #20 french/10 milliliter (ML) Supraprubic catheter with plug every day shift every 29 days for maintenance, last changed on 12/01/24 and an order dated 02/14/25 to flush the catheter every day shift until clear discharge for sediment. There were no orders for daily indwelling urinary catheter care and/or monitoring the insertion site. Review of Resident #21's treatment administration record (TAR) dated 01/01/25 to 02/19/25 revealed no orders for indwelling urinary catheter care and no orders for monitoring insertion site. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed moderately impaired cognition with a BIMS score of 10 out of possible 15. Resident #21 required assistance with completion of activities of daily living tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. An interview on 02/20/25 at 11:35 A.M. with the Director of Nursing (DON) confirmed there were no indwelling urinary catheter care orders implemented for Resident #21 and there were no orders to monitor the insertion site of the suprapubic indwelling urinary catheter for Resident #21. Review of the facility's policy titled, Infection Control - Indwelling Catheter Care undated revealed, It is the policy of this facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice.

Based on medical record review, interview and facility policy review the facility failed to obtain urinary testing prior to administration of an antibiotic medication for a possible urinary tract infection and failed to complete criteria for the use of an antibiotic medication. This deficient practice affected one resident (Resident #21) of two residents reviewed for antibiotic medication use. The census was 53. Findings Include: Review of Resident #21's medical record revealed admitted [DATE] with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #19 had moderately impaired cognition with a BIMS score of 10 out of possible 15 dated 01/20/25. Resident #21 required assistance with completion of ADL tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. Review of Resident #21's signed physician orders dated 02/01/25 to 02/19/25 revealed an order dated 02/13/25 for antibiotic medication Amoxicillin oral tablet 500 milligram (MG) give one tablet by mouth three times a day for a urinary tract infection until 02/20/25. There were no orders to obtain a urine sample for urinary laboratory testing and culture/sensitivity to accurately prescribe the appropriate antibiotic based on the bacteria identified in the resident's urine specimen Review of Resident #21's medical record revealed there was no assessment to determine if the use of an antibiotic was appropriate before the antibiotic was administered. Review of Resident #21's progress notes dated 02/12/25 at 4:43 P.M. authored Licensed Practical Nurse (LPN) #244 revealed the nurse had attempted to collect a urine sample from Resident #21 due to complaints of flank pain but was unable to do so. LPN #244 flushed Resident #21's catheter with 60 milliliters (ml) of normal saline and returned a thick yellow colored discharge with a foul odor noted from the catheter. The physician was notified. Further review of Resident #21's progress notes reveal a progress note dated 02/13/25 at 12:56 P.M. authored by LPN #244 revealed the physician was in to see Resident #21 regarding his flank pain with new orders for Amoxicillin 500 mg three times per day for 7 days for UTI and flush catheter with 50 ml normal saline daily until clear. Interview on 02/20/25 at 11:15 A.M. with the Assistant Director of Nursing (ADON) confirmed there was no assessment completed to determine if Resident #21's urinary symptoms met criteria for a UTI and warranted treatment with an antibiotic. In addition, there had been only one attempt to obtain a urine sample for laboratory testing for Resident #21's reported flank pain and foul smelling discharge from the indwelling catheter. There were no further attempts to obtain a urine sample. The ADON stated there should have been a culture and sensitivy laboratory test completed so that the most effective antibiotic medication could be ordered for Resident #21. Review of the facility's policy titled, Infection Control - Indwelling Catheter Care undated revealed, It is the policy of this facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice.

Based on record review, staff interview, and policy review the facility failed to ensure Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the the influenza vaccination. This affected two residents (Resident #9 and #17) of five residents reviewed for vaccinations. The facility census was 52. Findings include: 1. Review of the medical record of Resident #9 revealed an admitted [DATE]. Diagnoses included unspecified dementia, schizophrenia, and peripheral vascular disease. Review of Resident #9's Immunization Audit Report revealed the resident refused the influenza vaccine on 02/17/23 and education was not provided. The report did not show evidence the resident was offered the vaccine in 2024 or 2025. 2. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, diabetes mellitus, and anxiety disorder. Review of Resident #17's Immunization Audit Report revealed the resident was never offered the influenza vaccine in 2024 or 2025. Interview on 02/20/25 at 3:29 P.M. with the facility's Director of Nursing verified Resident #9 and Resident #17 were not educated or offered the influenza vaccine in 2024 or 2025. She reported all residents should be offered the vaccine on admission and yearly when they become available. Review of the Influenza and Pneumococcal Vaccine policy revised 04/06/21 revealed the purpose was to ensure all residents or their representative are educated in the benefits and side effects of receiving the influenza and Pneumococcal immunizations. The influenza vaccine will be offered between 10/01 and 03/31 each year. At admission the resident or their representative will receive education on the benefits and side effects of the immunizations including but not limited to the recommendations from the Centers for Disease Control (CDC).

Based on observation, medical record review, facility investigation review, Emergency Medical Services report review, hospital record review, staff interview and policy review, the facility failed to provide Resident #50, who was identified to have intermittent confusion, adequate supervision, and assistance to prevent a fall with injury. Immediate Jeopardy and serious harm and injury occurred on 11/07/23 when staff assisted Resident #50 to the facility front porch to be transported to an outside appointment. The resident was left unattended in a wheelchair thought to not have properly functioning brakes. After being left unattended, the resident moved her wheelchair from the facility porch/portico and began to roll approximately 50 feet across the parking lot toward six concrete steps. Once the wheelchair reached the first concrete step, the resident was ejected from the wheelchair and fell to a concrete pad, located at the bottom of the six steps, landing on her abdomen. The resident was assessed to have a large hematoma to the right side of her forehead and was unresponsive upon initial assessment. The resident was transported to a local hospital and diagnosed with a right temporal and right frontal lobe brain bleed. The resident was life-flighted to a trauma center for further evaluation. The resident subsequently suffered cerebral vascular accidents during her hospital stay and was discharged to another facility under hospice care. This affected one resident (Resident #50) of three residents reviewed for falls. The facility census was 49. On 11/22/23 at 12:01 P.M. the Administrator and Director of Nursing (DON) were notified the Immediate Jeopardy began on 11/07/23 at approximately 12:50 P.M. when the facility failed to provide appropriate supervision and assistance to Resident #50 resulting in serious injury when the resident rolled across the parking lot, was ejected from her wheelchair, and fell , causing a brain bleed, cerebral vascular accidents, and dysphasia (difficulty speaking). The Immediate Jeopardy was removed on 11/27/23 when the facility implemented the following corrective action: On 11/07/23 at approximately 1:15 P.M. Resident #50 was transported to the hospital for evaluation and treatment. On 11/07/23, immediately after the incident, Resident #50's wheelchair was locked in the Administrator's office, by the DON, to prevent staff use. On 11/07/23 at 2:00 P.M. Medical Director #520 was updated by the Director of Nursing. On 11/07/23, 3:40 P.M. State tested Nursing Assistant (STNA) #140 was provided immediate 1:1 education by the DON regarding resident supervision levels. On 11/08/23, the process was changed for transportation to pick up residents at the back entrance of the facility. On 11/08/23 at 9:40 A.M. the Administrator notified the transportation company by telephone of the new process for pick-up of the residents at the facility. On 11/08/23 and 11/09/23, AD Hoc QAPI meetings were held with the Administrator, the Director of Nursing, and Senior Living President #515 to discuss the action plan items. All items were approved. On 11/09/23 at 10:00 A.M. Medical Director #520 was updated by the Director of Nursing of the action taken since 11/07/2023 and upcoming in-services of staff. On 11/09/23, Maintenance Staff #420 and #530 evaluated all wheelchairs and other mobility equipment in the facility for safety and working order. No equipment was identified as not in working order, including the chair utilized by Resident #50 on 11/7/23. By 11/10/23, [NAME] Data Set (MDS) Registered Nurse (RN) #470 reassessed all 48 residents residing in the facility at the time for updated elopement risks and need for supervision outside of the facility. Residents #17 and #16 were determined to