Every finding on record at Countryside Manor Nursing and Rehabilitation LLC

Based on observation, staff interview, and review of facility policy, the facility failed to safely store refrigerated and freezer items. This had the potential to affect all residents who receive food from the kitchen. The facility identified one (#45) resident who does not receive food from the kitchen. The facility census was 65. Observation on 05/11/26 at 9:00 A.M. of the walk-in freezer revealed the thermometer was placed in the cooling fan. The thermometer read 20 degrees Fahrenheit. Further observation revealed what appeared to be melted vanilla ice cream on the floor and on the container lids below the ice cream. All six three gallon ice cream containers were soft and felt melted from the outside of the cardboard container. Observation on 05/11/26 at 9:05 A.M. of the walk-in refrigerator verified four- one gallon jugs of 2% milk with a sell by date of 04/23/26 (18 days ago) and four- one gallon jugs of 2% milk with a sell by date of 05/06/26 (5 days ago). Interview on 05/11/26 at 9:09 A.M. with Dietary Manager #106 verified the ice cream containers were soft to the touch and melted ice cream was on the container lids below the ice cream and on the floor. Dietary Manager #106 stated the freezer had kicked off this morning and it was reset. Dietary Manager #106 verified the 2% milk sell by date was past the time for resident use. Observation on 05/11/26 at 9:28 A.M. of the walk-in freezer revealed the thermometer now placed near the door read 20 degrees Fahrenheit. Observation on 05/11/26 at 9:42 A.M. of the walk-in freezer revealed the thermometer now placed near the door read 10 degrees Fahrenheit. Review of voicemail from the milk producer's customer service on 05/21/26 at 9:44 A.M. verified the best buy date is not a date of expiration. There is not an exact date of expiration, just when the product shows any signs of spoilage. It is recommend using the milk by the best by date based on testing. It can sometimes be good a few days after the best buy date. Review of the undated facility policy titled Food Receiving and Storage revealed the freezer must keep frozen foods frozen solid and all food stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).

Based on observation, staff interviews, and review of facility policy, the facility failed to maintain a clean, sanitary, and homelike environment. This affected all 65 residents residing in the facility. Findings include: 1.Observation on 05/12/26 at 12:53 P.M. of Resident #42's room revealed the area immediately surrounding the resident's toilet was discolored with a sticky, amber-colored substance, with miscellaneous pieces of black debris adhered to the surface. Further observation of Resident #42's restroom revealed the windowsill was broken and could be lifted off the wall. Additional miscellaneous debris was observed scattered throughout the resident's room floor. Interview on 05/12/26 at 12:53 P.M. with Resident #42 revealed she did not feel the facility did an adequate job of keeping her resident room and restroom clean to her satisfaction. Interview on 05/12/26 at 1:25 P.M. with Certified Nursing Assistant (CNA) #501 verified the sticky, amber-colored substance with miscellaneous pieces of black debris adhered to the surface immediately surrounding Resident #42's toilet, the broken window sill that could be lifted off the wall, and miscellaneous debris scattered throughout the resident's room floor. 2. Observation on 05/18/26 at 7:26 A.M. of the 200-Hallway between Resident #42's room and Resident #28's room revealed multiple areas of an unidentified brown substance on the floor. The first area measured approximately one-quarter inch in height, one-half inch in width, and one inch in length. Approximately one foot away, a second area of the same unidentified brown substance was observed, measuring approximately one-quarter inch in height, one and one-half inches in width, and four inches in length. Roughly two feet from the second area, a third area of unidentified brown substance was observed, similar in shape and size to the second. Approximately one foot beyond the third area, a fourth area of unidentified brown substance was noted, measuring approximately one inch in width and five inches in length. Interview on 05/18/26 at 7:27 A.M. with Registered Nurse (RN) #502 verified the multiple areas of unidentified brown substance on the floor of the 200-Hallway between Resident #42's room and Resident #28's room. Observation on 05/18/26 at 7:36 A.M. of the floor is the 200-Hallway revealed miscellaneous grime and debris by the nursing station and nursing unit hallways. Interview on 05/28/26 at 7:38 A.M. with RN #147 verified the floor of the 200-Hallway by the nursing station and nursing unit hallways contained miscellaneous areas of grime and debris. Observation on 05/18/26 at 7:38 A.M. of the floor in the 300-Hallway revealed an unidentified brown and green substance and miscellaneous grime and debris by the nursing station and miscellaneous grime on the floors of the B wing. Interview on 05/18/26 at 7:40 A.M. with Housekeeping Aide #153 verified the floor in the 300-Hallway contained an unidentified brown and green substance and miscellaneous grime and debris by the nursing station and miscellaneous grime on the floors of the B wing. Review of the facility policy titled Quality of Life – Homelike Environment, revised May 2017, revealed residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment. 3. Observation on 05/11/26 at 10:39 A.M. noted the common shower next room [ROOM NUMBER]. The toilet and floor next to the toilet were covered in a brown substance on the surface. Scattered debris was also identified on the floor including paper and a disposable glove. Observation on 05/11/26 at 12:18 P.M. of the common shower next to room [ROOM NUMBER] revealed the shower stall floor with black substance to the tile floor, orange and brown substance to the base of the wall and floor in the shower, and debris in the sink and on the floor. In addition broken drywall was noted to the base of the wall entering the shower stall. Interview on 05/11/26 12:21 P.M. with Licensed Practical Nurse (LPN) #154 verified the environmental conditions inside both second floor common showers. Interview on 05/18/26 at 12:10 P.M. the Administrator identified 15 residents (#6, #9, #18, #20, #21, #33, #36, #46, #50, #52, #55, #59, #60, #61, #70) residing on the second floor that utilized the common shower rooms. This deficiency represents non-compliance investigated under Complaint Number 2806427, 279115, 2667933, 2618793, 2589881, and 2581692.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure fall prevention interventions were implemented for two (#9, #32) of three residents reviewed for fall prevention. In addition, the facility failed to ensure resident smoking assessments were completed affecting two (#13, #40) of two residents reviewed for smoking. The facility identified 11 residents (#13, #20, #29, #36, #40, #42, #52, #56, #58, #61, and #64) as smokers in a facility census of 65. Findings Include: 1. Review of the medical record revealed Resident #9 admitted to the facility on [DATE]. Diagnoses included dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #9 with intact cognition, psychosis related hallucinations and delusions, range of motion impairment on one side upper and lower extremities, dependent on staff for the completion of activities of daily living including bed mobility and transfer, always incontinent of bowel and bladder, utilized a wheelchair independently for mobility, and experienced two or more falls since admission. Review of nursing plan of care revised 03/26/25 to address Resident #9 risk of falling. Interventions included replace dycem to wheelchair (initiated 02/19/26). New interventions on 05/02/26 included to place dycem between bottom and mechanical lift pad with a sign to be hung by the wheelchair to remind staff to properly place dycem.Review of the Visual/Bedside Kardex, undated, under the area of safety noted instructions to replace dycem to wheelchair as needed. Review of the fall risk assessment dated [DATE] fall risk assessment revealed Resident #9 to have a high risk with multiple falls. Review of interdisciplinary team (IDT) post fall incident investigation summary noted an incident dated 05/02/26 at 6:30 A.M. The resident's wheelchair does not tilt back so he is able to lean forward and slide out of the chair. The resident's wheelchair was not locked. New intervention/Care plan decision included dycem between resident and lift sling and chair. Review of IDT note on 05/04/26 at 9:47 A.M. documented fall from 05/02/26 reviewed per IDT. Resident found in dining room on floor on his buttocks in front of the wheelchair. Resident stated he could get up and move by himself. Staff educated this is not accurate and he needed to ask for assistance. Observation on 05/13/2026 at 11:26 A.M. noted Certified Nurse Assistant (CNA) #170 and CNA #181 respond to Resident #9's room. Resident #9 was seated in a wheelchair with a Hoyer lift sling placed under him in the seat of the chair. CNA #170 and CNA #181 proceeded to transfer the resident to his bed with the Hoyer lift. No dycem was in place between the resident and his sling or under the sling on the chair seat. CNA #181 provided Resident #9 with care in the bed and proceeded to place the lift sling under the resident with no dycem placed. No sign was observed to be posted in the room to remind the staff to place the dycem. Interview at the time of the observation on 05/13/2026 at 11:26 A.M. with CNA #170 and CNA #181 at the time verified no dycem was in place as per the care plan. CNA #170 and CNA #181 also verified no sign was in Resident #9's room to remind staff to properly place dycem. CNA #170 and CNA #181 stated no dycem was available in Resident #9's room and both were unaware dycem was to be placed between the resident and Hoyer lift sling. On 05/13/26 at 12:14 P.M. interview with Licensed Practical Nurse (LPN) #108 verified dycem was not in place to Resident #9 as indicated in the fall prevention plan of care. Review of facility policy titled Falls Clinical Protocol, revised September 2012, noted based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2.Review of medical record for Resident #32 revealed an admission date of 12/08/20. Diagnoses included bilateral primary osteoarthritis of knee, congestive heart failure, dementia, and chronic kidney disease. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of care plan dated 05/19/26 revealed the resident was at risk for falls related to deconditioning, gait/balance problems, history of falls, medication side effects, and noncompliance with waiting for assistance with ransfers. Interventions included keep bed in lowest position with mat on each side of the bed, non-skid strips in front of the toilet, and sign in bathroom reading call before you fall. Observation and interview on 05/11/26 at 10:28 A.M. of Resident #32 revealed the resident lying in bed with a visitor sitting in folding chair beside the bed. Bed was observed to be in a high position with no mats were on the floor. Observation on 05/18/26 at 2:25 P.M. of Resident #32's room revealed no mats were present in the room. Interview on 05/18/26 at 2:27 P.M. with CNA #103 verified there were no mats in Resident #32's room. CNA #103 stated the resident's bed had been moved a while ago and they may have taken the mats out at that time. Interview on 05/19/26 at 9:24 A.M. with MDS Coordinator #163 verified the care plan for Resident #32 still had interventions for mats to both sides of the bed for fall intervention. Review of policy titled Falls-Clinical Protocol, revised September 2012, revealed the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention is resolved. 3. Review of medical record for Resident #40 revealed an admission date of 03/12/26. Diagnoses included nicotine dependence cigarettes. Review of the MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of care plan dated 03/25/25 revealed the resident was smoker. Interventions included smoking assessment quarterly and as necessary. Review of smoking safety evaluation dated 03/12/26 revealed the resident was a smoker with short- and long-term memory intact. Resident is an unsupervised smoker. Review of smoking safety evaluation dated 04/19/26 revealed the resident does not smoke. Review of smoking safety evaluation dated 05/04/26 revealed the resident does not smoke. Review of list provided by the facility of current smokers revealed Resident #40 was on the list. Interview on 05/19/24 at 9:24 A.M. with MDS Coordinator #163 verified Resident #40 was a smoker and goes out on smoke breaks. MDS Coordinator #163 verified the smoking evaluations completed in April and May 2026 were incorrect. Review of policy titled Smoking Policy-Residents, revised July 2017, revealed a resident's ability to smoke safely will be re-evaluated quarterly, upon significant change and as determined by staff. 4. Review of the medical record for Resident #13 revealed an admission date of 12/07/25. Diagnoses included type two diabetes mellitus, convulsions, hypotension, anemia, transient ischemic attack, hypertension, and alcohol use. Review of the MDS assessment, dated 03/19/26, revealed Resident #13's cognition was moderately impaired. Review of the admission smoking assessment for Resident #13, completed 12/07/25, revealed Resident #13 was not a smoker. Review of the quarterly smoking assessment for Resident #13, completed 03/07/26, revealed Resident #13 was a smoker. Review of Resident #13's smoking assessments revealed there were no smoking assessments completed between 12/07/25 and 03/07/26. Interview on 05/12/26 at 3:30 P.M. with Resident #13 revealed he began smoking in February 2026 and told the Director of Nursing (DON) when he began smoking. Interview on 05/12/26 at 3:37 P.M. LPN #108 stated Resident #13 was not a smoker when he admitted on [DATE]. He began to go outside and smoke a couple of months after his admission. Further interview with LPN #108 revealed she completed Resident #13's smoking assessment on 03/07/26. Interview on 05/12/26 at 3:43 P.M. with the DON and LPN #163 revealed Resident #13 began smoking in February 2026. The DON verified there were no smoking assessments completed between 12/07/25 and 03/07/26. This deficiency represents non-compliance investigated under Complaint Number #1321980.

