Every finding on record at Divine Rehabilitation and Nursing at Shane Hill

Based on observation, staff interview, and policy review, the facility failed to ensure safe temperatures were maintained and documented for resident personal refrigerators. This deficient practice affected four (#7, #37, #38, and #40) of four residents reviewed for personal refrigerators. The facility census was 54.Findings include:Observation on 06/08/26 at 9:50 A.M. revealed Resident #37 had a personal refrigerator with soda and bologna inside. The refrigerator had no thermometer or documented monitoring of temperatures.Observation on 06/08/26 at 10:00 A.M. revealed Resident #7 had a personal refrigerator with nutritional shakes, soda, cheese, energy drink, and candy inside. The refrigerator had no thermometer or documented monitoring of temperatures.Observation on 06/08/26 at 10:16 A.M. revealed Resident #38 had a personal refrigerator with soda inside. The refrigerator had no thermometer or documented monitoring of temperatures.Observation on 06/08/26 at 10:24 A.M. revealed Resident #40 had a personal refrigerator with soda inside. The refrigerator had no thermometer or documented monitoring of temperatures.Interview on 06/08/26 at 10:01 A.M. with Laundry Aid #37 revealed there was no recorded refrigerator temperature monitoring for Resident #7, #37, #38, and #40, and no thermometers to monitor the temperature for Resident #37, #38, and #40.Review of the undated facility policy titled, Resident Refrigerators, revealed maintenance staff shall record refrigerator temperature weekly on a temperature log attached to the refrigerator. A thermometer shall remain in the refrigerator.

Based on observation, family representative interview, staff interview, and facility policy review, the facility failed to maintain the building in a safe, clean, and homelike manner. This affected two (#10 and #48) of 20 residents residing on the Memory Care Unit. The census was 54.Findings Include:Observation on 06/08/26 at 9:30 A.M. during tour of the Memory Care Unit dining room revealed, on the East wall, an air conditioning (AC) unit was installed in the wall under a window. Around the AC unit and along the wall near the floor there appeared to be three large black-green fuzzy spots on the wall. On the North wall, the wallpaper located next to the door leading into the kitchen area was torn and peeling off the wall in four spots. There appeared to be brown residue on the floor where the wall connected to the flooring under the torn wallpaper. On the North wall of the dining room there was a counter with a kitchen-style sink, and under the sink there were brown-red stains observed with a pervasive odor noted.Observation on 06/08/26 at 9:40 A.M. of the Memory Care Unit dining room floor revealed, along the South wall from the [NAME] to East wall, there were missing or broken tiles with what appeared to be sharp edges.Observation on 06/08/26 from approximately 9:40 A.M. to 10:00 A.M., Resident #48 was observed taking off his socks and walking barefoot around the dining room in the Memory Care Unit. Resident #48 appeared confused, was talking to himself, and appeared to be visual hallucinating. Resident #48 was observed walking on the broken tiles and around the dining room areas including the area of the AC unit by the window on the East wall.Interview on 06/08/26 at 10:02 A.M. with Certified Nurse Aide (CNA) #18 verified there were broken and missing tiles on the dining room floor. CNA #18 verified Resident #48 would take off his socks and ambulate independently around the dining room in his bare feet at times. CNA #18 verified the condition of the wall with the AC unit, the spill under the sink, the peeling wallpaper, and overall unsanitary condition of the dining room area. CNA #18 stated staff have reported the concerns to the maintenance department and were waiting for repairs.Interview on 06/08/26 at 12:47 P.M. with Resident #10's family representative revealed the resident no longer liked eating in the dining room due to the cleanliness and condition of the dining room itself. Per the family representative, the dining room was in disrepair and it was, Too gross to eat in. Interview on 06/08/26 at 12:33 P.M. with Regional Maintenance Director (RMD) #76 and Maintenance Tech (MT) #44, during a tour of the Memory Care Unit dining room, verified the three large black-green fuzzy spots on the wall and the North wall wallpaper located next to the door leading into the kitchen area was torn and peeling off the wall in three to four spots. RMD #76 verified there were missing and broken tiles all along the East wall of the dining room.Review of the facility policy titled, Homelike Environment, dated 2025, revealed the facility will provide a clean, safe, and comfortable homelike environment.Review of the undated facility policy titled, Dining and Resident Activity Rooms, revealed the facility will provide a room designated for resident dining which is safe, functional, and sanitary.This deficiency represents non-compliance investigated under Complaint Number 3034522.