be safe outside of the facility without supervision. By 11/10/23, The Administrator and the Director of Nursing (DON) in-serviced all 44 staff on the new facility policy and procedure related to transfer and pick up procedures, the elopement policy and procedure and updated elopement risks and residents needing supervision, the abuse and neglect policy and procedure, and wheelchair and equipment maintenance and review of the new process for when malfunctioning equipment is identified by staff. On 11/16/23 the Quality Assurance Committee met and reviewed the results of the in-services and the updated resident elopement assessments. On 11/27/23 the DON and designees began random audits of resident equipment and transportation pickups to ensure all equipment was functioning properly and residents were transported and supervised in accordance with their plan of care. The audits will be conducted three times a week for four weeks and then weekly for four weeks. The results of the audits will be reviewed at the end of the month or within the first week of the following month by the Interdisciplinary Team for ongoing compliance. The results of the audits will be reviewed again at the quarterly Quality Assurance Committee meeting. Due to the audit process, equipment that is found to not be working properly will be removed from use until the equipment is working properly. Additional staff education and in-services will occur if concerns are identified with supervision and/or the new transportation process. On 11/28/23 from 1:10 P.M. through 2:45 P.M. surveyor interviews with RN #400, LPN #395 and STNAs #55, #80, #90, and #130 revealed the staff received in-service/education and were knowledgeable of the new facility policy and procedure related to transfer and pick up, the elopement policy and procedure and updated resident elopement risks and residents needing supervision, the abuse and neglect policy and procedure, and wheelchair and equipment maintenance and review of the new process for when malfunctioning equipment is identified by staff. Although the Immediate Jeopardy was removed on 11/27/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (chemical imbalance in the blood that affects the brain) unspecified dementia, lung cancer, chronic obstructive pulmonary disease, anxiety, and repeated falls. Review of Resident #50's skilled nursing assessment dated [DATE] and completed by RN #490 revealed Resident #50 used a wheelchair for mobility during transport to appointments and while out of the facility with family. Review of Resident #50's care plan initiated on 10/11/23 revealed Resident #50 was at risk for falls related to the diagnoses of dementia, anxiety, fibromyalgia, and history of falls. Interventions were implemented including monitor resident for changes in ambulation and assist with bed mobility, transfers and ambulation as needed. Further review revealed Resident #50 had cognitive deficit which put Resident #50 at risk for wandering and elopement. The intervention for the use of a wander guard was implemented on 10/20/23. Review of Resident #50's quarterly [NAME] Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had impaired cognition, used a walker for independent ambulation assistance, required extensive assistance from one to two staff members for transfers, bed mobility and toilet use. Resident #50 was receiving speech therapy, occupational therapy, and physical therapy to improve strength, coordination, and cognition. Review of Resident #50's fall risk screen assessment dated [DATE] completed by RN #400 revealed Resident #50 was identified as a high risk for falls with a score of 12. Review of Resident #50's wandering/elopement risk assessment dated [DATE] and completed by LPN #375 revealed Resident #50 was at high risk for wandering related to history of wandering and impaired cognition. The intervention for placement of a wander guard (a bracelet that residents wear that will alert staff if the resident approaches a monitored exit door) was implemented on 10/20/23. Review of Resident #50's physician orders listing for November 2023 revealed signed physician orders dated 10/20/23 for placement check of a wander guard to Resident #50's right ankle was to be completed every shift and to check function of the wander guard to be completed on every night shift. Review of Resident #50's nurse progress notes dated 11/07/23 at 1:00 P.M. and authored by RN #400 revealed Resident #50 was observed lying face down on the sidewalk and grass at the base of six concrete steps at the front of the facility. Resident #50 had skin tears to bilateral hands and a hematoma with abrasion was noted above the right temple. Resident #50 was alert but could not respond appropriately to questions. Review of Resident #50's nurse progress notes dated 11/07/23 at 1:51 P.M. and authored by LPN #375 revealed LPN #375 was called outside by a State tested Nursing Assistant (STNA) (not identified in the progress note) due to Resident #50 falling out of the wheelchair and down the first flight of concrete stairs. Resident #50 was alert but could not respond appropriately to orientation questions. Resident #50's fall was witnessed by a therapy staff member leaving the facility for the day. Review of the Emergency Medical Services (EMS) Patient Care Record dated 11/07/23 at 1:05 P.M. revealed Resident #50 was observed lying on her back with facility staff securing Resident #50's head and neck. Resident #50 was noted to be looking around but was unable to answer questions appropriately or follow verbal commands. EMS notified the medical helicopter service for transport of Resident #50 due to her age and mechanism of injury. EMS transported Resident #50 to the emergency room for further evaluation. Review of Resident #50's hospital emergency room progress notes dated 11/07/23 at 1:30 P.M. revealed the results of Resident #50's head Computed Tomography (CT) of acute right frontal and temporal lobe parenchymal hemorrhage (bleeding from ruptured blood vessels into the parenchyma or functioning tissue of the brain), a small right subdural hematoma (occurs when blood vessels rupture between the skull and the brain (subdural space) is damaged. Blood escapes from the blood vessel, leading to the formation of a blood clot (hematoma) that places pressure on the brain and damages the brain) with no significant mass effect of midline shift of the brain. Resident #50 was noted to be able to follow commands, open eyes, but was confused. Resident #50's airway was intact. Resident #50 was transferred via medical helicopter to a higher-level trauma center. As part of the facility investigation, incident report, post incident evaluation, and staff statements were obtained which revealed the following: Review of the Accident/Incident Report completed by the DON dated 11/07/23 revealed Resident #50 had been leaving the facility for an appointment when she was left unattended outside the facility and fell down the front steps with the wheelchair. Resident #50 was unable to respond to the DON concerning Resident #50's activity prior to the fall. Resident #50's status and related factors were marked as confused/disoriented, the use of psychotropic, cardiac, and high blood pressure medications and the use of mobility devices including a walker and wheelchair. Notifications were completed for the responsible party, the physician, and the DON. Resident #50 was transported to the emergency room by the emergency medical services (EMS) with injuries noted as hematoma to the right temple and skin tears to bilateral hands. Review of the Post Incident Evaluation completed by the Director of Nursing (DON) on 11/07/23 revealed the location of Resident #50's fall was the front steps of the facility. The injuries sustained were hematoma to the right temple and skin tears to both hands. Physical Therapist Assistant (PTA) #525 witnessed the incident. The Medical Director #520 and responsible party were notified by Licensed Practical Nurse (LPN) #375. There were no alarms or restraints in place at the time of the fall. Review of State tested Nursing Assistant (STNA) #140 statement dated 11/07/23 revealed STNA #140 had wheeled Resident #50 out the front doors of the facility to the porch area for transportation to an appointment. Transportation Personnel #500 requested a different wheelchair due to the brakes not locking on Resident #50's wheelchair and the need for footrests on the wheelchair for transportation of the resident. STNA #140 returned inside the facility to get a different wheelchair for the resident, leaving Resident #50 outside with Transportation Personnel #500. STNA #140 was inside the facility for approximately three to five minutes when Transportation Personnel #500 entered the facility leaving Resident #50 unattended outside of the facility. STNA #140 was exiting the facility with a different wheelchair, when Transportation Personnel #500 notified her, a nurse was needed outside. STNA #140 yelled for a nurse and then exited the facility. STNA #140 observed Resident #50 lying face down with her arms at her sides on the landing at the bottom of the first set of stairs with Physical Therapy Assistant (PTA) #525 at her side with the wheelchair sitting upright to the side of Resident #50. Review of Licensed Practical Nurse (LPN) #375 statement dated 11/07/23 revealed LPN #375 responded to the request of a nurse required outside in front of the facility. LPN #375 observed Resident #50 lying on her back with RN #400, STNA #140 and the Director of Nursing (DON) kneeling beside her. RN #400 was calling emergency medical services. At approximately 1:15 P.M. LPN #375 notified Resident #50's son concerning the incident. At 3:30 P.M. LPN #375 called [NAME] Community Hospital for an update on Resident #50. LPN #375 was notified Resident #50 was air lifted to a trauma center. Review of Registered Nurse (RN) #400 statement dated 11/07/23 revealed RN #400 heard STNA #140 shouting from the front doors that a nurse was needed out front. Upon exiting the building, RN #400 observed the transportation vehicle with the driver standing beside the van. RN #400 ran down the steps and observed Resident #50 lying face down on the landing at the bottom of the first set (of steps) with the wheelchair a few feet away. RN #400 noted Resident #50 had a pulse with her eyes rolled back and shallow, slow respirations were observed. Resident #50 did not verbally respond to RN #400. RN #400 promptly called 911 for emergency medical services (EMS). RN #400, the DON, LPN #375 and STNA #140 assisted in log rolling Resident #50 onto her back. EMS arrived and transported Resident #50 to the emergency room . Review of Physical Therapy Assistant (PTA) #525 statement dated 11/07/23 revealed PTA #525 was pulling her vehicle around to leave the facility when she noticed Resident #50 rolling across the driveway. She put her vehicle into park and got out and ran towards Resident #50 in an attempt to stop the wheelchair. PTA #525 witnessed Resident #50 being ejected from the wheelchair and flew down the steps landing face down on the concrete landing. PTA #525 removed the wheelchair from on top of Resident #50 and placed the wheelchair to the side of Resident #50 activating the brakes to secure the wheels from rolling. Transportation Personnel #500 stated he would go get help and then nursing came out and took over her care. PTA #525 assisted in log rolling Resident #50 to her back. On 11/21/23 at 2:27 P.M. an interview with Registered Nurse (RN) #400 revealed on 11/07/23 State tested Nursing Assistant (STNA) #140 notified her there was a situation outside in the front of the facility and a nurse was required. Upon exiting the facility through the front doors, Resident #50 was observed lying face down on the landing at the bottom of the first flight of stairs, there was a manual wheelchair sitting upright to the side of where Resident #50 was lying. Physical Therapy Assistant (PTA) #525 was observed kneeling beside Resident #50. Transportation Personnel #500 was observed standing near the transportation van. RN #400 assessed Resident #50 for injuries and noted bleeding from skin tears to Resident #50's hands. RN #400 observed Resident #50 was not responding to verbal stimuli and Resident #50's eyes were noted to be rolled back. Resident #50 was log rolled to her back by the RN #400, therapy staff #525, and the Director of Nursing (DON) for further injury assessment. RN #400 observed a hematoma with abrasion located above Resident #50's right temple. Emergency medical services (EMS) were notified, arrived at the facility, and transported Resident #50 to the emergency room . LPN #375 notified Resident #50's son and notified the medical director concerning the incident. On 11/21/23 at 2:41 P.M. an interview with Licensed Practical Nurse (LPN) #375 revealed Resident #50's cognitive baseline was orientated with intermittent confusion; Resident #50 was independent with ambulation using a walker throughout the facility with impaired safety awareness. Resident #50 had recently started using a manual wheelchair for transportation and longer distance mobility. Resident #50 had been on her assigned hallway for 11/07/23 and had a cardiologist appointment requiring transportation. STNA #140 had gotten Resident #50 ready and placed in a manual wheelchair and then had taken Resident #50 to the front porch area for pick up by the transportation company. LPN #375 was notified of an accident involving Resident #50 outside in front of the facility. LPN #375 went out the front doors of the facility and observed RN #400, STNA #140, the DON, and Physical Therapy Assistant (PTA) #525 kneeling beside Resident #50 who was lying on her back on the landing at the bottom of the first flight of stairs at the front of the facility. LPN #375 observed a hematoma above the right temple and skin tears on both hands. Resident #50 was alert but not responding verbally to LPN #375. RN #400 notified the emergency medical services (EMS) for transportation of Resident #50 to the emergency room . On 11/21/23 at 3:32 P.M. an interview with State tested Nursing Assistant (STNA) #140 revealed on 11/07/23 Resident #50 had been assisted into a manual wheelchair and escorted to the front of the facility by STNA #140 for transportation to a physician's appointment via a transportation company's van. When STNA #140 had taken Resident #50 out the front doors to the covered porch area, Transportation Personnel #500 inspected Resident #50's manual wheelchair and stated to STNA #140 the wheelchair brakes did not lock and the wheelchair needed to have footrests in place for transport. STNA #140 left Resident #50 sitting outside in the porch area and returned inside the facility to get a different wheelchair for Resident #50. STNA #140 was in the facility for approximately 3-5 minutes when Transportation Personnel #500 entered the facility to assist STNA #140 in finding a replacement wheelchair for Resident #50. Transportation Personnel #500 then went back outside, as STNA #140 was pushing the replacement wheelchair out the first set of front doors, Transportation Personnel #500 came in the first set of doors and told STNA #140 to get a nurse to come outside. STNA #140 notified Registered Nurse (RN) #400 concerning an accident outside in the front of the facility. STNA #140 and RN #400 went out the front doors and crossed the driveway where Resident #50 was observed lying face down on the landing at the bottom of the first flight of concrete stairs. PTA #525 was observed with Resident #50 and Resident #50's wheelchair was noted to be sitting upright to the side of where Resident #50 was located. On 11/22/23 at 9:02 A.M. an interview with PTA #525 revealed on 11/07/23 at approximately 1:10 P.M. she was leaving the facility for the day. As PTA #525 was driving her vehicle up and around the corner of the driveway she observed Resident #50 sitting in a manual wheelchair freewheeling across the driveway towards the first set of stairs leading down to the parking lot. PTA #525 attempted to put her vehicle in park and exit the vehicle to stop Resident #50 from falling down the stairs, but PTA #525 wasn't able to fast enough and witnessed Resident #50 front wheels of the manual wheelchair go over the edge of the first step causing Resident #50 to be ejected from the seat of the manual wheelchair and fall down the remaining set of stairs ending up face down to the right side of the concrete landing with the manual wheelchair laying on top of Resident #50. Transportation Personnel #500 was observed walking across the driveway towards the set of steps talking on his cell phone. PTA #525 requested Transportation Personnel #500 to get a nurse from inside of the facility. RN #400 and the Director of Nursing (DON) was observed exiting the building. PTA #525 removed the manual wheelchair from atop Resident #50 and placed the manual wheelchair to the side of where Resident #50 was located on the stairs landing. PTA #525 applied the brakes to the wheelchair locking the wheels in place. PTA #525 assisted RN #400 and the DON in log rolling Resident #50 onto her back for airway protection and further injury assessment. On 11/22/23 at 9:37 A.M. an interview with the Director of Nursing (DON) revealed Resident #50 was alert with periods of intermittent confusion with occasional hallucinations. Resident #50 was independent with ambulation using a walker for assistance. Resident #50 had a wander guard in place due to wandering behavior. On 11/07/23 at approximately 1:10 P.M. the DON was notified of an accident involving Resident #50 outside in front of the facility. The DON observed Resident #50 lying face down on the landing at the bottom of the first set of steps leading down to the parking lot. PTA #525 was kneeling beside Resident #50 and Resident #50's wheelchair was sitting upright to the side of where the resident was located. The DON assisted in log rolling Resident #50 onto her back for airway protection and further injury assessment. Transportation personnel #500 was observed standing near the transportation van in front of the facility. The DON observed a hematoma above the right temple area and skin tears on both hands of Resident #50. RN #400 notified EMS and requested transport to the emergency room for further evaluation of Resident #50. On 11/24/23 at 9:45 A.M. an interview with the Medical Director #520 revealed he had been notified of the accident involving Resident #50 and had given the order for transport of Resident #50 to the emergency room for further evaluation. On 11/28/23 at 11:15 A.M. an interview with the Director of Nursing (DON) revealed during the interdisciplinary team investigation, there were several factors involved with Resident #50's accident and fall. The DON stated the resident should not have been left unattended outside of the facility. On 11/30/23 at 10:05 A.M. an interview with Medical Director #520 revealed he had attended the Quality Assurance Committee meeting on 11/16/23 and reviewed the results of the in-services and the updated resident elopement assessments. The medical director did not provide any additional information related to the incident. Several calls were made to the transportation company, but no return calls were provided. Review of the facility's policy titled, Fall prevention and Management Policy and Procedure dated 04/2021 revealed Each resident will be assessed for fall risk during the admission process. A plan of care based on identified risk factors will be implemented. This deficiency represents non-compliance investigated under Complaint Number OH00148435.