Based on review of Self-Reported Incidents (SRIs), review of facility investigation, interviews, and policy review the facility failed to report misappropriation of controlled substances for destruction to the State Survey Agency. This affected ten (#82, #83, #84, #85, #86, #87, #88, #89, #90, and #91) of 20 residents reviewed for controlled substances for destruction. The facility census was 65.Findings include:Review of the facility investigation dated 11/14/24 revealed controlled medications removed from use for disposal were not present in the facility and there was no evidence of destruction. The following medications were missing: nine oxycodone/acetaminophen 5/325 milligram (mg) tablets and 59 oxycodone/acetaminophen 5/325 mg tablets for Resident #82; 60 oxycodone 5 mg tablets and five oxycodone tablets for Resident #83; 11 oxycodone 5 mg tablets for Resident #84; 10 oxycodone/acetaminophen 5/325 mg tablets, 11 oxycodone/acetaminophen 5/325 mg tablets, and 42 oxycodone/acetaminophen 5/325 mg tablets for Resident #85; 33 oxycodone 10 mg tablets for Resident #85; 14 oxycodone 5 mg tablets for Resident #87; 10 oxycodone 5 mg tablets for Resident #88; 40 oxycodone 5 mg tablets for Resident #89; 32 oxycodone/acetaminophen 7.5/325 mg tablets for Resident #90; and Resident #91 was missing one hydrocodone 7.5/325 mg tablets, 56 hydrocodone/acetaminophen 7.5/325 mg tablets, and two hydrocodone 7.5/325 mg tablets.Review of facility SRIs revealed no SRI was reported on or around 11/14/24 for misappropriation of medications.Interview on 05/12/26 at approximately 3:45 P.M. Regional Clinical Director (RCD) #508 revealed they don't report a drug diversion to the Ohio Department of Health (ODH) as a SRI. RCD #508 stated they reported it to the Ohio Board of Nursing and the Pharmacy Board. RCD #508 stated she was not a part of whether the medications were credited back to the residents and if the facility paid for them. RCD #508 stated the medications were not active medications and they were set to be destroyed.Interview on 05/19/26 at 11:45 A.M. the Administrator stated the facility did not report the missing narcotics as misappropriation to ODH as the residents were no longer at the facility. The medications became the facility's property and not the residents since they were going to be destroyed. The Administrator stated if a resident was discharged to home they send the medications with them. Administrator stated the facility notified the local police department, Ohio Board of Nursing, and the Pharmacy Board.Review of policy titled Abuse and Neglect Protocol, dated 06/13/21, revealed it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. If an incident of suspected abuse occurs, facility shall report immediately, but not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to designated state agency. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the state agency within five working days or as designated by state law.This deficiency represents noncompliance investigated under Incident Number 2970249.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident representative and physician notification after a change in condition. This affected two (#62 and #76) of two residents reviewed for notification. The facility census was 65. Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] with reentry on 07/01/24. Diagnoses included conversion disorder with seizures or convulsions, hyperlipidemia, malignant neoplasm of thyroid gland, dementia, major depression, anxiety disorder, cerebral aneurysm, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident was cognitively intact. Review of nursing progress note, dated 07/23/25, revealed Resident #62 was sent to the emergency room for evaluation. The resident was having slurred speech, was weak, and trembling while trying to walk. Resident #62's blood pressure was slightly elevated and resident stated the writer had two faces. The on-call physician was notified and resident was sent to the emergency room for evaluation. There was no documentation of the family being notified. Review of nursing progress note, dated 11/28/25, revealed Resident #62 was standing in the hallway with a fixed stare, slurring words, and appearing very weak. Resident #62 was assisted back inside the room and place in a recliner. Staff sat with the resident providing one on one care. The resident then began having convulsions lasting approximately one minute. Vitals were obtained and were within normal limits. Staff sat with the resident until she became more alert. After becoming more alert she requested some Tylenol for a headache. The floor nurse was updated and Tylenol was provided. There was no documentation of family or physician notification of this episode. Review of nursing progress note, dated 12/09/25, revealed Resident #62 had seizure activity today at approximately 10:45 A.M. Vitals were within normal limits and the resident came to within a couple of minutes. The nurse encouraged the resident to rest in bed, call light in reach. Review of nursing progress note, dated 12/09/25, revealed Resident #62 had a second seizure like activity in the dining room at approximately 2:30 P.M. Vitals were within normal limits and the nurse brought the resident back to her room. Encouraged her to rest in her chair and use her call light if she needed anything. There was no documentation of family or physician notification of either episode. Review of nursing progress note, dated 03/28/26, revealed Resident #62 reported and presented with seizure like activity. The resident had some tremors to hands and slurred slowed speech noted. The resident reported she just had a seizure. The writer inquired what that was like from her perspective and the resident reported she generally has a headache when she seizes and the headache had since resolved. The writer sat with the resident through lunch and the resident's speech became clear, the tremors resolved, and the resident reported being fine. The tablet was not connecting for telehealth notification and a fax was sent to the physician's office. There was no documentation of the family being notified. Interview on 05/14/26 at 9:48 A.M. with the Director of Nursing (DON) verified on 12/09/25 there was no physician notification and no family notification on 07/23/25, 12/09/25, or 03/28/26. Interview on 05/19/26 at 11:58 A.M. with MDS Coordinator #163 verified on 11/28/25 family and physician notification did not occur. 2. Review of medical record revealed Resident #76 had an admission date of 01/24/25 and discharge date of 12/18/25. Diagnoses included acute osteomyelitis of right ankle and foot, history of falling, disorders of bone density and structure, and fibromyalgia. Review of MDS dated [DATE] revealed the resident was cognitively intact. Review of health status note dated 10/27/25 as a late entry revealed the resident was witnessed to slide to the floor from the wheelchair. The resident was waiting to return to bed after being unable to eat lunch due to emesis. The resident's vital signs were blood pressure 116/46, heart rate 18 and matched a radial pulse. Pedal pulses were present but faint due to edema. Respiratory rate was 18 and oxygen saturation was low at 83 percent (%) on three liters per nasal cannula. Resident #76 complained of pain to left side and hip and the left leg was abducted at an odd angle. Emergency Medical Service (EMS) called for the resident to be transferred to the hospital for evaluation and treatment. The Certified Nurse Practitioner (CNP) and the Assistant Director of Nursing (ADON) were notified at the time of the fall. There was no documentation the family was notified of the fall. Review of health status note dated 10/30/25 at 6:18 P.M. revealed the CNP gave an order to send the resident out the Emergency Department (ED) for decreased mobility to upper extremity due to pain and swelling. The resident transferred to the ED for evaluation and treatment. There was no documentation the family was notified of the swelling to the arm and the transfer Review of health status note dated 10/31/25 at 6:06 A.M. revealed the resident returned from the hospital via stretcher at 11:05 P.M. The left arm was in a sling related to possible radial head fracture. The on call CNP was aware of the residents return and condition. There was no documentation the family was notified of the resident's return. Interview on 05/19/26 at 9:42 A.M. with MDS Coordinator #163 verified there was no family notification for the fall on 10/27/25, the transfer to the hospital on [DATE] for swelling in the left arm, or when the resident returned from the hospital on [DATE]. Review of the facility policy titled Acute Condition Changes-Clinical Protocol, revised March 2018, revealed the nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request prompt response (within approximately one-half hour or less). This deficiency represents noncompliance investigated under Complaint Numbers 2577994 and 2667933.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure resident privacy was provided during incontinence care. This affected one (#9) of 20 residents observed for privacy in a facility census of 65. Findings include: Review of the medical record for Resident #9 revealed and admission to the facility on [DATE]. Diagnoses included dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis.Review of the Minimum Data Set assessment dated [DATE] revealed Resident #9 with intact cognition and was dependent on staff for the completion of activities of daily living. Observation on 05/13/26 at 11:25 A.M. revealed Activity Aide #146 propelled Resident #9 in his wheelchair to his room, activated the call light, and proceeded to exit the room. At 11:26 A.M. Certified Nurse Aide (CNA) #170 and CNA #181 responded to Resident #9 room. CNA #181 stated Resident #9 was requesting to use the toilet. Resident #9 was noted to be incontinent of urine through his pants and onto the mechanical lift sling in the wheelchair. CNA #181 and CNA #170 proceeded to transfer Resident #9 to his bed using the mechanical lift. The CNAs removed Resident #9's heavily soiled pants, brief and mechanical lift sling. Resident #9's bed was located within three feet of an exterior window which looked out onto the resident smoking area and associated patio. The curtains remained opened exposing Resident #9's perinium during incontinence care. Resident #9 was then positioned to his left side exposing his buttock and a moderate amount of incontinent formed stool. CNA #170 summoned Licensed Practical Nurse (LPN) #108 to the room and LPN #108 proceeded to apply a zinc barrier cream to the reddened skin. CNA #170 and CNA #181 proceeded to place a new incontinence brief and pants to Resident #9. No attempts to close the blind to the window occurred throughout the entire procedure. Interview with CNA #181 and CNA #170 on 05/13/26 at 12:07 P.M. verified the curtain was left open and Resident #9 was not provided with sufficient privacy when he was exposed during incontinence care. Review of facility policy titled Dignity, revised February 2021, revealed staff promote, maintain and protect privacy, including bodily privacy during assistance with personal care and during treatment procedures. This deficiency represents noncompliance investigated under Complaint Numbers 2999106, 2589881, and 2583063.

Based on record review, review of bed hold notifications, interview, and policy review, the facility failed to ensure the bed hold notifications contained all the required criteria and bed hold policies were provided upon a hospital transfer. This affected two (#2 and #76) of two residents reviewed for bed holds. The facility census was 65.Findings include:1.Review of medical record for Resident #2 revealed an admission date of 01/20/25. Diagnoses included multiple sclerosis, depression, anxiety, seizures, atrial fibrillation, and age-related osteoporosis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of nurses note dated 12/29/25 at 11:36 P.M. revealed the resident was having episode of brown emesis. Vital signs were temperature 104.4 degrees Fahrenheit, respirations 18, blood pressure 140/81, heart rate 96, and oxygen saturation 94 percent on room air. Upon consulting on call physicians and order was received to send the resident out to the emergency room as soon as possible for an evaluation.Review of bed hold notification/transfer letter dated 12/29/25 revealed the resident was being transferred to the hospital due to brown emesis. The box was checked stating you have 30 bed hold days left for the year 2025 under Ohio Medicaid guidelines. We will hold your bed for you until those days have been exhausted. The letter does not contain the reserve bed payment policy and address the return of the residents to the next available bed. There was no evidence the facility's bed hold policy or return policy was provided to the resident/resident representative.2.Review of medical record for Resident #76 revealed an admission date of 01/24/25 and discharge date of 12/18/25. Diagnoses included osteomyelitis of right ankle and foot, muscle weakness, disorders of bone density and structure, congestive heart failure, depression, and fibromyalgia.Review of MDS dated [DATE] revealed the resident was cognitively intact.Review of health status note dated 10/27/25 at 2:45 P.M. as a late entry revealed the resident was witnessed sliding to the floor from wheelchair. The resident complained of left side and hip pain with left leg abducted at an odd angle. Resident #76 was sent to the hospital for evaluation and treatment.Review of bed hold notification/transfer letter dated 10/27/25 revealed the resident was being transferred to the hospital due to a fall. The box was checked which documented the resident had no bed hold days left or was not eligible for bed hold. If you would like the facility to hold your bed for you, please reach out to the Admissions, Business Office, or Social Work department. The letter does not contain the reserve bed payment policy, duration of bed holds, and address the return of the residents to the next available bed. There was no evidence the facility's bed hold policy and return policy was provided to the resident/resident representative. Interview on 05/19/26 at 11:34 A.M. with Business Office Manager (BOM #166) revealed she gives the bed hold letter to the resident or responsible parties. BOM #166 stated every resident who goes out gets the same bed hold letter. BOM #166 verified the bed hold letter does not have how much it would cost to hold the bed if the resident is private pay or Medicare. BOM #166 verified the bed hold letter only contained information regarding how many bed hold days a Medicaid resident had or that the resident either did not have any bed hold days or they were not eligible for bed hold days and to notify the facility if they would like their bed held.Review of policy titled Transfer or Discharge Notices, revised on 07/30/25, revealed when a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the residents return is generally expected. Notice of the facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. Notices are provided in a form and manner the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments.

Based on record review, observation, and interview, the facility failed to ensure activities of daily living (ADL) care with removal of facial hair was provided to one (#49) of three residents reviewed for ADLs. The facility census was 65. Findings include: Review of the medical record revealed Resident #49 was admitted on [DATE] with reentry on 10/15/24. Diagnoses included multiple sclerosis, Alzheimer's disease, and major depressive disorder. Review of the Minimum Data Set assessment, dated 03/23/26, revealed the resident had moderate cognitive impairement and required partial/moderate assistance with personal hygiene. Observation on 05/12/26 at 7:53 A.M. of Resident #49 revealed the resident had numerous and long facial hair on her upper lip and chin. Interview on 05/13/26 9:01 A.M. with Resident #49 verified she would like to have her facial hair shaved. Observation on 05/14/26 at 11:33 A.M. of Resident #49 revealed the resident continued to have numerous and long facial hair. Interview on 05/14/26 at 11:35 A.M. with Unit Manager #125 verified Resident #49 had a shower on the prior day. Unit Manager #125 verified Resident #49 had noticeable facial hair on her upper lip and chin. This deficiency represents non-compliance investigated under 2583063, 2589881, 2618793, and 2791151.