Based on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new serious mental illness. This deficient practice affected one (#7) of one residents reviewed for PASARR. The facility census was 54.Findings include:Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral palsy, schizoaffective disorder, bipolar type, type two diabetes mellitus, neuromuscular dysfunction of bladder and conversion disorder with seizures.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to be dependent on oral hygiene, toileting, bathing, and dressing. Resident #7 took antipsychotic, antidepressant, opioid, insulin, and anticonvulsant medications during the assessment look-back period.Review of Resident #7's medical record revealed the resident had schizoaffective disorder added as a new diagnosis in April 2024. No PASARR was completed at time of the new diagnosis.Interview on 06/08/26 at 3:45 P.M. with the Director of Nursing (DON) verified no PASARR was completed after Resident #7 was diagnosed with schizoaffective disorder in April 2024.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were not pre-prepared for administration. This affected three (#48, #52, and #55) of three residents observed with medications which were pre-prepared and not given immediately after preparation. The facility census was 54.Findings include:Observation and interview on 06/10/26 at 8:05 A.M. revealed a medication cart in the locked room of the 100 Hall. A small plastic cup containing five opened tablets/capsules was on the top of the cart. Licensed Practical Nurse (LPN) #65 removed the cup, opened a drawer, and placed the cup in a small cubby. LPN #65 identified the medications as ready to be administered to Resident #52. Once the drawer was opened, two additional small plastic cups were in the drawer with opened medications. One cup contained crushed medications, identified by LPN #65 as ready to be administered to Resident #48, and the other contained 10 tablets/capsules, identified by LPN #65 as ready to be administered to Resident #55.Review of the medical record of Resident #48 revealed the medication administration record (MAR) indicated medications to be administered at 8:00 A.M. on 06/10/26 included aspirin 81 milligrams (mg) one tablet, Lasix 20 mg one tablet, lisinopril 20 mg one tablet, potassium chloride 10 milliequivalents (mEq) one tablet, sertraline 50 mg one tablet, Depakote sprinkles 125 mg two capsules, and acetaminophen extra strength 500 mg two tablets.Review of the medical record of Resident #52 revealed the MAR indicated medications to be administered at 8:00 A.M. on 06/10/26 included sertraline 100 mg two tablets, and Depakote sprinkles 125 mg four capsules and hydroxyzine pamoate 50 mg one capsule to be administered at 10:00 A.M.Review of the medical record of Resident #55 revealed the MAR indicated medications were to be administered at 8:00 A.M. on 06/10/26 included ferrous sulfate 325 mg one tablet, Flomax 0.4 mg one capsule, loratadine 10 mg one tablet, losartan 50 mg one tablet, sitagliptin 50 mg one tablet, clozapine 100 mg three tablets, nabumetone 500 mg one tablet, and ziprasidone 60 mg on capsule.Review of the undated policy titled, Medication Administration, revealed medications are to be administered in accordance with professional standards of practice.