Based on closed record review and interview the facility failed to adequately monitor Resident #50 related to non-pressure skin ulcers and failed to ensure wound care was completed as ordered. Actual harm occurred on 07/04/23 when staff identified a decline in the resident's non-pressure skin ulcer to the left foot with an increase in drainage, necrosis (dead tissue) and slough (dead tissue, usually cream or yellow in color that impeded healing and increases the potential for infection) to the wound without evidence the physician or wound clinic were notified of the decline. The facility also had no evidence of wound monitoring, especially after the identified decline in the status of the wound. The resident was subsequently admitted to the hospital in serious condition on 07/16/23 with cellulitis to the left lower extremity and possible sepsis. This affected one resident (Resident #50) of four sampled residents. Findings include: Review of Resident #50's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, atrial fibrillation, high blood pressure, peripheral vascular disease, end stage renal disease with hemodialysis and lower extremity wounds. The resident was discharged to the hospital on 07/16/23 and did not return to the facility. Review of the physician's orders revealed Resident #50 had an order for Doxycycline (antibiotic) 100 milligrams twice day for infection dated 05/10/23. He took the medication twice a day until he was admitted to the hospital on 07/16/23. Review of the facility wound Nurse Practitioner (NP) #500 notes dated 05/10/23 revealed Resident #50 had a vascular wound to the left lower extremity which measured 20 centimeters (cm) in length by 13 cm in width by 0.1 cm in depth with moderate amount for serous (clear fluid drainage) drainage. A wound to the foot (left or right not documented) which measured 1.2 cm in length by 0.3 cm in width by 0.2 cm in depth with a moderate amount of serosanguinous (fluid with some blood cells noted) drainage. A diabetic wound to the right planter foot which measured 6.5 cm in length by 5.3 cm in width by 0.0 cm in depth with a moderate amount of serosanguinous drainage. The wound bed was 100 percent covered in slough and the wound had a mild odor present. The last wound documented was a diabetic wound to the left lateral foot that had full thickness loss. The wound measured 15.2 cm in length by 4.0 cm in length by 0.3 cm in depth with moderate serosanguinous drainage. The wound bed was covered by 50 percent slough and had a mild odor. The wounds to the bilateral feet needed debridement; however the resident expressed he did not want the NP to do the debridement because he had his own physician who would do it for him. He was educated on the appearance and that debridement would help heal the wounds. The resident stated he spoke to his wife, and she told him to do what he felt was best. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact, he required extensive assistance of two or more staff for transfers, toilet use and extensive assistance of one staff member for bed mobility, dressing and personal hygiene. The resident was admitted with one venous/arterial ulcer/diabetic foot ulcer/open lesion to the foot. Review of the treatment administration records for 05/2023 revealed a treatment order for a wound to the resident's right plantar foot. The order was to cleanse with normal saline and cover with calcium alginate and apply an ABD and Kerlix. Record review revealed no evidence the wound treatment was completed as ordered on 05/12/23 or 05/18/23. Review of the 06/2023 treatment administration record revealed no evidence the treatment was completed as ordered on 06/01/23, 06/08/23, or 06/13/23. Review of the treatment administration records for 05/2023 revealed a treatment order for a wound to the fourth and fifth web space of the resident's toe/foot. The order was to cleanse with normal saline and apply silver alginate every day and when needed. Record review revealed no evidence the wound treatment was completed as ordered on 05/12/23, 0515/23, 05/18/23, 05/20/23, 05/21/23 or 05/28/23. Review of the treatment administration record for 06/2023 revealed an order for wound care to the resident's left dorsal hand. The order indicated to cleanse with normal saline, apply hydrogel to the wound, cover with bordered dressing, change daily and as needed. Record review revealed no evidence the wound treatment was completed as ordered on 06/03/23, 06/11/23, 06/13/23, 06/15/23 or 06/18/23. Review of the vascular physician's note dated 06/09/23 revealed Resident #50 was an established patient who presented to the office from the nursing home for concerns of possible need of wound debridement to bilateral lower extremities. The resident had refused to allow the facility physician to do the debridement. He was last seen on 05/16/23 with good granulating base on the left foot however the right foot continued to show some necrosis of the planter fascia. Review of the wound clinic notes dated 06/20/23 revealed the wounds for Resident #50 were improving at this time. The left planter foot measured 10.8 cm in length by 3.1 cm in width by 0.2 cm in depth with some muscle involvement, the right planter foot measured 4.6 cm in length by 2.1 cm in width by 0.3 cm in depth with muscle involvement, and the right lateral lower leg measured 1.7 cm in length by 2.4cm in width by 0.2 cm in depth with a fat layer exposed. He was to return in one week. However, there was no evidence the resident returned for the follow up appointment or any appointments after this date. Review of the July 2023 TAR revealed no documentation the treatment was completed to the resident's left foot on 07/01/23, to the medial right lower extremity on 07/01/23 and 07/07/23, or to the right foot on 07/01/23. Review of a nursing progress note, dated 07/04/23 at 11:59 P.M. revealed change in condition to left foot, prior to dressing change, an excess amount of drainage was noted to be covering the entire plantar area of Kerlix (gauze bandage used to wrap a wound), Abdominal pad (ABD pad (large gauze pad used for larger wounds or wounds with more drainage)) completely saturated. Upon careful removal of ABD, dated with the previous date, a large amount of tissue came off onto (the) ABD and hung from (the) peri wound (tissue surrounding the wound). Area of necrosis has increased in size. Amount of slough has increased as well. Open area separate from the large main wound, towards the center of the foot, has also become more open and deep. Resident had large amount of debris from the day in Hoyer (brand of mechanical lift) pad under legs, food and firework debris. Clear bugs also noted to have been under bilateral lower extremity dressings. No signs of bugs in wounds, wounds washed thoroughly. Review of this progress note revealed no evidence that the physician, nurse practitioner or wound clinic were notified of this change in condition/deterioration of wound. From 07/05/23 to 07/16/23 there were no progress notes, assessment, or evidence of monitoring of the condition of the resident's wounds, including the left foot/leg wound noted in the medical record. A progress note dated 07/11/23 at 8:04 P.M. revealed the resident's wound clinic visit for this date was canceled and rescheduled for 07/18/23. Review of the July 2023 Medication administration record revealed Resident #50 received two 325 milligram tablets of Acetaminophen on 07/15/23 at 7:46 P.M. for a fever of 100.2. There was no documentation the physician was notified. Review of a Skilled Observation Summary dated 07/16/23 at 12:38 A.M. reflected the most recent temperature of 100.2 on 07/15/23 at 7:46 P.M. and noted no new skin issues. Review of the nurse's note dated 07/16/23 at 2:01 P.M. revealed Resident #50 went to the hospital on 07/16/23 while on a leave of absence (LOA) with his wife. Review of hospital documentation, dated 07/16/23 at 12:04 P.M. included a history of present illness which noted the resident was a nursing home resident who was brought to the hospital by his wife on account of fevers, worsening lower extremity wounds and generalized weakness. The resident's wife had initially picked him up (from the nursing home) for church on this date. He had had a fever the last night and took some Tylenol. At church he was very weak, complained of shortness of breath and broke out in another fever so the wife brought him to the hospital. The resident was febrile with a temperature of 102.6 degrees Fahrenheit and he presented in mild distress. Assessment of his extremities revealed upon removal of his walking boots from his legs the resident was noted to have severe venous insufficiency bilaterally with a lot of skin breakdown on the volar aspects; however the left was quite deep with some black eschar and worsening redness. The resident's white blood cell count was elevated at 12.24 (normal 4.80-10.80) and sepsis alert was called source appears to be the left foot and leg. The plan was for antibiotics as well as fluid resuscitation. Hospital records noted Clinical Impression: Cellulitis left lower extremity with possible sepsis. Disposition: Admit; Patient Condition: Serious. On 07/31/23 at 2:10 P.M., an interview with the Director of Nursing (DON) verified wound care was not completed as ordered for Resident #50 during the dates noted above. On 08/09/23 at 10:55 A.M. a phone interview with Resident #50 revealed he only left the facility for dialysis, on Saturdays from 10:30 A.M. to 7:30 P.M. and on Sundays from 9:00 A.M. to 7:30 P.M. He stated the nurses changed his dressings to his legs on the midnight shift whenever they had time and sometimes, they did not get done. He stated on 07/16/23 his wife took him to the hospital because he had a fever and was weak. He also stated there was increased drainage and some odor coming from his leg and the hospital told him his legs were infected from not being taken care of properly. He stated he was in the hospital for ten days and his legs had to be debrided. He clarified he stayed out late on 07/04/23 to watch fireworks at church and there were bugs crawling on his dressings but stated they were not in his wound. On 08/09/23 at 2:20 P.M. an interview with the DON revealed the facility did not maintain or have any wound clinic notes for Resident #50, but stated she could call and get those notes. She stated staff should have been measuring his wounds, but verified facility staff weren't measuring his wounds. She stated the wound NP would come into the facility every Monday and Resident #50 was at dialysis on Mondays so she could not see him. The DON stated the resident was out of the facility so much and his wound care was hard to do while he was up in the chair, so they decided to move his dressing changes to night shift and the nurses just dropped the ball when it came to his wound assessment and measurement. She stated they were just not doing them. On 08/09/23 at 2:32 P.M. an interview with the DON revealed she spoke to the wound clinic and obtained information the resident had not been seen at the clinic in May 2023 and was only seen on 06/13/23 and 06/20/23. She stated Resident #50 refused to see their house wound NP and requested to go back to the wound clinic he had previously been going to and that was how he started going to the wound clinic to begin with. A follow-up interview at 2:41 P.M. revealed the facility had not set up any of the wound clinic appointments for Resident #50. She stated the wound clinic would give the resident an appointment card and he would set up his own transportation. She stated the facility was not tracking or coordinating care with the resident and the wound clinic to ensure a continuity of care was being provided. On 08/09/23 at 4:00 P.M. an interview with the DON revealed the expectation was when the nurse saw a decline in a wound, they were to notify the provider who was taking care of the wound. She stated she became aware of his decline in his wound on 07/05/23, but could not remember what they had done about it the resident's wound decline. The resident was subsequently taken to the hospital by his wife on 07/16/23 and admitted for medical intervention/care of his wounds. This deficiency represents non-compliance investigated under Complaint Number OH00144774.