Based on record review, interview, and policy review, the facility failed to ensure orders were obtained for the use of a sling and failed to ensure follow up orthopedic consults were obtained for one (#76) of four residents reviewed for falls. The facility census was 65.Findings include:Review of medical record for Resident #76 revealed an admission date of 01/24/25 and discharge date of 12/18/25. Diagnoses included coronary artery disease, congestive heart failure, and chronic kidney disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of health status note dated 10/30/25 at 6:18 P.M. revealed the Certified Nurse Practitioner (CNP) gave orders to send the resident to the Emergency Department (ED) for decreased mobility to left upper extremity due to pain and swelling. The resident transferred to the ED for evaluation and treatment.Review of ED documentation dated 10/30/25 revealed Resident #76 presented with a fall. The resident complained of left arm pain and general body aches after a fall three days ago where she was seen in the. The right side was x-rayed initially because the resident was complaining of right sided pain, Today she is complaining of the left side having pain. The resident denies any new falls or injury. Swelling was observed to the left forearm. An X-ray of left forearm revealed equivocal impacted fracture of radial head. X-ray of the left elbow revealed questionable radial head fracture. Recommend follow-up radiographs in seven to ten days.Review of health status note dated 10/31/25 at 6:06 A.M. revealed the resident returned from the hospital via stretcher at 11:05 P.M. Review of the physician visit progress note dated 11/03/25 at 8:00 A.M. revealed the resident was sent out to the ED for a large amount of swelling to her left arm into wrist and hand. Resident was unable to move her fingers and entire left upper limb with attempts to move being very painful. The resident was x-rayed and there was a concern for a left radius fracture. The resident returned to the facility with a sling. The resident is to have orthopedics follow her.Further review of the medical record revealed no physician order for the sling to left arm and no evidence an orthopedic consult was made for the resident.Interview on 05/19/26 at 9:24 A.M. with MDS Coordinator #163 verified there were no physician orders regarding the sling to the left arm or any evidence an orthopedic consult was obtained.Review of policy titled Acute Condition Changes-Clinical Protocol, revised March 2018, revealed the staff will monitor and document the resident progress and responses to treatment, and the physician will adjust treatment accordingly and the physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized.This deficiency represents noncompliance investigated under Complaint Number 26679933 and 1321980.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure incontinent residents received timely and effective incontinence care. This affected two (#5, #9) of two residents reviewed for incontinence care and services in a facility census of 65. Findings include: 1.Review of the medical record revealed Resident #5 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, obesity, panic disorder, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, generalized edema, hypertension, venous thrombosis and embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 with intact cognition, dependent on staff for the completion of activities of daily living, and always incontinent of bowel and bladder. Review of the Continence Care assessment dated [DATE] revealed Resident #5 was noted with a history of urinary tract infections, incontinent of varying amounts of urine daily using six incontinence briefs every 24 hours. Review of the 05/06/25 plan of care addressed Resident #5's bladder/bowel incontinence related to impaired mobility and physical limitations. Interventions included clean perinium with each incontinence episode, check as needed/required for incontinence, change clothing as needed (PRN) after incontinence episodes, and check the resident, during rounds and as required for incontinence. Review of Visual/Bedside Kardex Report (undated) noted to check resident during rounds and as required for incontinence. The resident's usual performance is dependent with toileting hygiene and not toileted due to mechanical lift transfers. Review of the plan of care response history between 04/12/26 and 05/13/26 noted Resident #5 was recorded as incontinent of urine daily. Interview on 05/11/26 at 10:23 A.M. Resident #5 stated she was not checked or changed every two hours for incontinence. Observation on 05/12/26 at 10:44 A.M. noted Resident #5 was in bed. Resident #5 stated she was last checked for incontinence by Certified Nurse Aide (CNA) #169 at approximately 6:00 A.M. Continued observation and interview on 05/12/26 at 12:57 P.M. revealed Resident #5 was in bed. Resident #5 stated she has not been checked since before breakfast by CNA #169. Resident #5 stated she was currently incontinent.Observation on 05/12/26 at 1:11 P.M. revealed Licensed Practical Nurse (LPN) #18 and CNA #501 entered Resident #5's room. CNA #501 obtained incontinence care supplies and proceeded to remove the front of Resident #5's incontinence brief. CNA#501 cleaned Resident #5;'sperinium and LPN #108 assisted with turning Resident #5 to the left, exposing a heavily soiled brief with urine through to the bed linen and a folded top sheet under the resident. Resident #5's skin area to the buttocks was observed to be red. After CNA #501 cleansed the resident, LPN #108 applied a zinc barrier cream, new brief and folded top sheet under the resident. Interview on 05/12/26 at 1:31 P.M. CNA #501 verified no attempts to check Resident #5 for incontinence had occurred since assuming care of the resident at 7:00 A.M. Interview on 05/12/26 at 1:32 P.M. LPN #108 verified Resident #5 was heavily soiled of urine and was noted with reddened skin to the buttocks caused by urine and associated moisture. 2. Review of the medical record for Resident #9 revealed and admission to the facility on [DATE]. Diagnoses included dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis.Review of the Minimum Data Set assessment dated [DATE] revealed Resident #9 with intact cognition and was dependent on staff for the completion of activities of daily living, and always incontinent of bowel and bladder. Review of the 06/21/25 Continence Care Assessment recorded Resident #9 as unable to report when incontinent of urine and utilizing 4-8 adult briefs in 24 hours. Review of the 06/18/24 nursing plan of care addressed Resident #9's activity daily living (ADL) self-care performance deficit related to dementia, paranoid schizophrenia, muscle weakness, major depression, poly arthritis, and myalgia. Resident requires staff assist to complete ADL tasks daily. Interventions included to monitor frequently for incontinence of bowel/bladder, no brief at night while in the bed, resident is dependent from one staff member for toilet hygiene, and resident not toileted due to mechanical lift. Review of the 05/06/25 a nursing plan of care addressed Resident #9's bladder/bowel incontinence due to behaviors and dependent on staff for activities of daily living (ADL's). Interventions included the resident uses adult disposable briefs for comfort and dignity, clean peri-area with each incontinence episode, check as needed/required for incontinence, wash, rinse and dry perineum, and change clothing as needed (PRN) after incontinence episodes. Review of Visual/Bedside Kardex Report (undated) under toileting instructed staff to check resident every two hours and assist with toileting as needed. Clean perinium (peri-area) with each incontinence episode. Resident not toileted due to mechanical lift. Observations and interviews on 05/13/26 at 11:25 A.M. noted Activity Aide #146 to propel Resident #9 in his wheelchair to his room. Activity Aide #146 activated the call light and proceeded to exit the room. At 11:26 A.M. CNA #170 and CNA #181 responded to Resident #9's room. CNA #181 stated Resident #9 was requesting to use the toilet. Resident #9 was noted to be incontinent of urine through his pants and onto the mechanical lift sling in the wheelchair. CNA #181 stated she was unaware when Resident #9 was last checked for incontinence. CNA #181 stated staff was unable to transfer the resident to the bathroom due to the size and using the Hoyer lift, therefore Resident #9 was incontinent in an adult brief and is to be checked every two hours. CNA #181 verified Resident #9 was not offered to use the toilet. CNA #181 stated Resident #9 was usually checked after breakfast but unsure of the time. CNA #181 and CNA #170 proceeded to transfer Resident #9 to his bed using the Hoyer lift. The CNAs removed Resident #9's heavily soiled pants, brief and Hoyer lift sling. CNA #181 obtained a basin of water, placed soap to a washcloth and cleansed Resident #9's bilateral groin and lower abdomen skin fold. No attempts were made to cleanse the resident's penis or perinium. CNA #181 proceeded to obtain a clean washcloth and cleanse the same areas. Resident #9 was then positioned to his left side exposing his buttock and a moderate amount of incontinent formed stool. CNA #181 cleansed the stool from Resident #9's buttocks and revealed Resident #9's bilateral inner posterior thighs with reddened skin. CNA #170 summoned LPN #108 to the room and LPN #108 proceeded to apply a zinc barrier cream to the reddened skin. CNA #170 and CNA #181 proceeded to place a new incontinence brief and pants on Resident #9. Interview with CNA #181 and CNA #170 on 05/13/26 at 12:07 P.M. verified Resident #9 was not properly cleansed following an incontinence episode, not provided toileting due to mechanical lift use, and not checked for incontinence every two hours. On 05/13/26 at 12:14 P.M. interview with LPN #108 verified Resident #9 was to be checked and changed for incontinence every two hours. Review of facility policy titled Urinary Incontinence Protocol, revised September 2012, revealed based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individuals continence status. Review of facility policy titled Perineal Care, revised October 2010, revealed for a male resident wet washcloth and apply soap or skin cleansing agent. Wash perineal area starting with urethra and working outward. Retract foreskin of the uncircumcised male. Wash and rinse urethral area using circular motion. Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra. Thoroughly rinse the perineal area in the same order, using fresh water and clean washcloth. Gently dry perineum following same sequence. This deficiency represents non-compliance investigated under Complaint Number 2618793.

Based on record review, observation, interview, and policy review, the facility failed to ensure fluid restrictions identified how much allowed per discipline and shift, failed to document fluid intakes, and failed to obtain daily weights. This affected two (#11 and #76) of two residents reviewed for fluid restrictions. The facility census was 65.Findings include:1.Review of medical record for Resident #11 revealed an admission date of 07/31/23. Diagnoses included polyarthritis, psychosis, hoarding disorder, adjustment disorder with anxiety, anemia, and osteoarthritis.Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of care plan dated 03/11/26 revealed the resident has the potential for dehydration or potential fluid deficit and was non-compliant with fluid restrictions. Interventions included limited to 1200 milliliter (ml) fluid restriction per 24 hours. The care plan did not break down the fluids per shift or discipline.Further review of care plan revealed that the resident is at nutritional risk related to cachexia, abnormal weight loss, osteoarthritis, anemia, and hyponatremia. Interventions included to provide and serve regular diet with thin liquids, 1200 ml/day fluid restriction, monitor intake and record every meal, weight per policy, and record. The care plan did not break down the fluids per shift or discipline.Review of current physician orders revealed 1200 ml fluid restriction. The order did not specify how many mls of fluid were to be provided by dietary for each meal and how much nursing was allowed during the 24 period to equal the 1200 ml/day fluid restriction.Review of treatment administration record (TAR) for April 2026 revealed fluid intake was not documented on 7:00 P.M.-7:00 A.M. shift on 04/01/26 and 7:00 A.M.- 7:00 P.M. shift on 04/04/26, 04/05/26, and 04/30/26.Observation and interview on 05/13/26 at 10:43 A.M. revealed the resident was lying in bed. Resident #11 stated he was not really on a fluid restriction. Resident #11 stated he drinks when he is thirsty and when he is not thirsty he does not drink. Observation of the resident's over the bed table revealed two stacks of three Styrofoam cups. One of the cups had a straw and lid. Resident #11 was observed to be short of breath, however the resident states he felt fine.Interview on 05/13/26 at 10:50 A.M. with Registered Nurse (RN #179) revealed Resident #11 was on a fluid restriction. RN #179 verified the physician order did not specify how much dietary provides and how much nursing can provide. RN #179 stated the resident always gets two milks for his meals. RN #179 stated nursing gives the resident approximately 600 mls of fluid daily. RN #179 verified the resident had Styrofoam cups in his room and could get water by himself.Follow up observation on 05/14/26 at 10:44 A.M. revealed the resident lying in bed. Two stacks of three Styrofoam cups were observed on the over bed table as well as several plastic cups.2. Review of medical record for Resident #76 revealed an admission date of 01/24/25 and discharge date of 12/18/25. Diagnoses included coronary artery disease, congestive heart failure, and chronic kidney disease.Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact.Review of physician orders revealed an 1800 ml/day fluid restriction and daily weight. The order did not specify how many mls of fluid were to be provided by dietary for each meal and how much nursing was allowed during the 24 period to equal the 1800 ml/day fluid restriction.Review of care plan dated 01/06/25 revealed the resident had a behavior problem of non-compliant with fluid restrictions. Interventions included administer medications as ordered and intervene as necessary to protect the rights and safety of others.Further review of care plan revealed the resident had potential nutritional problem related to diuretics in place and non-compliant with fluid restrictions. Interventions included but not limited to provide and serve low concentrated sweets mechanical diet with thin liquids: fluid restriction 1800 ml/day, monitor intake and record every meal.Review of TAR for October 2025 revealed daily weight not obtained on 10/30/25. Fluid intake was not documented on day shift 7:00 A.M.-7:00 P.M. on 10/01/25, 10/03/25, 10/07/25, 10/14/25, 10/15/25, 10/22/25, and 10/30/25.Review of TAR for November 2025 revealed daily weight not obtained on 11/0/25, 11/02/25, 11/04/25, 11/11/25, marked NA on 11/13/25, and 11/18/25. Fluid intake was not documented on day shift 7:00 A.M.-7:00 P.M. on 11/01/25, 11/02/25, 11/11/25, 11/12/25, 11/19/25, and 11/20/25.Review of TAR for December 2025 revealed fluid restriction was not documented on day shift 7:00 A.M.-7:00 P.M. on 12/01/25, 12/04/25, 12/08/25-12/10/25, and 12/14/25. Daily weight was not documented on 12/07/25, 12/13/25-12/15/25, and 12/22/25.Interview on 05/19/26 at 9:24 A.M. with MDS #163 verified the physician orders and care plans did not have the fluid restrictions broke down as to how much nursing and dietary could give per day. MDS #163 verified the documentation listed above for Resident #76 was not completed per order.Review of policy titled Encouraging and Restricting Fluids, dated October 2010, revealed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. Follow specific instructions concerning fluid intake or restrictions, be accurate when recording fluid intake, and record fluid intake on the intake side of the intake and output record and record the fluid intake in mls. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses to have the pitcher removed, notify the supervisor and in turn the physician.This deficiency represents noncompliance investigated under Complaint Number 2667933.

Based on medical record review, observation, staff interview, and review of facility programing, the facility failed to provide purposeful and meaningful engagement and activities to residents in the secured dementia unit. This affected two (#17 and #47) of three residents reviewed for dementia care with the potential to affect all 14 residents in the secure dementia unit. The facility census was 65. 1. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included Alzheimer's disease, panlobular emphysema, unspecified dementia with psychotic disturbance, generalized anxiety disorder, and depression.Review of the Minimum Data Set (MDS) assessment, dated 03/02/26, revealed the resident was severely cognitively impaired. Resident #17 was identified to have hallucinations, delusions, physical and verbal behaviors, and rejection of care four to six out of seven days. Review of the Activity Assessment/Evaluation, dated 01/09/26, revealed the resident was not able to participate in group activities due to mental status. Review of the Activity Participation Quarterly Review, dated 03/11/26, revealed the resident has a hard time attending group activities due to cognitive issues and enjoys one-on-one visits from staff. The resident was identified to enjoy talking to fellow residents, staff, and watching television.Review of one-on-one activities completed for the last thirty days, revealed Resident #17 was provided a food activity one day (04/23/26), a holiday party one day (04/30/26), and one-on-one activity (general conversation) one day (05/18/26). Resident #17 was documented as refusing activities three times in the last 30 days. Observation on 05/12/26 at 1:22 P.M. revealed Resident #17 in the common area with other residents. Resident #17 was facing away from the television and looking at other residents who were facing the television. Resident #17 spoke loudly across the room to other residents telling them to stop staring at her and to turn their heads. Other residents told her to shut up and who cares. 2. Review of the medical record revealed Resident #47 was initially admitted on [DATE]. Diagnoses included senile degeneration of brain, atherosclerotic heart disease of native coronary artery without angina pectoris, schizophrenia, dementia in other diseases classified elsewhere with agitation, essential hypertension, major depressive disorder recurrent, schizoaffective disorder, emphysema. Review of the MDS assessment, dated 03/04/26, revealed the resident was severely cognitively impaired and had delusions. Review of the care plan, dated 02/04/20, revealed Resident #47 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Interventions included to ensure the activities the resident is attending are compatible with physical and mental capabilities, compatible with known interests and preferences, to invite the resident to scheduled activities, provide a program of activities that are of interest and empowers the resident allowing for choice, self-expression, and responsibility. Review of the Activity Assessment, dated 01/14/26, revealed the following are very important: listening to music she likes, be around animals such as pets, to do things with groups of people, and to go outside for fresh air when the weather is good.Review of the Activity Participation Quarterly Review, dated 05/13/26, revealed Resident #47 is usually passive for group activities and enjoys one-on-one visits from staff and family. Resident #47 enjoys ice cream socials and listening to music. Review of documented activities completed in the last 30 days, revealed Resident #47 participated in three group activities including a food activity (04/23/26), a holiday party (04/30/26), and a music activity (05/12/26). Resident #47 was provided one-on-one activity of general conversation on three occasions (04/20/26, 04/23/26, and 04/25/26). Interview on 05/11/26 at 4:35 P.M. with Resident #47's family member reported Resident #47 has always been active and greatly enjoys activities but lately has not observed her in any. Observation on 05/12/26 at 1:14 P.M. revealed Resident #47 and five other residents in the common area with the television on but no one appeared to be watching it. Resident #47 was alert sitting in a chair looking around.Observation on 05/12/26 at 1:32 P.M. revealed Resident #47 get up from the chair, walk to the surveyor, and attempted to take off surveyor's necklace. Certified Nursing Assistant (CNA) #119 directed Resident #47 back to the chair. Resident #47 refused to sit down. CNA #119 stated she needed to make up a bed and afterwards will do something with her. CNA #119 returned a couple of minutes later and tells Resident #47 she thinks she is tired and walks her to the resident room to lay down. CNA #119 was heard stating Do you want to lay down in your bed? and the resident replied No. Observation on 05/12/26 at 1:39 P.M. revealed Resident #47 sitting on the edge of her bed staring straight ahead. Observation on 05/13/26 at 10:12 A.M. revealed Activities Aide #146 taking two residents on the secured unit to an exercise activity outside the unit. Five residents on the secured unit remain in the common area watching television. Observation on 05/13/26 at 11:10 A.M. revealed Resident #47 had fallen. The resident was assisted back into the chair where she was assessed. Resident #47 stated she was hungry and an unknown resident stated she was also hungry. The residents were not observed to be provided a snack. Observation on 05/18/26 at 1:11 P.M. revealed Resident #47 in the common area with the television on sitting on a loveseat. Resident #47 got up, walked to the nurses station, and attempted to open the half door. Licensed Practical Nurse (LPN) #124 tell her hello and that she cannot come back in the nurse's station. LPN #124 locks the half door. Resident #47 reaches for a small fan on the counter and LPN #124 moves the fan. LPN #124 asks Resident #47 to have a seat. Resident #47 touches a nearby resident's babydoll and reaches out to touch the resident. LPN #124 tells Resident #47 not to touch and to sit down. Resident #47 was then assisted by an aide out of the area. Interview on 05/19/26 at 10:53 A.M. with Activity Director #101 revealed the aides are supposed to offer activities to the residents outside of the activities offered by the activities department. The facility utilizes a All About Me program which provides programing individualized to the different levels of dementia. Activity Director #101 stated activities do not start or end with the activity calendar. It was reported there are activity ideas and supplies on the secure unit for the aides to utilize. Review of facility provided document, The Global Deterioration Scale for Assessment of Primary Degenerative Dementia, no date, revealed identifying characteristics for seven levels of dementia with programing needs including group and individual activities.