Based on observation, medical record review, staff interview, review of medication packaging, and policy review, the facility failed to ensure medications were administered as ordered resulting in a medication error rate greater than five (5) percent (%). A total of two (2) medication errors were observed out of 29 opportunities for a medication error rate of 6.9%. This affected two (#22 and #40) of four residents observed for medication administration. The facility census was 54.Findings include:1. Review of the medical record of Resident #22 revealed an admission date of 04/08/26. Diagnoses included dementia, anxiety, and chronic obstructive pulmonary disease.Review of the physician order dated 06/01/26 revealed Resident #22 was ordered fluticasone propionate nasal suspension 50 micrograms per activation (mcg/act) with instructions for one spray in both nostrils one time a day for seasonal rhinitis.Observation on 06/10/26 at 8:05 A.M. revealed Licensed Practical Nurse (LPN) #65 handed Resident #22 the bottle of fluticasone propionate nasal suspension 50 mcg/act. Resident #65 sprayed twice in each nostril and handed the bottle back to LPN #65. LPN #65 had not instructed Resident #22 to spray once in each nostril.Interview on 06/10/26 at 8:10 A.M. with LPN #65 provided verification he had not instructed Resident #22 to only spray once in each nostril per the physician order.2. Review of the medical record of Resident #40 revealed an admission date of 07/14/22. Diagnoses included chronic obstructive pulmonary disease, chronic diastolic heart disease, and blindness category five. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact.Review of the physician order dated 09/10/25 revealed Resident #40 was ordered Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 mcg/act with instructions for one inhalation orally one time a day related to chronic obstructive pulmonary disease and to rinse the mouth with water after use.Observation and interview on 06/10/26 at 8:20 A.M. revealed LPN #33 handed Resident #40 the Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 mcg/act and Resident #40 inhaled once from the device. LPN #33 then left the room and had not instructed Resident #40 to rinse her mouth after the device use. This surveyor questioned LPN #33 on why the nurse had not instructed the resident to her mouth and she stated, She will rinse; she always does. LPN #33 then re-entered Resident #40's room and asked if she had rinsed to which Resident #40 replied, Why?Observation of the Trelegy Ellipta package box revealed the last step in the instructions on the back of the box included, Rinse your mouth after use.Review of the undated policy titled, Administration of Metered-Dose Inhaler, revealed for staff to allow the resident to rinse and gargle with water to remove medication from the mouth and back of the throat.

Based on medical record review, observation, staff interview, and review of a facility sign, the facility failed to ensure staff followed required infection control practices related to care of residents on enhanced barrier precautions. This deficient practice affected one (#4) of four residents reviewed for infection control. The facility census was 54.Findings include:Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses included sequelae of cerebrovascular disease, dysphagia, flaccid neuropathic bladder, and nontraumatic subarachnoid hemorrhage.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #4 had impaired cognition and was assessed to be dependent with all activities of daily living (ADLs).Review of the care plan dated 05/18/26 revealed Resident #4 was on enhanced barrier precautions (EBP) related to a gastrostomy tube (g-tube) site.Observation and interview on 06/08/26 at 1:33 P.M. of Resident #4 revealed Registered Nurse (RN) #24 was administering medication through the resident's g-tube without wearing a gown or gloves for EBP. RN #24 verified at the time of the observation she was not wearing the required personal protective equipment (PPE) for residents on EBP.Review of an undated facility sign for EBP revealed providers and staff must wear gloves and a gown for high-contact resident care, such as a feeding tube.