Based on observation, record review, and interview the facility failed to ensure pressure relieving interventions, including a low air loss mattress was in place for Resident #3 as ordered to promote healing the resident's pressure ulcer. This affected one resident (#3) of three residents reviewed for pressure ulcers. The facility census was 48. Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorders, type 2 diabetes, anxiety disorder, malignant neoplasm of left breast, and protein-calorie malnutrition. Review of a wound consult note dated 06/12/23 revealed Resident #3 had an in-house acquired Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure wound to coccyx that measured 3.4 centimeters (cm) long by 0.8 cm wide with 0.6 cm depth. Review of a nurse's note dated 07/28/23 at 5:05 P.M. revealed Resident #3 was transferred to the hospital for seizure activity. A nursing note dated 08/02/23 revealed Resident #3 returned to the facility. Review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed Resident #3 was at high risk for the development of pressure ulcers. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had cognitive impairment and required extensive assistance from two staff for bed mobility and transfers. The MDS also revealed Resident #3 had a Stage III pressure ulcer that was not present on admission. Review of a wound consult note dated 08/28/23 revealed Resident #3 had an in-house acquired Stage III pressure wound that measured 2.2 cm long by 2.5 cm wide with 0.4 cm depth. Review of a plan of care revised on 08/31/23 revealed Resident #3 was at risk for alteration in skin integrity. Interventions included peri care after each incontinence episode and a low air loss (LAL) mattress (dated 05/12/18). Review of physician's orders and treatment administration record (TAR) for August and September 2023 revealed no evidence of LAL air mattress being in place. On 09/05/23 at 9:51 A.M. Resident #3 was observed lying in bed on her back. An interview with Resident #3 at the time of the observation revealed the resident indicated she had a sore on her bottom and stated staff did not turn and reposition her frequently. A LAL mattress was not observed to the resident's bed. Interview on 09/05/23 at 1:39 P.M. with the Director of Nursing (DON) verified Resident #3 did not have a LAL mattress in place. The DON stated Resident #3 had a hospital stay the end of July 2023 and the LAL mattress must have been removed while Resident #3 was at the hospital. The DON also verified the use of a LAL mattress was care planned but there were no orders or documentation on the August or September 2023 administration records of the LAL being in place. The DON verified Resident #3 was identified as being a high risk for the development of pressure ulcers and had developed a Stage III pressure ulcer at the facility.

Based on record review, review of incident and accident documentation, review of hospital documentation, review of the facility policy and procedure for Elopement and Falls and staff interview the facility failed to provide adequate supervision for Resident #5, who was cognitively impaired and at risk for falls and elopement to prevent the resident from sustaining a fall with injury outside the facility. The facility also failed to conduct a complete and thorough investigation of the fall incident. This affected one resident (#5) of three residents reviewed for falls. Actual harm occurred on 06/30/20 when Resident #5 exited an unlocked door from the main kitchen to the outside of the facility without staff knowledge. The resident was subsequently found on the ground on the bottom step of the loading dock, with his wheelchair turned over. Resident #5 sustained skin tears to his bilateral hands, right forearm, abrasions to his bilateral knees and bruising to back of head, complained of pain all over including when taking a deep breath and was subsequently transferred to the hospital for evaluation. Upon return from the hospital, the resident received [MEDICATION NAME] medication for pain. Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering/Elopement Risk Assessment, dated 04/29/20 revealed Resident #5 was at high risk for wandering and had wander guard device in place. Review of the Fall Risk Assessment, dated 04/29/20 revealed Resident #5 was at high risk for falls. Review of the plan of care, dated 06/10/20 revealed the resident had cognitive deficit related to dementia with behavioral disturbances. Interventions included a SecureCare/Wander guard transmitter to be worn on the resident's ankle, check for proper placement every shift and function daily and to redirect the resident. Review of the plan of care, dated 6/10/20 revealed the resident had an alteration in self mobility related to poor vision and dementia with poor safety awareness. Interventions included nonskid socks, anti-roll back on wheelchair, Dycem placed on wheelchair to prevent sliding forward in wheelchair and bring resident into hallway or lobby when out of bed for closer supervision. Review of a nurse's note, dated 06/30/20 at 9:50 P.M. revealed Resident #5 was found at the bottom of the loading dock sitting on a step at 8:40 P.M. with his wheelchair turned over and yelling for help. The resident was alert to self and answered questions appropriately. Resident #5 complained of pain all over and complained of pain when taking a deep breath. The resident had skin tears to his bilateral hands and right forearm, with abrasions to his bilateral knees. Resident #5 had bruising to back of his head with a slight raised area. The squad was called and Resident #5 was transported (to the hospital) at 9:10 P.M. The Certified Nurse Practitioner and resident's power of attorney were notified. A nursing note, dated 07/01/20 at 6:43 A.M. revealed Resident #5 returned to facility at 12:00 A.M. with no complaint of headache or dizziness. His range of motion was slow and the resident was sore. No further injuries were noted and as needed Tylenol was given for pain all over at 2:00 A.M. and 6:00 A.M. and at 10:30 A.M. for complaint of left knee pain. The resident also stated taking deep breaths gave him discomfort. Continued review of the nursing progress notes from 07/02/20 through 07/13/20 revealed Resident #5 continued to receive PRN pain medication due to fall on 06/30/20 during this time period. Review of incident log documentation, dated 06/30/20 (time not noted) revealed Resident #5 was found on the steps of the loading dock with his wheelchair overturned and yelling for help. Skin tears were noted to his bilateral hands and right forearm and bilateral knees. Range of motion was normal. The resident was assisted back into his wheelchair with two staff and returned into the facility. The resident complained of pain all over. The physician was notified and orders were received to send the resident to the hospital. The resident was sent out at 9:10 PM and returned at 12:00 A.M. with no new injuries noted. Interventions following the incident included to ensure all staff were aware the kitchen door was locked when kitchen staff left and was to remained locked. A corresponding Accident/Incident Report, dated 06/30/20 revealed Resident #5 was found outside of the kitchen exit door sitting on a step of the loading dock with his wheelchair overturned, yelling for help at 8:40 P.M. Resident #5 was assisted back into the facility via two staff members. Resident #5 sustained skin tears to his bilateral hands, right forearm and abrasions to bilateral knees. Resident #5 complained of all over pain and complained of pain when taking a deep breath. Resident #5 was unable to state what happened. Immediate interventions were to apply dressings to his bilateral hands and right forearm skin tears. Resident #5 was kept at nurses' station with staff until transferred to hospital. Resident #5 complained of pain to his bilateral arms, chest and legs and when taking a deep breath. Resident #5 was transported to hospital for evaluation and treatment at 9:10 P.M. and then returned to facility at 12:00 A.M. with no new injuries noted. Neurological checks were initiated per protocol, every shift for three days. Review of the hospital documentation from 06/30/20 revealed Resident #5 did not sustain any additional major injuries other than the skin tears to his bilateral hands and right forearm and abrasions to bilateral knees from fall. Review of the physician's orders for July 2020 revealed Resident #5 had an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the 06/30/20 dietary staff schedule revealed the last dietary aide left the faciity on this date at 7:30 P.M. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/02/21 revealed Resident #5 was moderately impaired for daily decision making and required extensive assistance from one staff for transfers and supervision from one staff for locomotion on and off the unit. This assessment was consistent with the assessments completed prior. Record review revealed no additional incidents of elopement or falls outside the facility occurred involving Resident #5 between 07/01/20 and 02/23/21. On 02/23/21 at 10:45 A.M. interview with the Director of Nursing (DON) revealed she was hired in November 2020 and did not have first-hand knowledge of Resident #5's falls prior to that time. During the interview, review of the documentation for the fall sustained by Resident #5 on 06/30/20, the DON verified the lack of a thorough investigation. The investigation failed to contain staff statements of all staff involved or with knowledge of the incident. The investigation lacked evidence of staff education related to ensuring the kitchen door was locked when staff were not working in the kitchen. The DON verified the last dietary staff member working on 06/30/21 clocked out at 7:30 P.M. and the kitchen door should have been locked at that time. However, the door had not been locked and Resident #5 was able to exit out the door without staff knowledge. On 02/23/21 at 11:01 A.M. interview with Registered Nurse (RN) #560 revealed Resident #5 was an elopement risk and was wearing his wander guard bracelet at the time of fall on 06/30/20. However, the door he exited from was not equipped with the wander guard system because it should have been locked when staff were not in the kitchen. RN #560 revealed the kitchen door was to be locked after dietary staff left for the day. RN #560 revealed