Based on staff interview, record review, and review of facility policy, the facility failed to offer clinical rationale to support a provider's disagreement with a gradual dose reduction (GDR) as suggested by the pharmacist. This affected one (resident #3) of five residents reviewed for unnecessary medications. The facility census was 65. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/12/25. Diagnoses included cognitive communication deficit, major depressive disorder, bipolar disorder, and hypersomnia. Review of the Medication Regimen Review (MRR), dated 09/02/25, revealed a pharmacist recommendation to taper and/or discontinue Vraylar (an atypical antipsychotic) 4.5 milligrams (mg) via gastrostomy tube (g tube) in the evening for restlessness. Concurrent review of this MRR revealed the provider did not think an attempt to taper and/or discontinue this medication could be attempted as the benefits of antipsychotic use outweigh the risks. Further review of this MRR revealed the provider disagreed with this recommendation but did not provide clinical rationale for their decision. Interview on 05/14/26 at 10:43 A.M. the Director of Nursing (DON) verified there was no clinical rationale provided by the provider for their disagreement with the pharmacist's recommendation to taper and/or discontinue Resident #3's Vraylar.Review of the facility policy titled Medication Utilization and Prescribing-Clinical Protocol, revised July 2016, revealed the consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regiments that are not supported based on clinical signs or symptoms. The physician will provide and/or document rationale when the dose, duration, or frequency of a prescribed medication is greater than commonly accepted practice or the manufacturer's recommendations or the medication is considered high0risk compared to other available, relevant alternatives. The physician will explain and/or document the rationale for not modifying a medication in a situation where an adverse drug reaction is likely.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as prescribed by the physician with an error rate of less than five percent. This affected one (#45) of one resident observed for gastrostomy tube medication administration. A total of 27 medication opportunities with seven errors were observed for an error rate of 25.93 percent. The facility census was 65. Findings include: Observation on 05/12/26 at 7:59 A.M. noted Registered Nurse (RN) #502 preparing Resident #45's medications for administration via the percutaneous endoscopic gastrostomy (PEG)) tube. RN #502 crushed one multivitamin, one glycopyrrolate 1 milligram (mg) tablet, one furosemide 20 mg tablet, one Eliquis 5 mg tablet, one Baclofen 10 mg tablet, and one famotidine 20 mg tablet. RN #502 then placed the medications together (cocktailed) in the same cup with 50 milliliters (ml) of tap water. RN #502 also obtained levetiracetam (Keppra) oral solution 20 ml 100 mg/ml solution and poured to a 30 ml medication cup. At 8:07 A.M. RN #502 entered Resident #45's room with the medications and placed them on the over bed table at the bedside. Inside the room RN #502 obtained a 60 ml piston syringe and an additional 100 ml of tap water inside a piston syringe irrigation set bottle. RN #502 removed the tube feeding solution tubing from the PEG tube and checked a residual which verified placement of the PEG tube. RN #502 poured 30 ml of water into the PEG tube then poured the cocktailed medications into the tube. Observation of the medication cup identified multiple medication residual particulate inside the cup. RN #502 flushed the tube with 30 ml water and then administered the liquid Keppra followed by a flush of 30 ml of water. Observation inside the medication cup noted 10 ml of Keppra remaining in the cup. RN #502 did not attempt to administer the residual medications inside the cocktailed medication cup or the remaining Keppra and discarded the cups to a trash receptacle inside Resident #45's room. Interview on 05/12/26 at 8:19 A.M. RN #502 verified residual medications were inside the medication cups which resulted in Resident #45 not receiving the entire prescribed dose of the medications. Review of Resident #45's medical record revealed current physician orders for all medications to be crushed and administered via PE tube. 03/24/26 Current medication orders included multivitamin adults one oral tablet in morning, glycopyrrolate 1 mg three times a day, furosemide 20 mg two times a day, Eliquis 5 mg two times a day, Baclofen 10 mg three times a day, famotidine 20 mg two times, and levetiracetam oral solution 100mg/ml give 20 ml two times a day. for seizures. There was no physician order indicated medications were to be cocktailed (mixed) together when administering the PEG tube. Review of facility policy titled Administering Medications Through An Enteral Tube, revised March 2015, revealed do not mix medications together prior to administering through an enteral tube. Administer each medication separately. Dilute the crushed or split medication with 15-30 milliliters (ml) room temperature water. Attached 60 ml syringe to feeding tube. Administer medication by gravity flow. Pour medication into the barrel of the syringe while holding the tube slightly above level of insertion. Open the clamp and deliver medication slowly. Clamp tubing before the tubing drains completely. If administering more than one medication, flush with 15 ml room temperature water between medications. When the last medication begins to drain from the tubing., flush the tubing with 15 ml of room temperature water. Quickly clamp the tubing when the flush is complete. Remove syringe. Observations during the total medication administration revealed a total of 27 medication opportunities with seven errors observed for an error rate of 25.93 percent. This deficiency represents noncompliance investigated under Complaint Number 2999106, 2975913, 2589881, 2791151, and 257794.

Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure enhanced barrier infection control precautions were implemented for residents at risk for infection. This affected two (#45, #5) of 20 residents reviewed for infection control practices in a facility census of 65. Findings include: 1. Review of the medical record revealed Resident #45 admitted to the facility on [DATE]. Diagnoses include anoxic brain damage, chronic respiratory failure with hypercapnia, persistent vegetative state, pulmonary embolism, dependence on ventilator, myoclonus, tracheostomy, hypertension, atrial fibrillation, anemia in chronic kidney disease, and gastrostomy.Review of the Minimum Data Set assessment dated [DATE] revealed Resident #45 in a persistent vegetative state with no discernible consciousness, received all nutrition via tube feeding, received tracheostomy care, and invasive mechanical ventilator. On 03/05/26 a physician order was implemented for Resident #45 to be placed on enhanced barrier precautions related to tracheostomy and gastrostomy tube (g -tube). On 12/30/25 a nursing plan of care was revised to address Resident #45 Enhanced Barrier Precautions secondary to risk for potential infection related to tracheostomy, catheter, feeding tube, ventilator dependent, history multiple pressure ulcers, and history of extended spectrum beta lactamase (ESBL). Interventions included to follow enhanced barrier precautions. Observation on 05/12/26 at 8:07 A.M. of Resident #45's room revealed a sign posted at the entry indicating Resident #45 was in enhanced barrier precautions. Registered Nurse (RN) #502 prepared Resident #45's medications for g-tube administration and entered Resident #45's room. No personal protective equipment (PPE) was applied other than disposable plastic gloves. RN #502 proceeded to administered Resident #45's medications via g-tube, discarded plastic gloves, washed hands and exited the room. Interview on 05/12/26 at 8:07 A.M. with RN #502 immediately after exiting Resident #45's room revealed RN #502 was unaware PPE was to be applied during close contact with the resident including while administering medications via his g-tube. Review of facility policy titled Administering Medications, revised April 2019, revealed staff follows established facility infection control procedures for the administration of medications. 2. Review of the medical record revealed Resident #5 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, hypertension, venoReview of the MDS assessment dated [DATE] revealed Resident #5 with intact cognition with one arterial/venous ulcer. On 03/04/26 a physician order was initiated for a treatment application to Resident #5's left upper posterior thigh to cleanse, apply calcium alginate and cover with border gauze. Complete every shift for wound care and as needed for wound care. No documentation contained in the medical record included the implementation of enhanced barrier precautions. Observation on 05/12/26 at 12:57 P.M. revealed Resident #5 was in bed. No signage or PPE was in place indicating Resident #5 was in enhanced barrier precautions. At 1:11 P.M. Licensed Practical Nurse (LPN) #108 and Certified Nurse Aide (CNA) #501 entered Resident #5's room and provided incontinence are to the resident. After CNA #501 cleansed the resident, LPN #108 applied a zinc barrier cream and removed the existing dressing from Resident #5's left posterior thigh. LPN #108 then replaced the dressing with a clean dressing. CNA #501 and LPN #108 gathered soiled linen and associated supplies and exited the room. No PPE was worn by either CNA #501 or LPN #108 Interview on 05/12/26 at 1:31 P.M. CNA #501 verified she was unaware Resident #5 required PPE during close contact care for incontinence or was to have enhanced barrier precautions. On 05/12/26 at 1:32 P.M. interview with LPN #108 verified Resident #5 required enhanced barrier precautions due to the presence of a wound and enhanced barrier precautions were not in place. LPN #108 verified no PPE was applied during provision of incontinence care and dressing change. Review of facility policy titled Enhanced Barrier Precautions (EBP), dated August 2022, revealed enhanced barrier precautions employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. PPE is changed before caring for another resident. Face protection may be used if there is a risk of splash or spray. Examples of high-contact resident care activities requiring use of gown and gloves for enhanced barrier precautions include: dressing, bathing/showering, transfering, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, feeding tube, tracheostomy/ventilator) and wound care (any skin opening requiring a dressing). Enhanced barrier precautions are indicated, when contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms.

Based on observation, medical record review, and staff interview, the facility failed to ensure resident beds were properly maintained in a safe manner. This affected two (#5, #9) of 20 residents reviewed for safe integrity of beds in a facility census of 65. Findings include:1. Review of the medical record revealed Resident #5 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, obesity, panic disorder, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, hypertension, venous thrombosis and embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 with intact cognition. no recorded behaviors and dependent on staff for the completion of activities of daily living including bed mobility. Review of the nursing plan of care dated 01/13/25 addressed activity of daily living (ADL) self-care performance deficit with an intervention including quarter upper bilateral side rails for bed mobility and transfer ability enabler to promote independence. Review of bed system measurement device test results worksheet dated 11/11/25 noted Resident #5's bed to be evaluated for safety and pass. Observation on 05/11/26 at 10:24 A.M. noted Resident #5 in bed. The bed frame was observed extending out from the underside of the mattress with approximately four inches of exposed metal bed frame to the right side of the bed. A gap was noted between the edge of the mattress and the right upper quarter side rail measuring four inches. Observation on 05/12/26 at 1:11 P.M. Licensed Practical Nurse (LPN) #108 and Certified Nurse Aide (CNA) #501 entered Resident #5's room and assisted with turning Resident #5 from side to side. When Resident #5 was turned to the right side her right foot was noted to contact the metal bed frame identified with sharp edges. Interview on 05/12/26 at 1:32 P.M. LPN #108 verified Resident #5 mattress was undersized and exposed the metal bed frame with a gap between the bed rail and edge of the mattress. Observation and interview on 05/12/26 at 1:45 P.M. Maintenance Director #110 measured between the edge of the mattress and edge of bed frame. There was a gap between the mattress and bedframe of six inches at the foot of the bed, four inches middle bed, and three inches between the rail and mattress. Maintenance Director #110 stated he was unaware when Resident #5's bed and mattress were assessed for proper fit. 2. Review of the medical record revealed Resident #9 admitted to the facility on [DATE]. Diagnoses included dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, Review of the MDS assessment dated [DATE] revealed Resident #9 with intact cognition, psychosis related hallucinations and delusions, range of motion impairment on one side upper and lower extremities, dependent on staff for the completion of activities of daily living including bed mobility and transfer, and experienced two or more falls since admission. Review of the 06/18/24 nursing plan of care addressed Resident #9 had an ADL self-care performance deficit related to dementia, paranoid schizophrenia, muscle spasms, muscle weakness, major depression, polyarthritis, and myalgia. Intervention included upper quarter bilateral side rails for bed mobility and transfer ability as an enabler to promote independence. Review of the physician order on 03/05/26 noted quarter upper bilateral side rails for bed mobility and transfer ability enabler to promote independence. Observation and interview on 05/13/26 at 11:26 A.M. noted CNA #170 and CNA #181 responded to Resident #9's room. Resident #9's bed was equipped with a quarter side rail to the left bed, which was loose, and no quarter side rail was observed to the right side of the bed. CNA #181 verified Resident #9's left bed rail was loose and no bed rail was installed to the right side of the bed. CNA #181 stated Resident #9 used the side rails when being positioned in the bed and was fearful of falling from the bed without them in place. CNA #181 and CNA #170 proceeded to transfer Resident #9 to his bed using the mechanical (Hoyer) lift. The CNA's provided care and transferred Resident #9 back to the wheelchair using the Hoyer lift. Interview with CNA #181 and CNA #170 on 05/13/26 at 12:07 P.M. verified Resident #9's bed was equipped with a loose bed rail to the left side of the bed and no rail to the right. Observation and interview on 05/14/26 at 6:06 A.M. RN #510 verified Resident #9's left bedrail was loose and the right bed rail was missing. RN #510 stated she was unaware where the missing rail was located. Interview on 05/14/26 at 7:30 A.M. Maintenance Director #110 revealed he was unaware of the loose bed rail and missing bed rail to Resident #9's bed. This deficiency represents non-compliance investigated under Complaint Number 2791151.