Based on observation, medical record review, resident and resident representative interview, staff interview, and review of posted meal times, the facility failed to serve meals in a manner to preserve resident dignity. This affected two (#45 and #10) of two residents directly observed during meals. The facility census was 54.Findings include:1. Observation on 06/08/26 at 12:30 P.M. revealed 14 residents seated in the dining room at seven tables. Two residents were assisted to eat by two staff members at one table. Two tables had one resident seated at a table with two additional residents which had food and were eating while the other two residents waited. Two tables had one resident seated at the table with one additional resident who had food and was eating while the other resident waited. Three tables had only one resident at the table. The additional residents, seated at tables with those already served, were served their meals sporadically. The last resident (#45) served was seated at a table with two additional residents who both had their food and were eating for five minutes prior to the last meal served. Review of the medical record of Resident #45 revealed an admission date of 12/55/23 with diagnoses including depression and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact.Interview on 06/08/26 at 12:47 P.M. with Resident #45 revealed she did not enjoy sitting at the table and waiting on her food while the other two ate their food and it happened regularly. Interview on 06/08/26 at 12:50 P.M. with Certified Nurse Aide (CNA) #55 verified the residents were not served in a dignified manner stating, It would be better if all at the table were served simultaneously.2. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #10 include Alzheimer's disease, dementia with agitation, macular degeneration, heart disease, and thrombocytopenia. Review of the MDS assessment dated [DATE] revealed Resident #10 had impaired cognition and had no issues with swallowing or nutritional status.Review of the posted meal times revealed for the 100 hall (Memory Care Unit) the meal trays were to be served at 12:00 P.M.Interview on 06/08/26 at 12:40 P.M. with Resident #10's family representative revealed the resident no longer liked eating in the dining room due to the cleanliness and condition of the dining room itself. Per the family representative, Resident #10 now ate in her room which delayed the delivery of her food trays. Per the family representative, the scheduled lunch meal should start being served by 12:00 P.M. per the posted time, but stated the meals are always late and usually are not served until after 12:15 P.M. to 12:30 P.M.Observation on 06/08/26 at 12:47 P.M. Resident #10's meal tray was brought into the resident's room.Interview on 06/11/26 at 8:45 A.M. with Licensed Practical Nurse (LPN) #28 verified the meal service was always served after the posted times. LPN #28 verified there have been residents and family complaints regarding the late meal service. LPN #28 stated the lunch meal trays are always served after 12:15 P.M.Observation and interview on 06/11/26 from 11:50 A.M. to 12:45 P.M. of the lunch meal service in the kitchen revealed at 12:15 P.M. the trays for the Memory Care Unit were transported out of the kitchen. Observation at 12:20 P.M. revealed CNA #16 was the only staff member on the unit delivering food trays. CNA #16 verified the meal trays were delivered to the unit 15 minutes after the posted time of 12:00 P.M. which caused a delay for all 20 residents on the unit receiving their meals. CNA #16 stated the residents on the locked unit usually gather in the dining room [ROOM NUMBER] to 15 minutes before 12:00 P.M. to wait for their meals.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure residents were free from abuse and neglect. This affected one (#10) of three residents reviewed for abuse. The facility census was 64. Findings include: Review of medical record for Resident #10 revealed an admission date of 08/22/22 diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety major depressive disorder, single episode, unspecified, other cerebrovascular disease. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 13 indicating intact cognition. She was independent for eating, was dependent for toileting and required maximum assistance for bed mobility and transfers. Review of Resident #10's progress note dated 05/04/25 at 7:15 P.M. revealed the resident was heard yelling from her room and found lying beside her bed. There was no further documentation regarding the incident. Interview on 06/04/25 at 3:10 P.M. with the Administrator and Director of Nursing (DON) revealed it was brought to their attention on 05/08/25 that Certified Nursing Assistant (CNA) #50 had witnessed the abuse of Resident #10 by CNA #51 and Licensed Practical Nurse (LPN) #52 on 05/04/25. CNA #50 had informed management during her training by CNA #51 they entered Resident #10's room and CNA #51 informed Resident #10 she was going to put her in an incontinence product, and she should urinate in it and they would be back to check and change her. The DON explained Resident #10 was able to call staff when needed and ambulate to the bathroom and did not require an incontinence product routinely. The DON explained when she questioned CNA #50, she was informed due to previous experiences at reporting incidents at her previous employer, CNA #50 did not believe her concerns would be addressed and she feared the retribution she experienced there. During the interview, the