Resident #5 wandered in his wheelchair throughout the facility and would often go to the kitchen to get coffee throughout the day. RN #560 revealed she was unaware of when staff had last seen Resident #5 prior to him being found outside the facility on 06/30/20. RN #560 revealed she could not recall any staff being interviewed or completing statements related to the incident on 06/30/20. RN #560 also revealed there was no staff education after the incident. RN #560 verified staff involved in the incident should have filled out a statement related to the fall/elopement. On 02/23/21 at 11:25 P.M. interview with Licensed Practical Nurse (LPN) #502 revealed she was Resident #5's nurse on 06/30/20 at the time he was found outside the facility on the ground. LPN #502 revealed Resident #5 always goes all over the building in his wheelchair and staff would go looking for him if they had not seen him for awhile. LPN #502 was also aware Resident #5 would go to the kitchen to get coffee at times. LPN #502 revealed she could not state when she or other staff had last seen Resident #5 prior to him being found outside on the ground on 06/30/20. LPN #502 revealed she had filled out the incident report and then gave it to the DON and indicated the DON would have then been responsible for an investigation. LPN #502 revealed two nurses coming in early had gone to the kitchen for coffee and heard yelling outside. Upon investigation, they found Resident #5 yelling for help outside by the loading dock. The LPN revealed it was these nurses who found Resident #5 sitting on the step at the bottom of loading dock with his wheelchair laying at the bottom of loading dock steps. Resident #5 had skin tears to his bilateral hands and right forearm and abrasions to his bilateral knees. The staff assisted him to his wheelchair, brought him back into the facility and then called the physician. The resident was then sent to the emergency room for evaluation and treatment. Resident #5 returned to the facility with no fractures or other major injuries. LPN #502 verified the nurses should have all written a statement related to the incident. LPN #502 verified Resident #5 had continued pain for days following the incident which was controlled with [MEDICATION NAME] medication. Review of the facility policy titled, Fall and Fall Risk Managing, dated 12/2007 revealed the staff would identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the facility policy titled, Elopement, dated 12/2007 revealed the facility would be aware of the location of their residents to ensure their safety. This deficiency substantiates Complaint Number OH 768 and Complaint Number OH 007.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL, dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), record reviews, review of a facility investigation timeline, review of facility policy and procedures, observations and interviews with staff, the facility failed to implement effective and recommended infection control practices including adequate implementation of personal protective equipment (PPE) to prevent the transmission of COVID-19 in the facility. This resulted in Immediate Jeopardy when Resident #44 was re-admitted to the facility on [DATE] from the hospital and staff did not use appropriate PPE per CDC guidelines while the resident was on quarantine guidelines. Actual harm occurred when staff did not implement the appropriate infection control practices during care of Resident #44 who resided on Unit #1 (non-COVID unit) and tested positive for COVID-19. Residents #11, #18, #21, #35, #46, #48, #53, #56, #60 and #63, who also resided on Unit #1 subsequently tested positive for COVID-19. Residents #48, #60 and #63 were hospitalized due to complications related to COVID-19. Resident #60 expired in the hospital on [DATE] but had not been tested . Resident #11 expired in the facility on [DATE] as a result of COVID-19 complications. Three additional residents, Residents #20, #30 and #61, who resided on other units were also hospitalized due to COVID-19 complications. During the survey on [DATE] and [DATE], the facility had 26 of 59 residents (Residents #2, #7, #8, #12, #15, #16, #18, #20, #21, #23, #29, #32, #34, #35, #36, #44, #46, #48, #53, #55, #56, #60, #61, #62, #63, and #64) who also tested positive for COVID-19 as a result of the facility not implementing and/or following appropriate quarantine measures and not utilizing proper PPE when caring for these residents. Observations on [DATE] at 12:43 P.M. during the facility tour determined inadequate infection control practices including a staff member, Licensed Practical Nurse (LPN) #19, who was observed with a surgical mask over the N95 mask. She exited the room of Resident #30 who was exhibiting symptoms of COVID-19, wearing the same PPE she had worn in that room and she was observed passing the next meal tray to Resident #22. Resident #30 was subsequently hospitalized with a positive COVID-19 diagnosis. This finding had the potential to affect all 35 residents in the facility residing on Units #2 and #3 including Residents #1, #3, #4, #6, #9, #10, #13, #14, #17, #19, #22, #24, #25, #26, #27, #28, #31, #33, #37, #38, #39, #40, #41, #42, #43, #45, #47, #49, #50, #51, #52, #54, #57, #58, #59. Additional staff interviews on [DATE] at 5:39 P.M. confirmed COVID-19 test results were obtained for ten additional residents on the non-COVID unit including Residents #13, #17, #19, #25, #30, #40, #50, #51, #52 and #59. Residents #17, #19, #40, #50, #51 and #59 were positive for COVID-19 and moved to the COVID unit on [DATE]. Once a COVID-19 unit was established, staff were observed exiting the unit without removing PPE worn in the unit. On [DATE] at 4:36 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #44 was readmitted to her room on Unit #1 and was placed in quarantine or shelter in place precautions. Facility staff caring for Resident #44 did not utilize the appropriate full PPE, including an N95 mask, goggles/face shield, gown and gloves during provision of care and then provided care for other residents in the facility. Ten additional residents on Unit #1 subsequently tested positive for COVID-19. A total of twenty-seven residents tested positive for COVID-19, six residents were hospitalized with complications related to COVID-19, one resident expired in the hospital and one resident expired in the facility with complications related to COVID-19. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction action: · On [DATE], all staff in the facility were tested by the National Guard for COVID-19. The results were not obtained until [DATE]. Twelve staff members tested positive for COVID-19. · On [DATE], the facility developed a COVID-19 unit utilizing resident Rooms #105 to #114. The unit was separated from the other facility areas by fire doors which were closed. The donning and doffing station for the unit was located at the front entrance. · On [DATE], the COVID-19 unit was expanded to include resident Rooms #105-#,[DATE]. · On [DATE] the DON placed signs on the second set of doors at the back of the of the COVID-19 unit for staff to not use these doors and the sign indicated, NOT AN EXIT. Only one entrance and exit were to be used by the donning and doffing room. · On [DATE] and [DATE], 28 additional residents were tested for COVID-19. All tests were sent to the local health department. Ten of the residents tested had signs and symptoms of COVID-19. Those residents were placed on transmission-based precautions. · On [DATE], Registered Nurse (RN) #20 and Licensed Practical Nurse (LPN) #57 began COVID-19 testing for all residents residing on Units #2 and #3, the two non-COVID units. As of [DATE] six additional residents tested positive for COVID-19 including Residents #17, #19, #40, #50, #51 and #59. · On [DATE], the Medical Director contacted the DON and was updated on the COVID-19 status of residents and development of the COVID-19 unit along with policy and procedures for appropriate use of PPE. On this same date, the Medical Director (MD) did rounds with the DON and recommended testing all remaining residents in the facility who had not been tested for COVID-19. He also recommended additional staff education on use of PPE and signs and symptoms of COVID-19. · An audit was completed on [DATE] by the DON of all resident rooms to ensure compliance of PPE outside of resident rooms and signs on doors indicating the use of PPE on the doors. At this time, all residents in precautions or quarantine status, but not COVID-19 positive, were moved to Unit #3. All residents COVID-19 positive were moved to Unit #1 and all other residents were moved to or remained on Unit #2. · As of [DATE], all facility staff were required to wear full PPE in house, which included N95 masks, eye coverings, gowns and gloves, regardless of where they were working. This procedure would continue until the facility had no COVID-19 positive residents. Staff would continue to be screened each shift. · On [DATE], the facility implemented new policy and procedures regarding the use of transmission -based precautions and infection control titled, COVID Positive Residents: Screening and Management and COVID-19 Infection Control - Staff and COVID-19 Return to Work. · The DON or Infection Control/Designee began in-servicing all staff on [DATE] on appropriate infection control including the procedure for donning and doffing PPE and the above new policies and procedures, including quarantine procedures, use of PPE on various units and entering and exiting the dedicated COVID-19 unit. In-servicing would be completed by [DATE]. Staff not in-serviced by that date would not be permitted to work until in-servicing was completed. On [DATE] the DON in-serviced four STNAs, three LPNs, one housekeeper, one cook and one dietary aide. On [DATE] the DON in-serviced two LPNs, one RN, one housekeeper and the Activity Director. The DON confirmed the in-services were ongoing. · The DON confirmed on [DATE] the Local Health Department was aware of the additional six residents who tested positive for COVID-19 including Residents #17, #19, #40, #50, #51 and #59. · The DON and Administrator were in-serviced by the Corporate Clinical Nurse on [DATE] on the need to ensure that all residents in the facility would be placed on droplet precautions in accordance with the facility policy. · The DON or infection preventionist or