Based on closed medical record review, staff interview, review of the Emergency Medical Services (EMS) run report, review of hospital records, review of the death certificate, review of staff witness statements, and review of facility policy, the facility failed to ensure residents were served foods in the correct texture to meet individual needs and further failed to ensure residents were accurately assessed for supervision needs during meals. This resulted in Immediate Jeopardy on 01/16/26 for one (#77) resident who experienced serious life-threatening harm and negative health outcomes resulting in death when Certified Nursing Assistant (CNA) #151 served Resident #77, who had a physician ordered mechanical soft texture diet (foods are ground, chopped, or naturally soft), a regular texture sandwich during an evening snack. Subsequently, Resident #77 choked, lost consciousness, and required staff intervention to perform the Heimlich maneuver (a first-aid method for choking that includes abdominal thrusts), cardiopulmonary resuscitation (CPR), and EMS response to remove the food from the trachea where it was preventing air flow to and from the lungs. Consequently, Resident #77 died at the hospital on [DATE]. This affected one (#77) of three residents reviewed for mechanically altered diets. The facility identified 13 residents (#63, #73, #39, #42, #60, #46, #41, #37, #50, #33, #43, #68, #66) who had physician ordered mechanically altered diets. The facility census was 71. On 02/25/26 at 4:14 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Operations (RDO) #201, Regional Clinical Director (RCD) #202, and Licensed Practical Nurse Unit Manager (LPN/UM) #135 were notified Immediate Jeopardy began on 01/16/26 when CNA #151 served Resident #77 a regular texture ham sandwich during the evening snack, contrary to the resident's physician ordered mechanical soft texture diet, and no supervision was provided while the resident consumed the sandwich. At approximately 9:30 P.M., Registered Nurse (RN) #134 observed Resident #77 in the doorway of his room with his hands up to his throat and inserting his finger into his mouth to make himself gag. RN #134 approached Resident #77 and asked if he was choking and Resident #77 nodded yes. Resident #77 was unable to cough and dislodge the food item. RN #134 called for assistance and attempted the Heimlich maneuver, which was unsuccessful. CNA #111, CNA #151, CNA #117, and Respiratory Therapist (RT) #185 responded and attempted the Heimlich maneuver, with each attempt being unsuccessful at dislodging the foreign object. Subsequently, Resident #77 lost consciousness, suffered cardiac arrest, and CPR was initiated and continued until EMS arrived and assumed care, which included the use of a laryngoscopy (specialized medical instrument used to view the larynx and surrounding structures), [NAME] forceps (specialized, angled surgical instrument primarily used for airway management), CPR, defibrillation, suctioning, intravenous (IV) epinephrine (used to treat severe, acute conditions by rapidly stimulating the heart and opening the airways), and intubation (placement of a flexible tube through the mouth or nose and into the trachea to maintain an open airway). EMS removed a large piece of meat that was completely covering Resident #77's trachea and preventing the flow of air to the lungs and at 9:48 P.M., and the resident had a pulse. Resident #77 was transferred to the hospital and subsequently died on [DATE] due to anoxic brain death (death occurring after the brain has been completely and irreversibly deprived of oxygen - signifies the permanent cessation of all brain functions), cardiac arrest, and choking on food. The Immediate Jeopardy was removed on 01/19/26 when the facility implemented the following corrective actions: -On 01/16/26, RN #134 responded to Resident #77, EMS was called, and the resident was subsequently transferred to the hospital. Resident #77 did not return to the facility. -On 01/16/26, RN #134 notified Resident #77's physician of the incident. -On 01/16/26, the DON reviewed Resident #77's diet order for accuracy. -On 01/16/26, the DON initiated an investigation of events surrounding Resident #77's choking incident. -On 01/18/26, the DON conducted a root cause analysis and determined Resident #77 choked when CNA #151 provided Resident #77 with the incorrect diet texture during the evening snack. -On 01/18/26, the DON reviewed all facility residents' care plans to ensure they accurately reflected current diet orders. -On 01/18/26, the DON conducted a full house audit to ensure no additional residents received incorrect diet consistency or improper feeding assistance, with no issues identified. -On 01/18/26, the DON educated CNA #151 on ensuring each resident received their diet as ordered. -On 01/18/26, the DON educated all nursing staff and Dietetic Technician (DT) #203 on ensuring resident care plans accurately reflected current diet needs. -On 01/18/26, the DON educated all nursing staff on the facility policy to ensure each resident received their diet as ordered and where to verify a resident's diet order. -On 01/18/26, the Administrator, the DON, LPN/UM #135, RDO #201, and RCD #202 reviewed facility policies on assisting residents with in-room meals, snack serving, and therapeutic diets. No changes were made to the policies. -On 01/19/26, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the choking incident and the facility's corrective action. In attendance were the Administrator, DON, LPN/UM #135, Business Office Manager (BOM) #102, Human Resources (HR) #103, Maintenance Director (MD) #105, Minimum Data Set Coordinator (MDSC) #158, Dietary Manager (DM) #160, Housekeeping/Laundry Director (HLD) #170, Activities Director (AD) #177, Social Services Director (SSD) #181, Admissions #101, Marketing #100, Respiratory Therapy Director (RTD) #183, and Medical Records (MR) #157. -On 01/19/26, DM #160 posted a list of mechanical soft approved foods in the nutrition rooms on each floor of the facility. -On 01/19/26, DM #160 posted a list of residents with mechanically altered diets in the nutrition rooms on each floor of the facility. DM #160 and/or designee will be responsible for monitoring and updating the lists as diet orders change, with new admissions, and as needed. -On 01/19/26, DM #160 placed separate bins identifying regular snacks and mechanically altered snacks in the nutrition rooms. DM #160 and/or designee, will be responsible for ensuring appropriate food items are placed in each bin, based on safe foods for each diet texture. -Beginning on 01/19/26, the DON would audit four nursing staff three times a week for four weeks to ensure understanding of mechanically altered diets. The results of the audits would be reported to the QAPI committee. -Beginning on 01/19/26, the DON would audit two residents three times per week for four weeks to ensure meals and snacks being served are appropriate based on the ordered diet. The results of the audits would be reported to the QAPI committee. -On 02/25/26, the DON audited all Nutrition and Hydration Status Assessments to ensure accuracy regarding residents' feeding capabilities, including supervision and assistance (if applicable). Any inaccuracies were corrected immediately by DT #203. -On 02/25/26, the DON reviewed all residents' care plans to ensure they accurately reflected the residents' feeding and eating capabilities, including supervision and assistance (if applicable). -On 02/25/26, the DON educated all nursing staff on following the care plan and Kardex (summary of a resident's care plan, used as a quick reference) to identify a resident's level of assistance required when eating. -On 02/25/26, Registered Dietitian (RD) #204 educated DT #203 on the completion of Nutrition and Hydration Status Assessments to accurately reflect a resident's level of assistance required when eating. -Beginning on 02/25/26, the DON would audit two residents three times a week for four weeks to ensure they are receiving feeding assistance and supervision as needed. The results of the audits would be reported to the QAPI committee. -Beginning on 02/25/26, the DON would complete random audits of three resident charts for the most recent admission, quarterly, and change of condition Nutrition and Hydration Status Assessments for accuracy of the resident's level of assistance required when eating for four weeks. The results of the audits would be reported to the QAPI committee. -Observations on 02/25/26 of the nutrition rooms verified bins were maintained for regular and mechanically altered diets. -Interviews on 02/25/26 and 02/26/26 with RN #134, CNA #151, RN #129, and DT #203 confirmed the facility provided education regarding dietary orders, textures, and meal supervision. Although the Immediate Jeopardy was removed on 01/19/26, 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 had not yet audited the 13 residents currently residing in the facility, identified to have physician ordered mechanical soft diets, to ensure the Nutrition and Hydration Assessments and care plans were reviewed and updated for accuracy, that staff education was completed related to appropriate supervision during meals, and 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 closed medical record for Resident #77 revealed an admission date of 02/14/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominate side, facial weakness following cerebral infarction, and phantom limb syndrome with pain. Resident #77 transferred to the hospital on [DATE] and was discharged from the facility on 01/20/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/06/25, revealed Resident #77 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. The assessment indicated Resident #77 required set-up assistance with eating, supervision with toileting, partial assistance with showers, and supervision with transferring. Review of the care plan focus area initiated 02/27/25 revealed Resident #77 had an Activities of Daily Living (ADLs) self-care performance deficit related to disease process. Resident #77 required staff assistance to complete ADL tasks daily. Fluctuations were expected related to diagnoses, and the resident was at risk for decline in physical function. Interventions included: usual performance with meals was set up/clean up assistance and provide milkshakes or liquid food supplements when the resident refused or had difficulty with solid food or provide nutritious foods that could be taken from a cup or a mug, where appropriate. Additionally, fluctuations were expected related to diagnosis/condition. Allow for increased support as necessary related to tiredness/weakness, respiratory status, time of day, post-therapy, et cetera (etc.). Further review revealed a focus area revised on 06/12/25 for a mechanically altered diet that may affect appetite. Interventions included provide and serve a low concentrated sweet (LCS), no added salt (NAS), mechanical soft, thin liquid diet as ordered. Review of the physician orders revealed an order dated 06/12/25 for a LCS, NAS, mechanical soft texture, regular (thin) consistency liquids, and a divided plate with meals. Review of the Nutrition and Hydration Status Assessment, dated 11/09/25, revealed Resident #77 had the following diagnoses with nutritional significance: cardiovascular accident, aphasic pneumonia due to food inhalation, below the knee amputation, hypertension, hemiplegia, and hemiparesis. Resident #77 had a chewing problem and fed self with supervision. Review of the Speech Therapy (ST) Discharge summary, dated [DATE], revealed Resident #77 had a medical history of aspiration (food/liquid enters the trachea and lungs instead of being swallowed into the esophagus and stomach), cerebrovascular disease, hypertension, and muscle weakness. Goals included skilled treatment instructing and training Resident #77 in safe swallowing strategies in order to increase safety and independence during daily living tasks and meals. Upon discharge from ST services, Resident #77 exhibited difficulty with oral containment and secretions zero to 25 percent (%) of the time and required supervision/assistance at mealtime due to swallow safety zero to 25% of the time. Resident #77 had a Dysphagia Outcome and Severity Scale ([DOSS] clinical tool used to rate the functional severity of a person's swallowing difficulty) of five out of seven, meaning one or two diet consistencies were restricted and distant supervision was required (caregiver within earshot or nearby to check in periodically). Discharge recommendations included mechanical soft/chopped textures, sit upright, alternate between food/liquid, and take small bites. Review of the late entry nursing progress note dated 01/16/26 at 9:30 P.M. revealed RN #134 observed Resident #77 in his room at 9:06 P.M. during medication administration. At 9:30 P.M., RN #134 saw Resident #77 in his wheelchair at the door of his room, clutching his throat with two hands, and then saw Resident #77 inserting his finger into his mouth making himself gag. RN #134 asked Resident #77 if he was choking and he nodded but could not speak. RN #134 instructed Resident #77 to cough but he couldn't. RN #134 visually inspected Resident #77's mouth for any visible objects, such as food, but none was seen. RN #134 called for help down the hallway while staying with Resident #77. After calling for help, RN #134 immediately attempted the Heimlich maneuver and was not successful. Other staff members were present including an RT (#185), CNAs (#111, #117 and #151), and another RN (#129). The CNAs and the RT each attempted the Heimlich maneuver and were not successful at expelling the foreign object. At this time, another RN (#129) called nine-one-one (911). At 9:32 P.M., despite repeated Heimlich maneuver attempts, the obstruction was not relieved and the resident lost consciousness. RN #134 instructed the CNA to get the CPR board, another RN secured the crash cart, a second CNA secured the oxygen tank, and a third CNA secured oxygen tubing. At 9:33 P.M., Resident #77 went unresponsive. RN #134 assessed for a carotid pulse and found the pulse was absent. Staff immediately transferred Resident #77 to the bed from the wheelchair, utilizing the backboard to support the resident. The backboard was kept in place with the resident on the bed. At 9:34 P.M., RN #134 initiated chest compressions while RT #185 provided ventilation using a bag-valve mask (Ambu bag) connected to oxygen in coordination with chest compressions. The staff continued CPR without interruption, monitoring for signs of breathing, pulse, and/or expulsion of the foreign object. CPR was maintained until EMS arrived on the scene. At 9:37 P.M., EMS arrived. Upon EMS arrival, RN #134 provided report detailing the choking event, loss of consciousness, initiation of CPR and duration of care rendered. EMS was successful with utilizing the laryngoscope and [NAME] forceps to extract the object from Resident #77's throat. EMS continued CPR, started intravenous (IV) fluid, epinephrine (used to treat severe, acute conditions by rapidly stimulating the heart and opening the airways), suctioning, defibrillation, and intubation. At 10:00 P.M., Resident #77 was sent to the hospital and, at 10:01 P.M., RN #134 called report to the hospital, Nurse Practitioner (NP), emergency contact, and the DON. Review of the respiratory therapy note dated 01/16/26 at 10:08 P.M. revealed RT #185 was called to the code, assisted Resident #77 to sit up with the nurse's help in the chair and did five Heimlich maneuvers with nothing coming out. Resident #77 was transferred to his bed with the help of an aide and began CPR on resident at 9:30 P.M. until EMS came around 9:38 P.M., then EMS took over CPR duties. Review of the EMS run report dated 01/16/25 revealed a call was placed to 911 on 01/16/25 at 9:25 P.M. with a chief complaint of he was totally normal, then started choking and went unresponsive. EMS was at bedside at 9:34 P.M. and Resident #77 was found supine (on back) in bed and effective CPR was in progress by staff. Resident #77 was pulseless and apneic (not breathing), with reported full airway obstruction. Further review of the EMS run report revealed at 9:37 P.M., EMS inserted [NAME] forceps under video laryngoscopy, a large piece of meat was noted to be completely obstructing the trachea and was removed without incident, and Resident #77 was subsequently intubated. At 9:48 P.M., Resident #77 had a pulse. At 10:05 P.M., Resident #77 was placed in the ambulance and transferred to the hospital. Review of CNA #151's witness statement, dated 01/16/26, revealed CNA #151 gave Resident #77 ice water and snacks at 9:00 P.M. At 9:30 P.M., CNA #151 was asked to help with Resident #77, who was in the wheelchair clutching his throat. CNA #151 was asked to get help and call 911. At 9:32 P.M., CNA #151 helped with the Heimlich maneuver and helped with the oxygen tank for Resident #77. At 9:37 P.M., EMS arrived and took over. At 10:00 P.M., EMS took Resident #77 to the hospital. Review of CNA #117's witness statement revealed on 01/16/26 at 9:30 P.M., CNA #117 was motioned by another aide (CNA #111) from the other end of the hall. CNA #117 noticed the way CNA #111 was motioning was a serious manner, so CNA #117 ran down the hall. CNA #151 was giving Resident #77 the Heimlich, then the nurse tried, then CNA #117 tried. CNA #151 tried once more, then the nurse (RN #134), then CNA #117, then CNA #117 asked where the RT was. The nurse tried again, and CNA #117 ran to get the RT. CNA #117 and RT #185 returned to Resident #77 and tried again, then transferred Resident #77 to the bed. While staff were trying on the bed (CPR), EMS came and CNA #117 left the room and waited in the hallway. Review of CNA #111's witness statement revealed on 01/16/26, CNA #111 observed Resident #77 was choking in his chair. The nurse (RN #134) was assisting in the Heimlich maneuver and yelled for more help. CNA #111 was instructed to grab the CPR board, while RN #129 retrieved the crash cart, CNA #151 grabbed the oxygen, and CNA #117 got the oxygen tube. In the midst of that, CPR continued until the ambulance arrived on scene and took over. CNA #111 returned to CNA duties in the hallway. Review of RN #129's witness statement revealed on 01/16/26, RN #129 was working on the skilled hall. While doing medication pass at around 9:30 P.M., the CNAs were yelling for help from Resident #77's room. RN #129 ran and saw that Resident #77 was choking and his nurse, RN #134, was doing the Heimlich maneuver. RN #129 ran towards the (nurses') station to call 911 for emergency procedure and called code blue on the radio. RN #129 took the crash cart, and the CNAs secured the oxygen tank, tube and CPR board. RN #129 set up the suction machine, while RT #185 was bagging (provide air to the lungs) and RN #134 was doing compressions. At 9:37 P.M., EMS arrived with a stretcher. RN #134 informed EMS of what happened while doing compressions. EMS