Administrator shared CNA #50 also informed them after Resident #10 had fallen on 05/04/25, LPN #52 had instructed CNA #50 and #51 to assist her off the floor and onto the bed. CNA #50 stated Resident #10 began to yell when she was moved, and LPN #52 placed her hand on the mouth of Resident #10 and asked her to be quiet. Both staff members were removed from the schedule pending the investigation. The Administrator revealed she reviewed camera footage from 7:00 P.M. to 12:00 A.M. on 05/04/25 which showed LPN #52 went into Resident #10's room for 13 seconds around the time of her fall and then exited the room. The Administrator stated LPN #52 did not return to the room until the 8:00 P.M. with medication pass, when she was in the room for about 36 seconds. The Administrator stated during her investigation she interviewed both CNA #51 and LPN #52 who verified the allegation involving Resident #10 were accurate and each were terminated. Interview on 06/04/25 at 3:33 P.M. with CNA #50 revealed Resident #10 was able to use her call light, was able to inform staff when she needed to use the bathroom and was able to ambulate with assistance from staff. CNA #50 shared CNA #51 placed an incontinent product on Resident #10 because she did not want to toilet her frequently, and informed Resident #10 she would be in to check and change her later throughout the shift. CNA #50 stated a short time later into the shift, they found Resident #10 on the floor beside her bed. LPN #52 was notified and came into the room when she instructed CNA #50 and #51 to assist Resident #10 up and back into her bed. CNA #50 stated Resident #10 began to yell when they moved her, and LPN #52 put her hand over Resident #10's mouth to quiet her. CNA #50 shared she did not report her concern to management and explained at the facility previously worked at would not investigate concerns she had brought to management's attention, and she felt there was retribution for reporting issues. CNA #50 stated when she reported the concern to the scheduler why she no longer wanted to work at the facility; she was contacted by management and an investigation was initiated. CNA #50 stated she did receive education regarding the timeliness of reporting abuse and denied she had any further concern for the care and or treatment of residents at the facility. Review of a facility SRI dated 05/09/25 titled Neglect/Mistreatment Abuse revealed it was reported that Resident #10 had a fall and the LPN #52 did not assess her before they got her off the floor. It was also reported that LPN #52 put her hand over Resident #10's mouth because she was yelling out. It was also reported that CNA #51 told Resident #10 she was putting a brief on her stating we are not doing this. The SRI did not indicate the day the allegation occurred. The allegation was investigated by the facility and substantiated. Review of the typed statement of the DON revealed she interviewed LPN #52 who verified she did not do an assessment of Resident #10 prior to instructing CNA's #50 and #51 to assist her back to bed. Review of the electronic mail statement from CNA #51 documented on 05/04/25 Resident #10 had fallen and the nurse instructed CNA #50 and #51 to assist Resident #10 back to bed without an assessment or taking vitals. Review of the facility provided termination document for CNA #51 revealed a violation of putting an incontinence product on Resident #10 in order not to toilet her frequently. This was signed by CNA #51 on 05/12/25. Review of the electronic mail statement from LPN #52 revealed after Resident #10 had fallen, she began to yell as staff assisted her from the floor. LPN #52 put her hand up to Resident #10's mouth and asked her to please stop yelling. Review of the facility provided termination document for LPN #52 revealed a violation which included a violation of abuse policy. This was signed by LPN #52 on 05/12/25. Review of the facilities undated policy titled Abuse, Neglect and Exploitation revealed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further indicated alleged violations would be reported to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/25: • On 05/09/25, the facility submitted an SRI and began an investigation into the allegation involving Resident #10. • CNA #51 and LPN #52 were terminated by the facility on 05/12/25. • All staff received education on the abuse policy including the timeliness of reporting concerns was completed by 05/12/25. The education was completed by the Administrator or designee. • The facility conducted ongoing monitoring and there were no further abuse concerns. • Interviews on 06/04/25 with LPN #45, LPN #46, CNA #40, CNA #48, CNA #49 and CNA #50 reported they had received training on abuse and timeliness of reporting. • Interview of Resident #10 on 06/04/25 revealed she did not have a concern for her safety at the facility. This deficiency represents non-compliance investigated under Complaint Number OH00165736.