designee would conduct daily observations of staff on all units to ensure staff were using PPE appropriately, donning and doffing appropriately and disposing of PPE appropriately. The observations would be performed for the next four weeks. · The DON and infection preventionist would monitor all newly diagnosed residents and newly admitted residents or readmitted residents to ensure they were placed in the appropriate transmission-based precautions according to their diagnosis. · On [DATE], interview with the DON at 3:38 P.M. verified all staff in-services had been completed this day at 3:00 P.M. · The Quality Assurance and Performance Improvement (QAPI) committee would review the plan by [DATE] and revise the plan as needed Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the CDC guidelines for Nursing Homes and Long-Term Care Facilities revised [DATE] confirmed for new admissions and readmissions whose COVID-19 status was unknown, Health Care Providers (HCP) should wear an N95 or higher-level respirator, eye protection including goggles or a face shield that covers the front and sides of the face, gloves and a gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for fourteen days after their admission. Review of the Levering Management Policy for Caring for a Patient with Suspected Coronavirus Infection Control Preparedness Plan form dated [DATE] confirmed staff were to maintain adherence to standard, contact and airborne precautions including the use of eye protection when caring for COVID residents. Review of Resident #44's undated facility timeline authored by the DON indicated on [DATE] the resident developed severe abdominal pain and was sent to the emergency room for evaluation and treatment. The resident had a cholecystectomy (gallbladder removal) and returned to the facility on [DATE] on a Level #1 protocol. A Level #1 surveillance protocol was for any resident that went out of the facility and returned with no known exposure to COVID-19. The facility also called a Level 1, a shelter in place status (quarantine). PPE included a surgical mask and gloves anytime a HCP entered the room with handwashing required after leaving the room and changing the surgical mask when leaving the room. Resident #44 was placed in her previous room on Unit #1(general population) upon return to the facility, without a roommate, and was placed on Level #1 precautions for fourteen days. The facility did not have a COVID unit set-up at that time. The facility's undated timeline indicated on [DATE], Resident #44 was tested for COVID-19 at the community hospital for preparation for an upcoming surgery on [DATE] for a nasal polyp removal. On [DATE] at approximately 12:30 P.M., the DON received a phone call from the local health department confirming Resident #44 was positive for COVID-19. On [DATE], Resident #44 was placed on Level #4 protocol which indicated the resident had tested positive for COVID-19 but was asymptomatic. Resident #44 had exhibited no symptoms up to this point and PPE involved a head cover, goggles or face shield, N95 mask, gown and shoe covers for any HCP entering her room. Staff removed the PPE at the door to her room and COVID-19 assessments were completed every four hours on the resident including monitoring of vital signs. Observation on [DATE] at 8:20 A.M. with the DON in attendance, and subsequent interview with LPN #21, revealed LPN #21 exited the COVID-19 unit through the back door wearing a mask, gown, face shield, and gloves and went onto Unit #3 (a non-COVID unit). At the time of the observation, the DON indicated the COVID-19 unit had two doorways, one at each end of the unit, but only the main entrance was to be used to enter and exit the unit. The back door was not to be used, though it was connected to the rest of the facility (the facility was shaped as a square). The DON indicated there were no donning/doffing PPE stations at the back door of the unit, it was only at the front entrance of the unit. LPN #21 confirmed she had worn the same PPE into the non-COVID-19 unit that she was wearing in the COVID-19 unit. LPN #21 also verified there were no PPE don/doff station at the back door where she exited the unit. She said she had doffed her COVID contaminated PPE on the COVID-19 unit in resident room [ROOM NUMBER]. She then donned new PPE outside of room [ROOM NUMBER] and exited the back door of the unit, after walking past resident Rooms #123, #124, #125, #126, and #127 onto Unit #3 (a non-COVID unit). After confirmation, LPN #21 removed her contaminated PPE in Resident #59's room and donned new PPE. Resident #59 later tested positive for COVID-19 on [DATE] at 9:19 A.M. Interview on [DATE] at 10:29 A.M. with Registered Nurse (RN) #15 revealed staff would constantly use the back door of the COVID-19 unit as a shortcut to move medications and papers but she did not specify where the staff would doff and don PPE. She stated the staff were doing this until [DATE], when they were instructed not to. She further stated that during Resident #44's quarantine that started [DATE], she remembered staff wearing masks, gown and gloves into the resident's room. Interview on [DATE] at 9:19 A.M. with RN #27 revealed she did not know staff could not use the back door of the COVID-19 unit as a shortcut until [DATE] when she was instructed not to use it. Interview on [DATE] at 9:30 A.M. with RN #25 revealed when Resident #44 was first quarantined, after her readmission to the facility on [DATE], the staff were only required to wear a mask and gloves for protection. She said they weren't required to wear a gown until a few days later. She did not mention the use of any other PPE used during the resident's quarantine period. Interview on [DATE] at 12:28 P.M. with State tested Nursing Assistant (STNA) #37 revealed when she worked with Resident #44 during the 14-day surveillance period after her readmission to the facility on [DATE], the only PPE she was required to wear was a mask, gown and gloves. Observation on [DATE] at 12:30 P.M. revealed Resident #26 had a white sign on the door which indicated the resident was to shelter in place and a PPE cart was outside the resident's door. The resident's room did not have a sign on the door for staff direction on contact precautions or to see the nurse prior to entering as required, which was confirmed by LPN #19 at that time. Interview on [DATE] at 12:38 P.M. with RN #20 indicated Resident #30 was symptomatic of COVID-19 with symptoms including cough, congestion, low oxygen level and poor appetite. RN #20 verified Resident #30 was to be tested on [DATE]. RN #20 also confirmed Resident #30 had a PPE cart outside the resident's room but did not have a sign on the door for contact precautions as required. Observation on [DATE] at 12:43 P.M. revealed LPN #19 entered Resident 30's room carrying the resident's lunch meal tray. LPN #19 wore a N95 respirator mask covering her mouth and nose with a surgical mask over the top of the respirator mask. She delivered Resident #30's tray, cut up the resident's food, washed her hands and then left the room. The N95 mask and surgical mask were still in place when the nurse exited the room. Interview with LPN #19 at the time of the observation confirmed she should have changed her surgical mask upon exiting the room and should have worn an isolation gown when in the room. LPN #19 confirmed she was not aware the resident was displaying positive COVID-19 symptoms and said if she did, she would have worn the appropriate PPE. LPN #19 also confirmed Resident #30's door did not have a sign confirming the appropriate PPE to be worn during care of the resident. The nurse indicated she was working as a nursing assistant. Interview on [DATE] at 12:55 P.M. with the DON revealed residents who were admitted or readmitted from the hospital prior to the first COVID-19 positive resident should have a shelter in place protocol and staff were to stay six feet from the resident when appropriate, wear gloves and a surgical mask. The DON also indicated as of [DATE], the facility upgraded the policy to include gowns. The DON also indicated staff were supposed to change the surgical masks and gowns when coming out of a shelter in place room, remove gloves and wash their hands. On [DATE] at 1:06 P.M. the DON indicated Resident #44 had dedicated staff beginning [DATE] which included STNA #37, LPN #5 and LPN #17. The DON confirmed after [DATE], the resident no longer had dedicated staff as more positive residents were identified. The DON confirmed Resident #44 went to the hospital on [DATE] and returned to the facility on [DATE] and was put on precautions for fourteen days. The DON revealed staff were required to wear surgical masks and gloves when caring for Resident #44 prior to the confirmed COVID-19 diagnosis. The DON verified Resident #44 was tested for COVID-19 on [DATE] and the results came back on [DATE] which were positive. The DON also confirmed after the facility was aware of the positive results, the staff were required to wear PPE including an N95 mask, gown, gloves, goggles/face shield, shoe covers and should complete COVID-19 assessments, use disposable utensils and disposable meal trays. Interview on [DATE] at 1:30 P.M. with LPN #5 revealed staff had worn just a surgical mask and gloves for caring for Resident #44 when she returned from the hospital and prior to her testing positive for COVID-19. LPN #5 confirmed she was assigned as dedicated staff for Resident #44 until [DATE]. She said then more residents were identified as having COVID-19 on [DATE]. Interview on [DATE] at 2:25 P.M. with the DON confirmed the facility started moving residents to Unit #1, to make a dedicated COVID-19 unit, the morning of [DATE]. The DON verified the COVID-19 unit was not started until the day following confirmation that Resident #44 was positive for COVID-19. The DON confirmed additional residents were tested for COVID-19 and on [DATE] Residents #2, #7, #12, #16, #34, #36, #48 and #61 tested positive. On [DATE], Residents #15, #21, #23, #55 and #57 tested positive. On [DATE], Residents #29, #32, #46, #56 and #60 tested positive. On [DATE], Resident #63 was sent to the hospital for nausea, vomiting, an elevated temperature and shortness of breath and suspected COVID-19. On [DATE], Residents #8, #11, #18, #20, #35 and #53 tested positive and on [DATE] Resident #62 tested positive. The DON confirmed Resident #60 expired in the hospital on [DATE] but he was unable to report what was the actual cause of the resident's death. The DON confirmed STNA #41 was the first staff member who was reported as COVID-19 positive. STNA #41 went to an urgent care on [DATE] and was tested for COVID-19. STNA #41 obtained her positive results on [DATE]. The DON confirmed STNA #41's last date of work was completed on [DATE] and she had worked on Unit #1 with Resident #44. Interview on [DATE] at 2:37 P.M. with STNA #41 confirmed she exhibited symptoms including cold chills, body aches and cough on [DATE] and went to the local emergency room (ER) and was treated for [REDACTED].