took over the compressions and bagging. At 10:00 P.M., Resident #77 was transported via stretcher while bagging and with an IV line. Review of RT #185's witness statement revealed on 01/16/26, RT #185 was called to the code. RT #185 got Resident #77 to sit up with the nurse's help in the chair. RT #185 did five Heimlich maneuvers with nothing coming out, transferred Resident #77 to bed with the help of an aide, and began CPR on Resident #77 at 9:30 P.M. until EMS came around 9:38 P.M., then EMS took over CPR duties. Review of a written staff interview with CNA #151, conducted by the DON, revealed CNA #151 was questioned if she knew that Resident #77 was on an altered diet of mechanical soft and CNA #151 stated yes. CNA #151 admitted to giving Resident #77 a ham sandwich (regular texture) and thought it was ok because the ham was very thinly sliced and not a big hunk of meat. One-on-one education was provided to CNA #151 on mechanical soft diets. Review of the Hospitalist History and Physical (H&P), dated 01/17/26, revealed Resident #77 was a nursing home resident who was brought to the emergency department (ED) after sustaining cardiac arrest in the nursing home after choking. Resident #77 was intubated, ventilated mechanically, and received norepinephrine infusion (medication to raise blood pressure in patients with severe, acute low blood pressure). Resident #77 was comatose and given medication for intubation. The physician assessment and plan revealed Resident #77 had acute hypoxic respiratory failure due to choking, followed by cardiac arrest, and was successfully resuscitated after postcardiac arrest shock state. Resident #77 had aspiration pneumonia in the left lung. Resident #77 was to continue supportive care with mechanical ventilation and medications. Review of the Certificate of Death, certified 01/26/26, revealed Resident #77 died in the hospital on [DATE]. The immediate cause of death was anoxic brain death due to cardiac arrest and choking on food. An interview on 02/25/26 at 10:38 A.M. with DT #160 revealed a mechanical soft sandwich would be soft food items, such as egg salad, or chopped ham, turkey or tuna salad. DT #160 stated Resident #77 was ordered a mechanical soft diet but was given a regular texture ham sandwich on the day he choked at the facility. An interview on 02/25/26 at 11:18 A.M. with the DON revealed she received a telephone call on 01/16/26 from RN #134 about Resident #77's choking incident and the details on how staff responded. The DON verified CNA #151 provided Resident #77 with a regular texture deli ham sandwich because the resident asked for a sandwich and she thought it was okay because the ham was thinly sliced. The DON confirmed the ham was not chopped, or the appropriate texture for a mechanical soft diet. The DON stated CNA #151 had one-on-one training on mechanically altered diets and appropriate snacks and meals. The DON confirmed Resident #77 was not supervised during the snack, stating he only required set-up assistance for meals. Further interview, and concurrent review of the Nutrition and Hydration assessment dated [DATE], revealed the resident was assessed to require supervision during meals. The DON stated supervision on the assessment only meant set-up assistance. An interview on 02/26/26 at 9:52 A.M. with RN #134 revealed on 01/16/26 at approximately 9:00 P.M., she gave Resident #77 his medication. RN #134 stated she continued to pass medications and at approximately 9:30 P.M., she saw Resident #77 clenching his neck. RN #134 asked Resident #77 if he was choking, and Resident #77 shook his head yes. RN #134 stated she looked in Resident #77's mouth and did not see any obstruction and she began doing the Heimlich maneuver and back blows. RN #134 stated she yelled for help and CNA #151 was the first to respond. RN #134 stated she was unsure of what Resident #77 was choking on and further stated the resident had difficulty swallowing and had incidents with swallowing before. An interview on 02/26/26 at 11:18 A.M. with CNA #151 verified on 01/16/26, she gave Resident #77 a regular texture ham sandwich. CNA #151 confirmed she was aware Resident #77 was on a mechanical soft diet but thought the ham sandwich was safe. CNA #151 stated Resident #77's choking incident was over one month ago, and she could not recall specifics. Interview on 02/26/26 at 11:06 A.M. with DT #203 revealed she completed the Nutrition and Hydration Assessment on 11/06/25 that indicated Resident #77 required supervision during meals. DT #203 stated she was called by the facility on 02/25/26 regarding her assessment. DT #203 confirmed Resident #77's assessment indicated twice that he required supervision with meals, but this was human error and the resident only required set-up assistance. DT #203 stated she generally left that section blank if supervision was not required. Review of the facility policy titled, Nutritional Assessment, revised October 2017, revealed as part of the comprehensive assessment, the nutritional assessment would be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of the facility policy titled, Assisting the Resident with In-Room Meals not dated, revealed check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Review the residents' care plan and provide for any special needs of the residents. Review of the facility policy titled, Resident Nutrition Services, undated, revealed nursing personnel would inspect food trays as they were delivered to ensure that the correct meal had been delivered. Review of the facility policy titled, Therapeutic Diets, undated, revealed snacks would be compatible with the therapeutic diet. This deficiency represents non-compliance investigated under Master Complaint Number 2785441.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure an adequate supply of clean linen was available to meet the residents' needs. This had the potential to affect all 46 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #78) residents who resided on the third floor. The facility census was 76. Findings include:Interview on 02/26/26 at 7:27 A.M. with Certified Nursing Assistant (CNA) #137 revealed there was no linen available to wash the residents. CNA #137 revealed, at times, towels were used instead of wash cloths. Interview on 02/26/26 at 7:33 A.M. with CNA #189 revealed it was common to not have linens available and stated pillowcases have been used to wash residents. Observation on 02/26/26 at approximately 7:40 A.M. of the third floor linen storage revealed there were six towels and no wash cloths available for 46 residents. Interview on 02/26/26 at 8:04 A.M. with CNA #197 verified there were no linens available at the start of their shift at 6:45 A.M. to wash and get residents up. CNA #197 stated it was a daily concern and linens were typically not brought up from laundry until 8:30 A.M. to 9:00 A.M.Interview on 02/26/26 at 8:14 A.M. with Laundry Aide (LA) #176 revealed she was the only laundry aide and worked from 5:00 A.M. to no later than 2:30 P.M. and at times they ran out of linens before laundry could wash and restock. Interview on 02/26/26 at 8:19 A.M. with Housekeeping/Laundry Supervisor (HLS) #170 revealed there was sufficient linen but no one at the facility to keep the linen clean. Review of the facility policy titled, Quality of Life, dated May 2017, revealed residents were provided with a safe, clean, comfortable and homelike environment. The facility staff and management shall maximize the characteristics of the facility that reflect a personalized homelike setting, including clean bed and linens that were in good condition. This was an incidental finding discovered during the complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#47) of two residents reviewed for medication administration. The facility census was 76.Findings include:Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included multiple sclerosis, Alzheimer's disease with late onset, essential hypertension, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/07/26, revealed the resident was moderately cognitively impaired and did not receive insulin. Review of a nursing progress note, dated 10/18/25 at 9:09 P.M., revealed the resident was given 15 milligram (mg) of glargine Lantus (long acting insulin) and it was not prescribed. The Nurse Practitioner (NP) was notified and gave an order to check the residents bp (not specified what this meant) every hour for six hours. The resident's current blood sugar was 109 milligrams per deciliter (mg/dl). Review of a NP progress note, dated 10/19/25, revealed notification was made by nursing that Resident #47 mistakenly received 15 units of Lantus and was not diabetic. Vitals were assessed and glucose was 107 mg/dl. Physician order entered for glucose check every hour for 12 hours and to notify provider for glucose less than 70 (mg/dl). Glucagon as needed ordered as well as needed glucose tabs. Nursing instructed to notify the Director of Nursing (DON). Ensure the resident eats breakfast and encourage snacks. Recheck vitals in four hours. Interview on 02/26/26 at 10:35 A.M. with the DON verified Resident #47 received insulin when it was not prescribed. Review of the facility policy titled, Administering Medications, dated April 2019, revealed medications were administered in a safe and timely manner, and as prescribed. The individual administering medications verified the resident's identity before giving the resident his/her medications. Methods of identifying the resident included checking the identification band, checking photograph attached to the medical record, and if necessary, verifying the resident identification with other facility personnel. This was an incidental findings discovered during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, resident and staff interview, review of a facility investigation, review of hospital documentation, policy review, and review of facility corrective action documentation, the facility failed to ensure the appropriate level of care and assistance was utilized during resident bathing which resulted in an avoidable fall. Actual harm occurred when Resident #22 was being bathed by one staff member when the resident's care plan indicated the resident required a two-person assist for bathing and the resident's abilities were known to fluctuate. Resident #22 was rolled to her side while in bed and was rolled onto the floor which necessitated the resident to be sent to the hospital for an evaluation. Resident #22 was determined to have sustained a left hip fracture which required surgical intervention. This affected one (#22) of five residents reviewed for falls. The facility census was 69. Findings include: Review of Resident #22's medical record revealed an admission date of 02/27/20. Diagnoses include unspecified dementia, obstructive sleep apnea, severe protein-calorie malnutrition, chronic atrial fibrillation, anxiety, essential hypertension, corneal ulcer of the left eye, chronic pain, inflammatory spondylopathy of the lumbar region, chronic kidney disease, presence of a cardiac pacemaker, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact. The resident was dependent for bathing and required the assistance of two staff. Further review revealed the resident required extensive assistance of one to two staff for bed mobility. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #22 had no falls since admission or the previous assessment. Review of a care plan initiated on 03/10/20, and revised on 05/18/21, revealed Resident #22 had an activities of daily living (ADLs) self-care performance deficit related to disease process. Resident #22 required staff assistance to complete daily ADLs and fluctuations in abilities were expected due to the resident's diagnoses. Review of an intervention initiated on 02/21/23 revealed Resident #22's need for assistance and additional staff support may fluctuate from day to day and hour to hour. Review of an intervention most recently revised on 10/18/23 revealed Resident #22 was dependent with assistance from two staff members for bathing and showers. Review of an additional intervention for bed mobility most recently revised on 10/18/23 revealed Resident #22 required extensive assistance of one to two staff members with her usual performance being dependent to roll from left to right. Review of the care plan dated 07/03/24 revealed Resident #22 was dependent and required two staff members to assist with bathing/bed baths. An intervention revealed Resident #22 required extensive assistance from one to two staff members for bed mobility. Review of the fall risk assessment dated [DATE] revealed Resident #22 was a high fall risk. Review of the fall risk assessment dated [DATE] revealed Resident #22 was a low fall risk. Review of Resident #22's nursing progress notes dated 09/01/24 revealed the resident slid out of bed while getting a bed bath early in the morning. Resident #22 indicated she hit her head. Vital signs were obtained, and neurological checks were completed. Resident #22 was sent to the emergency room (ER) due to facility policy since the resident hit her head. The provider was notified after Resident #22 was sent out to the hospital and the care team was updated. Review of the medical record for Resident #22 revealed she was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #22's hospital documentation dated 09/02/24 revealed the resident reported she was receiving a bed bath while at the nursing facility and she fell off the end of the bed while they were putting powder on her back. The resident landed on her left side as well as hit her head with no loss of consciousness. Resident #22 was complaining of severe aching pain to the left hip that was worse with any type of motion, and she did not receive anything for the pain prior to arrival. An x-ray was completed on 09/01/24 and revealed a comminuted displaced proximal left femoral, likely intertrochanteric, fracture (left hip fracture). The fracture required surgery and Resident #22 underwent surgical repair for her left hip fracture on 09/02/24. Review of the fall risk assessment dated [DATE] revealed Resident #22 was a high fall risk. Interview on 05/27/25 at 10:51 A.M. with Resident #22 revealed she was receiving a bed bath given by one certified nurse aide (CNA), CNA #595, when CNA #595 turned Resident #22 to apply powder to her back and her legs went over the side of the bed causing her to fall onto the floor. Resident #22 confirmed she sustained a broken hip as a result. Review of the investigation conducted by the facility revealed a witness statement dated 09/01/24 from CNA #600 which revealed Resident #22 was getting a bed bath and during the turn the resident slipped out of bed. Further review of the witness statement revealed the incident happened in Resident #22's room and CNA #600 became aware of the situation when she was called to help by CNA #595. The witness statement revealed Resident #22 indicated she turned too far and slipped out of bed. Review of the witness statement dated 09/01/24 from CNA #595 revealed she was giving Resident #22 a bed bath and turned the resident on her side to put powder on her back. Resident #22's feet started to go down off the bed and CNA #595 tried to catch her, but she could not. CNA #595 indicated Resident #22 fell off and slid down the opposite side of the bed. Resident #22 indicated she rolled too far and slipped out of the bed. Interview on 05/28/25 at 3:45 P.M. with the Assistant Director of Nursing (ADON) verified it was not proper nursing care to roll a resident away from the caregiver when there was only one person completing a bed bath. Furthermore, the ADON confirmed Resident #22's care plan specified two caregivers were required to be present for bathing/showering and confirmed there was only one staff member providing the bed bath on 09/01/24 when the resident was rolled out of bed and sustained the hip fracture. Review of a facility policy titled, Falls-Clinical Protocol, revised September 2012, revealed based on preceding assessments of a resident's falls and fall risks, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature category of falling, until falling reduces or stops, or until a reason is identified for its continuation. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 09/04/24: • On 09/01/24, Resident #22 was immediately assessed for pain, neurological impairment, skin integrity, and range of motion by Respiratory Therapist (RT)/LPN #557. • On 09/01/24, Resident #22 was transferred to the ER via emergency medical services upon assessment findings. The provider was notified on 09/01/24 by RT/LPN #557. • On 09/01/24, Resident #22's power of attorney (POA)/guardian was notified of the incident by RT/LPN #557. • On 09/01/24, all residents were assessed for the need for a bariatric bed based on their body shape by the ADON. Resident #1's fall risk care plan was updated on 09/01/24 to include an intervention for a bariatric bed. • Beginning on 09/02/24, the DON/designee audited two bariatric and immobile residents' bed baths to ensure bed baths were being completed properly per the protocol. The audits continued weekly for four weeks occurring on 09/06/24, 09/09/24, 09/13/24, 09/16/24, 09/20/24, 09/23/24, and 09/27/24 with no additional concerns identified. • On 09/03/24, a bariatric bed was ordered by Receptionist #553 for Resident #22 and was applied to the resident's bed. • On 09/03/24, all nursing staff were educated on bed mobility and bed positioning during bed baths by the ADON and subsequently, no staff were permitted to work on the floor prior to receiving the education. Review of the staff in-service sign-in sheets revealed all staff were trained by 09/03/24. • On 09/04/24, all residents who were bariatric and immobile had an occupational and physical therapy screening sent for bed mobility on various days. All resident screenings were completed by Therapy Director #590 on 09/04/24. • On 09/04/24, all residents who were bed-bound had their care plans reviewed and were updated by the ADON to require two people to assist when repositioning and for bed baths. • On 09/04/24, Resident #22's care plan was revised by the ADON to include an intervention for the resident to require two people to assist when repositioning and when providing bed baths. • On 05/29/25, four (#17, #42, #44, and #57) additional residents were reviewed for falls with no concerns identified. • On 05/29/25, interviews between 7:30 A.M. and 8:00 A.M. with CNA #582, CNA #547, LPN #516, and Transportation Aide #515 all verified they were provided education regarding residents who were bed-bound requiring a two person assist with bed mobility and bed baths and were able to demonstrate proficiency in the training. • On 05/29/25, the facility incident log was reviewed from January to May 2025 with no additional incidents of residents falling from the bed while being provided care by staff. There were no trends or patterns of incidents identified.