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure allegations of abuse and neglect were timely reported to the Administrator. This affected one (#10) of three residents reviewed for abuse. The facility census was 64. Findings include: Review of medical record for Resident #10 revealed an admission date of 08/22/22 diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety major depressive disorder, single episode, unspecified, other cerebrovascular disease. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 13 indicating intact cognition. She was independent for eating, was dependent for toileting and required maximum assistance for bed mobility and transfers. Review of Resident #10's progress note dated 05/04/25 at 7:15 P.M. revealed the resident was heard yelling from her room and found lying beside her bed. There was no further documentation regarding the incident. Interview on 06/11/25 at 3:10 P.M. with the Administrator and Director of Nursing (DON) revealed it was brought to their attention on 05/08/25 that Certified Nursing Assistant (CNA) #50 had reported an allegation of the abuse of Resident #10 by CNA #51 and Licensed Practical Nurse (LPN) #52 which occurred on 05/04/25. CNA #50 had informed management during her training by CNA #51 they entered Resident #10's room and CNA #51 informed Resident #10 she was going to put her in an incontinence product, and she should urinate in it and they would be back to change her later in the shift. The DON explained Resident #10 was able to call staff and ambulate to the bathroom. The DON explained when she questioned CNA #50, she was informed due to previous experiences at reporting incidents at her previous employer, CNA #50 did not believe her concerns would be addressed and she feared the same retribution she experienced there. Interview on 06/04/25 at 3:33 P.M. with CNA #50 revealed Resident #10 was able to use her call light, was able to inform staff when she needed to use the bathroom and was able to ambulate with assistance from staff. CNA #50 shared CNA #51 placed an incontinent product on Resident #10 because she did not want to toilet her frequently, and informed Resident #10 she would be in to check and change her later throughout the shift. CNA #50 stated a short time later into the shift, they found Resident #10 on the floor beside her bed. LPN #52 was notified and came into the room when she instructed CNA #50 and #51 to assist Resident #10 up and back into her bed. CNA #50 stated Resident #10 began to yell when they moved her, and LPN #52 put her hand over Resident #10's mouth to quiet her. CNA #50 shared she did not report her concern to management and explained at the facility previously worked at would not investigate concerns she had brought to management's attention, and she felt there was retribution for reporting issues. CNA #50 stated when she reported to the scheduler why she no longer wanted to work at the facility; she was contacted by management and an investigation was initiated. CNA #50 stated she did receive education regarding the timeliness of reporting abuse and denied she had any further concern for the care and or treatment of residents at the facility. Review of a facility SRI dated 05/09/25 titled Neglect/Mistreatment Abuse revealed it was reported that Resident #10 had a fall and the LPN #52 did not assess her before they got her off the floor. It was also reported that LPN #52 put her hand over Resident #10's mouth because she was yelling out. It was also reported that CNA #51 told Resident #10 she was putting a brief on her stating we are not doing this. The SRI did not indicate the day the allegation occurred. The allegation was investigated by the facility and substantiated. Review of the facilities undated policy titled Abuse, Neglect and Exploitation revealed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further indicated alleged violations would be reported to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/25: • On 05/09/25, the facility submitted an SRI and began an investigation into the allegation involving Resident #10. • CNA #51 and LPN #52 were terminated by the facility on 05/12/25. • All staff received education on the abuse policy including the timeliness of reporting concerns was completed by 05/12/25. The education was completed by the Administrator or designee. • The facility conducted ongoing monitoring and there were no further abuse concerns. • Interviews on 06/04/25 with LPN #45, LPN #46, CNA #40, CNA #48, CNA #49 and CNA #50 reported they had received training on abuse and timeliness of reporting. • Interview of Resident #10 on 06/04/25 revealed she did not have a concern for her safety at the facility. This deficiency represents non-compliance investigated under Complaint Number OH00165736.