#41 indicated she did not get better and went back to theER on [DATE] and was tested for COVID-19 which came back positive on [DATE], the same day because the ER had rushed the results. STNA #41 confirmed her last day worked was [DATE] on Unit #1. She said she only wore a surgical mask and gloves when entering Resident #44's room to care for her while she was in quarantine. Interview on [DATE] at 9:56 A.M. with the Medical Director confirmed Resident #44 was the first COVID-19 positive resident in the facility and he did not believe the resident was tested for COVID-19 in the hospital prior to the resident being returned to the facility on [DATE]. The Medical Director also confirmed admissions or readmissions required PPE including an N95 mask, gown, gloves and goggles. The Medical Director confirmed his last visit to see Resident #44 was on [DATE] and he brought his own N95 mask to utilize in the facility. The Medical Director also indicated he strongly suggested the facility test all residents currently residing in the facility for COVID-19. Interview on [DATE] at 1:06 P.M. with the Administrator confirmed on [DATE] when Resident #44 was readmitted to the facility, the facility had approximately 100 N95 masks. The Administrator verified that more N95 masks were purchased on [DATE] and [DATE]. The Administrator said the infection preventionist was on a medical leave the last few weeks and he was unaware of the current CDC guidance in which staff were to wear gown, gloves, N95 masks and goggles for new admissions or readmissions for fourteen days if their COVID-19 status was unknown upon admission or readmission. The Administrator also confirmed all other residents were tested for COVID-19 as of [DATE]. Interviews on [DATE] at 2:04 P.M. with RNs #94 and #95 confirmed they both worked at different facilities and were sharing the role of infection preventionist at this facility. They indicated the infection preventionist at this facility had been gone for approximately three weeks. Both nurses indicated they had visited the facility once since starting in this position, before the first resident tested positive. They indicated neither of them had not been involved in implementing any interventions since Resident #44 was readmitted or since she tested positive. Interview on [DATE] at 5:39 P.M. with LPN #12 confirmed ten residents whose COVID-19 test results were reviewed by the DON on [DATE] at 11:00 P.M. including Residents #17, #19, #40, #50, #51 and #59 who resided on the non-COVID-19 part of the facility had tested positive for COVID-19. Residents #13, #25, #30 and #52 tested negative for COVID-19. The COVID-19 positive residents were not moved to the COVID-19 unit the following day, [DATE]. Interview with the DON on [DATE] at 8:30 A.M. confirmed the facility had not used dedicated staff to care for Resident #44 while she was in her 14-day shelter in place (quarantine) status when she was readmitted on [DATE] until she tested positive on [DATE]. The DON verified the staff on Unit #1 provided care to Resident #44 and the other residents on that unit without wearing the appropriate full PPE. Review of the undated Census Positive Residents form provided by the facility confirmed Resident #44 was tested on [DATE]; Residents #2, #7, #12, #16, #34, #36, #48 and #61 were tested on [DATE]; Residents #15, #21, #23, #55 and #64 were tested on [DATE]; Residents #29, #32, #46, #56, and #60 were tested on [DATE]; Resident #63 was tested on [DATE]; Residents #8, #11, #18, #20, #35 and #53 were tested on [DATE]; and Resident #62 was tested on [DATE]. The facility confirmed all twenty-seven residents tested positive for COVID-19. Further review of the undated Census Positive Residents form revealed Resident #44 who tested positive for COVID-19 on [DATE] resided on Unit #1 and ten other residents who resided on Unit #1 including Residents #11, #18, #21, #35, #46, #48, #53, #56, #60 and #63 have since tested positive for COVID-19. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's Surveillance Observations form dated [DATE] confirmed the resident was on a Level #4 surveillance which confirmed the resident exhibited COVID-19 symptoms and facility staff were to maintain isolation and use PPE. The resident expired in the facility on [DATE] due to complications of COVID-19. Review of Resident #17's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Surveillance Observations form dated [DATE] at 8:00 P.M. indicated the resident was on Level #2 which indicated the resident had been exposed to a known COVID-19 person. Gloves and masks were required before entering the room. Review of Resident #17's progress note dated [DATE] at 9:38 A.M. indicated a message was left for family and the resident was aware of the positive COVID swab and a room change to the COVID unit. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Surveillance Observations form dated [DATE] indicated the resident was on Level #3 surveillance which confirmed the resident had tested positive for COVID-19 but was not symptomatic. Isolation was to be maintained and PPE used. Review of Resident #19's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's Surveillance Observations form dated [DATE] at 8:00 P.M. indicated the resident was on Level #4 which indicated he had symptoms of COVID-19 and had probably been exposed and was presumed positive. Isolation was to be maintained and PPE used. Review of Resident #19's progress note dated [DATE] at 9:42 A.M. indicated the resident's family was notified of a positive COVID swab and room change to the COVID-19 unit. Review of Resident #20's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's Surveillance Observation form dated [DATE] indicated the resident was on Level #4 surveillance which confirmed the resident exhibited COVID-19 symptoms. Staff were to maintain the resident's isolation and use PPE. Review of Resident #20's progress note dated [DATE] at 2:01 A.M. confirmed the resident was sent to the emergency room for evaluation and treatment on [DATE] for shortness of breath, declining condition. Resident #20 was admitted to the intensive care unit (ICU). The resident returned to the facility on [DATE] and was readmitted to the COVID-19 unit. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's Surveillance Observations form dated [DATE] indicated the resident was on Level #3 surveillance which indicated the resident tested positive for COVID-19 but was not symptomatic. Isolation was to be maintained and PPE was to be used. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's Surveillance Observations form dated [DATE] at 08:00 A.M. indicated the resident was on Level #4 surveillance which indicated the resident had symptoms of COVID-19. Isolation was to be maintained and PPE used. Review of Resident #30's progress note dated [DATE] at 9:45 P.M. indicated the nurse received a call and the resident was being admitted to the hospital. The resident had tested positive for COVID-19. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's Surveillance Observations form dated [DATE] indicated the resident was on Level #4 surveillance which indicated the resident exhibited COVID-19 symptoms. Isolation was to be maintained and PPE used. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #40's Surveillance Observations form dated [DATE] at 8:00 P.M. indicated the resident was on Level #2 surveillance which indicated the resident had been exposed to a known COVID-19 person. Gloves and masks were required before entering the room. Review of Resident #40's progress note dated [DATE] at 3:28 P.M. indicated the resident's family was notified of a positive COVID swab and the resident's room was changed. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's Surveillance Observations form dated [DATE] indicated the resident was on Level #3 surveillance which indicated the resident had tested positive but was not symptomatic. Isolation to be maintained and PPE used. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's Surveillance Observations form dated [DATE] revealed the resident was on Level #4 surveillance which indicated the resident exhibited COVID-19 symptoms. Staff were to maintain isolation and use PPE. Review of Resident #48's progress note dated [DATE] at 11:19 A.M. indicated the resident continued to remove his oxygen and the physician was notified. New orders were obtained to send the resident to the emergency room . The resident had not returned to the facility at the time of the survey. Review of Resident #50's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #50's Surveillance Observations form dated [DATE] at 8:00 P.M. indicated the resident was on Level #2 surveillance as the resident had been exposed to a known COVID-19 person. Gloves and masks were required before entering the room. Review of Resident #50's progress note dated [DATE] at 9:31 A.M. indicated the family was notified of a positive COVID-19 swab and the resident was moved to the COVID-19 unit. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's Surveillance Observations form dated [DATE] at 8:00 P.M. indicated the resident was on Level #2 surveillance stating the resident had been exposed to a known COVID person. Gloves and masks were required before entering room. Review of Resident #51's progress note dated [DATE] at 9:26 A.M. indicated the resident's family was notified of a positive COVID swab and the resident was moved to the COVID-19 unit. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #53's Surveillance Observations form dated [DATE] indicated the resident was on Level #4 surveillance which verified the resident exhibited COVID-19 symptoms. Isolation was to be maintained and PPE was to be used. Review of Resident #5 (TRUNCATED)