Based on medical record review, resident and staff interview, interview with Wound Care Nurse Practitioner (NP) #700, review of hospital records, review of an incident report, review of a facility self-reported incident (SRI), review of the facility investigation, review of witness statements, and review of a policy, the facility failed to ensure a resident (#09) was free from avoidable burns inflicted by a staff member. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 12/05/23 at approximately 2:45 A.M., State tested Nurse Aide (STNA) #195 used her personal lighter in an attempt to remove a diabetic wound dressing from Resident #09's right foot. Subsequently, Resident #09's wound dressing was set on fire, causing the resident and STNA #195 to catch fire, and Resident #09 was later hospitalized and treated for first-degree (top layer of skin) and second-degree (first two layer of skin) burns. This affected one (#09) of one resident reviewed for accidents. The facility census was 65. On 12/07/23 at 4:34 P.M., the Administrator and Regional Director of Operations #907 were notified Immediate Jeopardy began on 12/05/23 at approximately 2:45 A.M., when STNA #195 used her personal lighter in an attempt to remove a dressing on Resident #09's foot. STNA #195 took Resident #09 to the shower room for bathing where a diabetic wound dressing to Resident #09's right foot became wet and needed changed. STNA #195 attempted to independently remove the dressing but could not locate scissors to cut the dressing, so the nurse aide utilized a personal lighter to the wound dressing in an attempt to remove it from Resident #09's right foot. The flame from STNA #195's lighter ignited the wound dressing on Resident #09's right foot as well as STNA #195's left pant leg. Both fires to Resident #09 and STNA #195 were extinguished with staff intervention, and Resident #09 was sent to the hospitalized and treated for first and second-degree burns. The Immediate Jeopardy was removed on 12/06/23 when the facility implemented the following corrective actions: On 12/05/23 at 2:45 A.M., STNA #201 entered the shower room and extinguished the fire to Resident #09's right foot dressing. On 12/05/23 at 2:46 A.M., Agency Registered Nurse (RN) #488 was notified of the incident and assessed Resident #09. On 12/05/23 at 2:50 A.M., Agency RN #488 notified the Director of Nursing (DON) of the incident. STNA #195 was interviewed and was immediately suspended pending investigation. STNA #195 had not worked since the suspension was initiated. On 12/05/23 at 3:00 A.M., Agency RN #488 notified the on-call provider of the incident. On 12/05/23 at 3:10 A.M., a treatment was ordered for Resident #09 for a burn wound caused by the fire and applied by Agency RN #488. On 12/05/23 at 4:05 A.M., Agency RN #488 completed a pain assessment on Resident #09. On 12/05/23 at 4:30 A.M., Agency RN #488 administered as-needed pain medication (acetaminophen) to Resident #09. On 12/05/23 at 5:30 A.M., the DON assessed Resident #09. On 12/05/23 at 9:30 A.M., Wound Care Nurse Practitioner (NP) #700 assessed Resident #09 with an increased area of concern noted to the burn wound. On 12/05/23 at 10:00 A.M., the DON spoke with Resident #09 to discuss the occurrence and injury with family and the resident agreed. On 12/05/23 at 10:15 A.M., Resident #09's family was notified of the incident. On 12/05/23 at 10:30 A.M., Physician #704 was notified and new orders to administer a dose of oxycodone (narcotic pain medication) to Resident #09 and to send Resident #09 to the emergency department (ED) for evaluation and treatment were received by the DON. On 12/05/23 at 10:37 A.M., new orders were received for additional routine and as-needed pain medication for Resident #09. On 12/05/23 at 11:10 A.M., the Administrator submitted an SRI to the State Survey Agency to report the incident. On 12/05/23 at 11:15 A.M., RN #489 administered pain medication to Resident #09 per the new physician order. On 12/05/23 by 7:00 P.M., the Administrator, the DON, Director of Clinical Services #500, Director of Operations #505, Regional Nurse #510, and the Regional Director of Operations #907 reviewed and updated the STNA orientation checklist. On 12/05/23 by 7:00 P.M., the Assistant Director of Nursing (ADON) performed skin assessments on all residents assigned to STNA #195. On 12/05/23 by 7:00 P.M., the ADON and Unit Manager #912 assessed all residents with a dressing in place to ensure treatments were in place and no other injuries were noted. On 12/05/23 by 7:00 P.M., the Administrator, the DON, and Regional Nurse #510 completed the interdisciplinary team investigation. On 12/05/23 by 10:00 P.M., the DON/designee educated all staff that licensed nurses were the only individuals permitted to remove dressings, and also provided education on scope of practice, standards of practice, and reporting incidents. On 12/05/23 by 10:00 P.M., the Administrator/designee educated all staff on the policy for abuse and neglect, and the facility's fire policy including use of lighters. Beginning 12/06/23, the DON/designee would conduct audits related to dressings and protocol for removing dressings four times weekly for two weeks, followed by two times weekly for two months, and then as determined by the Quality Assurance Performance Improvement (QAPI) committee. Beginning 12/06/23, the Administrator/designee would conduct random audits to ensure fire safety practices were being followed and that staff understood the fire safety policies three times weekly for four weeks, followed by two times weekly for two months, and then as determined by the QAPI committee. Interviews on 12/11/23 between 11:49 A.M. and 2:10 P.M. with RN #489, STNA #347, STNA #900, and STNA #350, all verified education was provided by the Administrator/designee and DON/designee for all staff, and all possessed adequate knowledge of the education content. Although the Immediate Jeopardy was removed on 12/06/23, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan to ensure all residents at risk for staff removing wound dressings in an unsafe manner were monitored appropriately for on-going compliance. Findings include: Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with a foot ulcer, cellulitis, heart disease, dysphagia, arthritis, pain in left foot, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed the resident was assessed as cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and putting on and removing footwear. The resident was assessed with a diabetic foot ulcer with applications of ointments and medications and dressings to the feet. Review of the plan of care, revised 10/09/23, revealed Resident #09 had an actual impairment to skin integrity of the right heel to include a diabetic foot ulcer. The resident was followed by a wound team. Interventions included following facility protocols for treatment of the injury, monitoring the dressing to ensure it was intact and adhering, and providing treatment as ordered. Review of Resident #09's physician orders for November 2023 revealed an order to cleanse the right heel with Dakins solution, apply Dakins-moistened fluffed gauze, cover with ABD (absorbent pad), and wrap with rolled gauze. Instructions for the dressing included to date and time the dressing and change every day, and as needed, if the dressing was soiled, loose, or dislodged. Review of the incident report dated 12/05/23 and timed 2:45 A.M., revealed Resident #09 had a shower. After the shower, STNA #195 wanted to remove the dressing to the resident's right foot and did not have scissors. STNA #195 used her lighter to start to unravel the dressing; however, Resident #09's foot dressing caught fire and a second STNA extinguished the fire. Review of the nursing progress notes dated 12/05/23 and timed 3:00 A.M. revealed the DON received a call from Agency RN #488 indicating Resident #09 had altered skin integrity to his right foot. The nurse was advised to call the certified nurse practitioner (CNP) with her assessment. An order was received for a dressing to be applied to Resident #09's right foot. Review of the skin assessment dated [DATE] and timed 5:32 A.M., revealed Resident #09 had a burn to the top of right foot, which was four (4.0) centimeters (cm) long by eight (8.0) cm wide, a burn to the medial aspect of the right foot which was 10.0 cm long by 8.0 cm wide, and a blister to medial aspect of the right foot which was 5.5 cm long by 6.5 cm wide. Review of the nursing progress notes dated 12/05/23 and timed 5:36 A.M., revealed the DON assessed Resident #09's right foot and noted two areas to the top of the foot with the top layer of skin removed and a pink wound bed were present. There was an area to the medial right foot extending to the heel with the top layer of skin removed and pink wound bed also noted. There was also an intact blister to the lateral right heel and flesh-tone was noted. Review of the nursing progress notes dated 12/05/23 and timed 9:30 A.M. revealed the Wound Care NP #700 assessed Resident #09's wounds and changes were noted from an earlier assessment. The facility received new orders for care and treatment of Resident #09 at that time. Review of the wound care practitioner notes dated 12/05/23 and timed 10:42 A.M., revealed Resident #09 was seen for a right heal diabetic ulcer, a new skin tear to left hand from recent fall, and new skin breakdown to right foot reported per nursing staff. Per Resident #09's report, the resident's right wound dressing caught fire early that morning causing a burn to the right foot. The exact cause for this was being investigated per facility staff. A dressing was applied to the resident's right foot early that morning and found to be saturated at the time of assessment due to heavy drainage. The wound was noted as a right foot burn with treatment recommendations to cleanse with normal saline, apply Silvadene one percent (1%) cream followed by oil emulsion dressing to the base of the wound, secure with ABD and rolled gauze, and change twice per day and as needed. Review of the wound assessment report dated 12/05/23, revealed Resident #09 was seen for the diabetic foot ulcer, a new skin tear to the left hand, and new burns to the right foot. The burns were 16.0 cm long by 24.5 wide by 0.2 cm deep. Review of the health status notes dated 12/05/23 and timed 11:16 A.M., revealed the physician was called with a description of Resident #09's wounds. An order for pain medication and to send the resident to the ED was received. Review of the health status notes dated 12/05/23 and timed 11:36 A.M., revealed oxycodone was administered to Resident #09. The ED was notified of the resident's pending arrival, and was sent to the ED. The resident's family was contacted and updated. Review of the hospital records revealed Resident #09 was seen and admitted on [DATE] at 12:33 P.M. with a burn wound to the right foot. A nurse aide was trying to burn the dressing to remove it, and the dressing caught fire causing a burn to the dorsum (top) and plantar (bottom) aspects of the right foot. The resident had circumferential ulceration from the dorsum of the foot extending along the plantar vault and lateral aspects of the right foot and ankle from the burn wound. Review of radiographs of the right foot revealed osteomyelitis (bone infection) of the right calcaneus (heel bone) and the burn wound appeared to be mostly superficial without any exposure of deep structures. Selective debridement was performed on the burn wound to remove nonviable and sloughing (yellow, tan, gray green tissue that is usually moist and adhered to the wound bed) skin with a suture removal kit. The procedure was performed at the bedside down to the layer of the dermis (connective tissue layer) near the area of the burn wounds. The resident was prescribed vancomycin (antibiotic) 1,000 milligrams in sodium chloride intravenously every 24 hours and continued use of Silvadene to the burn wounds. Review of the hospitalist notes dated 12/06/23 revealed the burn was a first to second-degree burn. Review of the facility SRI dated 12/05/23 at 11:10 A.M., revealed the facility initiated a report of an incident involving a dressing to Resident #09's foot with an injury noted, and the resident was sent to the ED. Review of the facility investigative timeline, revealed Resident #09 received a shower on 12/05/23 between 2:30 A.M. and 2:45 A.M. At 2:45 A.M., the resident's wound dressing was lit on fire by STNA #195, and STNA #195 attempted to extinguish the fire and called for help. STNA #201 then entered the shower room and extinguished the fire. The nurse on duty was notified of the incident at 2:46 A.M. and assessed Resident #09 at 2:50 A.M. and notified the DON. The on-call provider was notified of the incident at 3:00 A.M. and new orders were received. The DON notified the Administrator at 3:10 A.M. and Agency RN #488 followed new wound care orders. At 3:30 A.M., the DON instructed STNA #195 to write a statement and leave the building. STNA #195 left the building at 4:00 A.M. At this time, Resident #09 was in his wheelchair, located in his room, and with no distress. The resident received acetaminophen at 4:05 A.M. The DON assessed the foot wound at 5:30 A.M. A wound care CNP assessed the wound at 9:30 A.M. and determined it had worsened. A new order for oxycodone was received at 10:37 A.M. The administrator submitted the SRI at 11:10 A.M. The physician was notified of the wound status and gave an order for pain medication and transfer to emergency department at 11:15 A.M. The DON called report to the emergency department and notified the resident's family at 11:30 A.M. Review of the written statement provided by STNA #195, dated 12/05/23, revealed STNA #195 assisted Resident #09 with his shower. Once finished, STNA #195 noticed the resident's bandages needed changed so she notified the nurse. The nurse asked STNA #195 to let her know once the resident was in bed so the nurse could perform wound care. STNA #195 finished caring for the resident and removed the bandage that was wet and peeling. STNA #195 started to finish removing what was already coming off. The tape had gotten stuck to the bandage and kept pulling. STNA #195 could not find any scissors, so she tried to burn the fringe to remove it. It immediately caught fire and the fire kept building like a forest fire. STNA #195 called the coworker who was closest to her (STNA #201), the staff members put out the fire, and notified the nurse immediately after. Review of the written statement provided by STNA #201, dated 12/05/23, revealed STNA #195 called STNA #201 into the shower room as STNA #201 was going to chart. STNA #201 saw that Resident #09's foot was on fire. STNA #201 took a towel and put the fire out. STNA #201 asked the resident if he was okay or if anything was burning or hurting. STNA #201 then asked STNA #195 if she was okay. After making sure everything was okay, STNA #201 went and retrieved the nurse. Review of the written statement provided by Agency RN #488, dated 12/05/23, revealed an STNA gave Resident #09 a shower at approximately 2:30 A.M. Agency RN #488 informed the STNA that Agency RN #488 would change the resident's dressing once he was in bed. At approximately 2:45 A.M., an STNA came and told the nurse Resident #09 had been injured from a burn to the right foot. Upon assessment of the right foot, the color was pink and top of the foot's epidermis (top layer of skin) was impaired. The resident denied pain and had full range of motion. First aide was given, and the foot was wrapped and dressed with Kerlix and ABD. The STNA indicated she was removing a bandage, and the threads began to pull. The STNA used a lighter to burn away threads and burned Resident #09's foot. During an interview on 12/07/23 at 12:59 P.M. with the Administrator, the Administrator reported early on the morning of 12/05/23, STNA #195 gave Resident #09 a shower. The resident's dressing was wet following the shower. The STNA informed the nurse the dressing needed to be changed, and the nurse stated she would change it soon. The STNA took it upon herself to take the dressing off. There was tape that was caught on the edges of the dressing, and the STNA did not have a pair of scissors, so she pulled a lighter out of her pocket and attempted to burn the edges of the dressing. The Administrator stated STNA #195 stated the entire thing lit up like a forest fire. The Administrator reported there were absolutely no open flames allowed in the building, so staff should never have lit a lighter. During an interview on 12/07/23 at 1:58 P.M. with STNA #195, the staff member reported assisting Resident #09 with a shower on the early morning of 12/05/23. Following the shower, the resident's bandages were almost all the way off due to the shower. STNA #195 notified the nurse on duty that the dressing needed to be changed. The nurse was busy at the time, so STNA #195 decided to remove the dressing. STNA #195 reported she began unraveling the dressing and it became stuck. STNA #195 could not find a pair of scissors, so she used her personal lighter to attempt to burn the fringe off around the bandage. Resident #09's dressing and STNA #195's entire left leg immediately caught fire. STNA #195 began to panic and rolled on the ground while yelling for help. STNA #201 entered the shower room and got both fires out using wet towels. Both STNAs then ran out of the shower room and informed the nurse of what had happened. The nurse immediately assessed the resident. STNA #195 reported she had not realized removing a dressing was considered wound care and realized she should not have used a lighter. During an interview on 12/07/23 at 7:12 P.M. with STNA #201, the staff member reported on 12/05/23 at approximately 2:45 A.M., she heard STNA #195 screaming her name from the shower room. STNA #201 ran into the shower room and saw that Resident #09's foot was on fire. STNA #201 grabbed a towel and smothered the fire. STNA #201 reported the bottom of a shower curtain was also on fire, so she yanked it down and the fire went out as the curtain fell into a bathtub. STNA #201 did not recall whether STNA #195 was also on fire. STNA #201 reported that STNA #195 stated she used a lighter in an attempt to remove Resident #09's dressing and it exploded into a fire. STNA #201 reported seeing the lighter and that it was a regular, standard lighter. During an interview on 12/07/23 at 7:31 P.M. with the DON, the DON reported assessing Resident #09's foot on the early morning of 12/05/23. The DON reported the areas on the resident's foot appeared pink with surface skin missing. When Wound Care NP #700 assessed the resident several hours later, the skin on the edges of the burns was peeling and the DON and Wound Care NP #700 were concerned since the wound was a burn it may have been worsening. The resident was subsequently sent to the ED for evaluation. Interview on 12/11/23 at 8:50 A.M. with Resident #09, revealed the resident recently returned from the hospital following an incident at the facility. Resident #09 reported a nurse aide assisted him with a shower and could not get his dressing off, so she used her lighter. Resident #09 reported his whole dressing caught on fire and the nurse aide's uniform caught on fire twice. During an interview on 12/11/23 at 2:06 P.M. with Wound Care NP #700, the NP reported she had previously been seeing Resident #09 for a diabetic foot ulcer. On 12/05/23, Wound Care NP #700 assessed Resident #09's foot for burns. Wound Care NP #700 and the DON discussed their assessments from that day and determined that the wound had worsened between assessments. Wound Care NP #700 reported this was due to the burns looking more reddish or pinkish during the DON's assessment, and when Wound Care NP #700 assessed the burn was starting to blister and draining heavily. Wound Care NP #700 reported originally documenting the burn as a third degree burn because it appeared full thickness. Upon review of hospital podiatry notes, the hospital only had to debride down to the dermis which was indicative of a second-degree burn. Review of a facility policy titled, Wound Care, revised October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds by licensed nursing staff to promote healing. There was no mention of the use of a lighter to remove a wound dressing in the procedure. This deficiency represents non-compliance investigated under Complaint Master Number OH00148949.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC) and Prevention, review of the facility's Coronavirus (COVID-19) policy and procedure, review of the facility's COVID-19 resident and employee positive test results, review of the facility's daily COVID-19 employee screening log, review of timecards, review of text communications, and interviews with staff and the Local Health Department (LHD), the facility failed to implement effective and recommended infection control practices, including following CDC guidelines for excluding health care personnel, who have had contact with someone with suspected or confirmed COVID-19 infection during the prior 14 days, from working to prevent the potential spread of COVID-19 within the facility. This resulted in Immediate Jeopardy and potential serious negative health outcomes and/or life-threatening harm on 08/26/21, when the Director of Nursing (DON) permitted Activity Aide/State tested Nursing Assistant AA/STNA #113 to work her eight-hour shifts beginning on 08/26/21 at 8:05 A.M., after AA/STNA #113 notified the DON that her son, who lived with her, had tested positive for COVID-19. AA/STNA #113 tested positive for COVID-19 on 08/30/21. Between 09/01/21 and 09/13/21, 38 residents tested positive for COVID-19 while residing in the facility, two residents with symptoms of nausea, vomiting and cough. Of the 38 residents who tested positive, AA/STNA #113 had cared for 10 (Residents #12, #18, #19, #25, #28, #42, #47, #49, #55, and #57) of the residents and nine of the 10 tested positive for COVID-19, excluding Resident #42. In addition, between 08/30/21 and 09/07/21, 13 staff members tested positive for COVID-19. The facility census was 56 residents. The Administrator was notified on 09/14/21 at 5:08 P.M., that Immediate Jeopardy began on 08/26/21 when the DON allowed AA/STNA #113 to work her eight-hour shifts beginning on 08/26/21 at 8:05 A.M., after AA/STNA #113 notified the DON that her son, who lived with her, had tested positive for COVID-19. AA/STNA #113 tested positive for COVID-19 on 08/30/21 and following AA/STNA #113's positive test results, 38 (Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #23, #24, #25, #26, #27, #28, #29, #31, #32, #35, #37, #40, #41, #43, #44, #46, #47, #48, #49, #50, #51, #53, #54, #55, #57, #60, #61, #64, and #65) residents tested positive for COVID-19. The Immediate Jeopardy was removed on 09/15/21 when the implemented the following corrective actions: · The facility COVID-19 policy was revised and updated on 09/14/21 to include verbiage that specifically addressed actions taken related to quarantine of unvaccinated staff who have had exposure outside of the facility. · All facility staff were educated by the DON/designee on the revision and update to the COVID-19 policy completed on 09/15/21. · STNA #113 tested positive on 08/30/21 and was sent home and quarantined for 14 days. · The DON and STNA #113 were educated by the Regional Director of Clinical Services on 09/15/21 on the revision and update to the COVID-19 policy as it relates to COVID-19 exposure, signs and symptoms and quarantine guidelines. (when to report and when to quarantine). · All facility residents will continue to have COVID-19 assessments for signs and symptoms at least twice daily every shift to ensure early identification and testing for positivity and quarantine as identified for a period of 12 months and will then be reviewed by Interdisciplinary Team (IDT) for continuation as needed. · COVID-19 testing in the facility will continue two times weekly regardless of vaccination status on all staff and residents until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. · The Administrator/designee completed education/in servicing to all staff members on or before 09/15/21 to ensure they report any exposure to COVID 19 and any signs or symptoms of illness prior to reporting to work to ensure they have accurate direction on any testing or quarantine requirements per revised updated COVID-19 policy. · The DON/designee will audit employee call off logs weekly for 12 weeks beginning 09/15/21 to ensure appropriate direction for quarantine per COVID-19 policy was followed. Results will be reported to Quality Assurance and Performance Improvement (QAPI) committee and audits will continue at discretion of the QAPI committee. · Interviews on 09/15/21 from 2:00 P.M. to 3:03 P.M. with STNA ' s #110, #113, 155, #110, Licensed Practical Nurse (LPN) #119, Licensed Social Worker (LSW) #153, Admission Director (AD) #100 and the DON, confirmed they were all in-serviced on the revised COVID-19 policy effective 09/15/21, regarding when to quarantine for unvaccinated staff who have had exposure outside of the facility due to COVID-19. No concerns were identified, and staff were knowledgeable regarding the in-service provided by the facility and when to quarantine. Although the Immediate Jeopardy was removed on 09/15/21, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Review of the facility screening tools used for all staff revealed staff were screened via body temperature and screening questions: International travel with in the past 14 days. Signs and symptoms of fever, chills, muscle aches, runny nose, sore throat, cough, nausea/vomiting, shortness of breath, headache, abdominal pain, diarrhea, loss of taste/smell, contact with someone with or under investigation of COVID-19, reside in a county that has a community-based transmission of COVID-19. Staff circled the date of entry and placed their initials. Review of the facility staff screening log dated 08/26/21, revealed AA/STNA #113 underwent the screening process with a body temperature of 99.3 degrees Fahrenheit (F) and answered the screening questions with no concerns. Review of the facility staff screening log dated 08/28/21, revealed AA/STNA #113 underwent the screening process with a body temperature of 99.8 degrees F and answered the screening questions with no concerns. Review of the facility staff screening log dated 08/29/21, revealed AA/STNA #113 underwent the screening process with a body temperature of 99.4 degrees F and answered the screening question contact with someone with COVID-19, answered yes. Review of daily timecard dated 08/26/21 to 08/29/21, revealed AA/STNA #113 clocked in on 08/26/21 at 8:05 A.M. and clocked out on 08/26/21 at 4:05 P.M. On 08/28/21, AA/STNA #113 clocked in at 7:55 A.M. and clocked out on 08/28/21 at 3:56 P.M. On 08/29/21, AA/STNA #113 clocked in at 7:57 A.M. and clocked out on 08/29/21 at 4:00 P.M. Review of a screen shot of text communication from the DON ' s cell phone with AA/STNA #113 dated 08/25/21 at 9:51 P.M., revealed AA/STNA #113 ' s son tested positive for COVID-19 and should she quarantine? On 08/26/21 at 5:04 A.M., the DON replied No. On 08/26/21 at 6:12 A.M., the DON asked, Are you symptomatic? AA /STNA #113 replied, No I ' m not. Then on 08/30/21 at 8:11 A.M., the DON indicated, I ' m hearing you are starting to get sick. If this is true, we should test you outside. The DON communicated to AA/STNA #113 that she was positive. The Administrator notified the LHD, Epidemiologist #160, that AA/STNA #113 had tested positive for COVID-19 on 08/30/21. The DON indicated AA/STNA #113 tested negative on 08/25/21 but was informed by staff that AA/STNA #113 was displaying symptoms on 08/29/21. Then on 08/30/21, the DON instructed AA/STNA #113 to quarantine for 14 days. Review of the resident COVID-19 positive reports from 09/01/21 to 09/13/21, revealed facility residents (#12, #13, #14, #15, #16, #17, #18, #19, #20, #23, #24, #25, #26, #27, #28, #29, #31, #32, #35, #37, #40, #41, #43, #44, #46, #47, #48, #49, #50, #51, #53, #54, #55, #57, #60, #61, #64, and #65), tested positive for COVID-19. Further review revealed AA/STNA #113 had cared for 10 (#12, #18, #19, #25, #28, #42, #47, #49, #55, and #57) of the 38 residents from 08/26/21 to 08/29/21. Review of the facility employee COVID-19 testing reports revealed 13 staff members tested positive for COVID-19 between 08/30/21 to 09/07/21. Telephone interview on 09/13/21 at 12:31 P.M., with AA/STNA #113 verified her son tested positive for COVID-19 and was in close contact with him as he was living with her. AA/STNA #113 reported sending a text message to the DON of her son testing positive for COVID-19, and indicated she was not vaccinated and asking if she should quarantine. She stated the DON replied no. AA/STNA #113 verified she had worked on 08/26/21 and helped pass meal trays. She stated on 08/28/21, she provided group activities that included coffee social and movie at 10:30 A.M. and at 1:00 P.M. Then on 08/29/21, she held a group activity of nails and manicures. AA/STNA #113 verified she was in close contact during group activities with residents on the third floor. Interview on 09/13/21 at 12:38 P.M., with the DON, verified AA/STNA #113 had sent a text message on 08/25/21 at 9:53 P.M., of her son testing positive and wanted to know if she should quarantine. The DON verified on 08/26/21 at 5:04 A.M. she replied, No. Telephone interview on 09/14/21 at 9:57 A.M. with LHD Epidemiologist #160, verified the facility sends reports to her of the COVID-19 positive staff and residents. Epidemiologist #160 verified AA/STNA #113 should have quarantined for 14 days as she was in direct contact with her son. Review of facility policy titled, COVID-19, dated 04/27/21, revealed symptomatic Health Care Personnel (HCP) with suspected or confirmed COVID-19 shall be excluded form work at least three days (72 hours) have passed since recovery defined as resolution of fever without the use of fever reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath), and at least 10 days have passed since symptoms first appeared. Unvaccinated HCP with laboratory confirmed COVID-19 who have not had any symptoms shall be excluded from work until 10 days have passed since the date of their first positive COVID-19 diagnostic test and assuming they have not subsequently developed symptoms since their positive test period if they develop symptoms, then symptom-based protocol shall commence. Fully vaccinated HCP with higher risk exposures who were asymptomatic do not need to be restricted from work for 14 days following their exposure. Asymptomatic HCP with a higher risk exposure and patients or residents with prolonged close contact with someone with [CONDITION(S)]-C0V-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] test for [CONDITION(S)]-CoV-2 infection. In these situations, testing was recommended immediately after five to seven days after exposure. Note because symptoms cannot be used to gauge where these individuals were in the course of their illness, it was possible that the duration of [CONDITION(S)] shedding could be longer or shorter than 10 days after their first positive test. The original facility policy titled, COVID-19, dated 04/27/21, did not address unvaccinated HCP who have exposure to COVID-19 be excluded from work for 14 days after last exposure. Review of the CDC guidance titled, Guidance for Asymptomatic HCP Who Were Exposed to Individuals with Confirmed [CONDITION(S)]-CoV-2 Infection (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html), updated 09/10/21, revealed a close contact was defined as anyone who has prolonged close contact (within six feet for a cumulative total of 15 minutes over 24 hours) to someone with [CONDITION(S)]-CoV-2 infection. However, when close contact occurs, factors that can reduce risk for transmission include, but were not limited to correct use of personal protective equipment (PPE) by HCP, use of well-fitting source control by the individual with [CONDITION(S)]-CoV-2 infection, and whether the HCP and/or the individual with [CONDITION(S)]-CoV-2 infection were fully vaccinated. All these factors should be considered when evaluating an exposure. Following a higher-risk exposure, testing and work restriction are recommended for unvaccinated HCP. This deficiency substantiates Complaint Number OH 660.