Based on review of the facility's Self-Reported Incidents (SRI), facility investigation documentation, staff interview, and review of facility policy, the facility failed to ensure staff were immediately removed from the floor when allegations of staff to resident verbal abuse occurred. This affected one resident (#5) of four residents reviewed. The facility census was 65. Findings Include: Review of Resident #5's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included major depressive disorder, altered mental status, type II diabetes, anxiety disorder, chronic pain, and insomnia. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required supervision with toilet use and personal hygiene. Resident #5 was independent with dressing, transfer and mobility. Resident #5 required maximal assistance with bathing. Resident #5 displayed no behaviors at the time of the review. Review of Resident #5's care plan canceled 02/28/25 revealed supports and interventions for self-care deficit, anemia, pain, diabetes, and depression. Review of the facility's Self-Reported Incident (SRI) 255532 revealed on 12/27/24 staff witnesses reported Certified Nursing Assistant (CNA) #499 was frustrated and argumentative with Resident #5. Review of the investigation documentation found on 12/27/24 at approximately 5:00 P.M. Resident #5 was seated in the dinning room, got up and went back to her room to get her dentures. Resident #5 was still in her room when her dinner tray came out of the kitchen and CNA #499 took Resident #5's dinner tray down to her room. Resident #5 was reported to have been cussing and yelling at CNA #499. CNA #499 was observed coming out of Resident #5's room with a raised voice saying Resident #5 was not going cuss at her when she was doing what she was told to do. She proceeded to drop Resident #5's dinner tray on the nurses station counter. CNA #499 was directed by Registered Nurse (RN) #572 to place the tray back at Resident #5's seat in the dining room. CNA #499 complied and was overheard continuing to yell and argue with Resident #5. It was noted CNA #499 grabbed her coat and went out to take a smoke break. CNA #499 commented she was getting agitated and it was what she was told to do. CNA #499 was noted to have stayed out of the building for about 20 minutes before returning to the floor. In CNA #499's statement she indicated she came back into the facility and spoke with another unidentified staff about getting through the night and it would get better. At 6:38 P.M. the Director of Nursing (DON) received a phone call about the situation and advised RN #572 to have CNA #499 to go home. At approximately 7:07 P.M. Licensed Practical Nurse (LPN) #548 told CNA #499 the DON wanted her to leave the building that night and to call in on Monday. At 7:15 P.M. CNA #499 clocked out. CNA #499 sent a text on 12/27/24 at 7:19 P.M. to the DON for confirmation she was to leave the building and reported she had already clocked out. The concern for staff to resident verbal abuse began on 12/27/24 at approximately 5:00 P.M. and CNA #499 continued to work in the facility until 7:15 P.M. when she clocked out. CNA #499 remained in the facility for approximately two hours after the concern arose. Interview on 03/14/25 at 12:54 P.M. with the Director of Nursing (DON) and the Administrator verified the verbal altercation began between CNA #499 and Resident #5 at approximately 5:00 P.M. and CNA #499 remained in the facility until 7:15 P.M. when she clocked out. Review of the facility policy titled, Abuse, Neglect, and Exploitation, revised August 2024 revealed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after the investigation. The staff were to respond immediately to protect the alleged victim.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), staff interview, and review of the facility misappropriation policy, the facility failed to ensure a resident was free from misappropriation of medication. This affected one (Resident #01) out of three residents reviewed for misappropriation. The facility census was 64. Findings include: Review of the medical record of Resident #01 revealed an admitted [DATE]. Diagnoses include Alzheimer's disease, dementia, moderate protein-calorie malnutrition, anxiety disorder, and supraventricular tachycardia. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #01 was severely cognitively impaired. The assessment further indicated Resident #01 was unable to respond to questions related to pain but did exhibit signs of pain to include non-verbal sound, verbal words (ouch, hurts), facial expressions, and protective body movements. Review of the Resident #01's physician orders reveaeld the resident had an order for Oxycodone (opiate) 5 milligrams (mg) one tablet by mouth two time a day for severe pain dated, dated 06/28/23. The doses were scheduled for 5:00 A.M. and 8:00 P.M. Oxycodone 5 mg give one by mouth every one hour as needed for pain, may give sublingual (SL) or by mouth (PO) dated 11/16/22 and discontinued on 11/04/24. Review of Resident #01's medication administration record (MAR) reveaeld the scheduled doses of Oxycodone were provided routinely and the resident did not usually take any as needed Oxycodone doses. The November 2024 MAR had four doses of the as needed Oxycodone documented as follows: 11/02/24 at 8:29 A.M. effectiveness unknown, 11/02/24 at 5:05 P.M. effective, 11/03/24 at 8:20 A.M. effectiveness unknown, and 11/03/24 at 3:47 P.M. effective. Review of the Controlled Substance Record (CSR) for the Oxycodone five mg for Resident #01 revealed the medication was documented as removed from the medication cart at the following times which were not documented on the MAR or documented in the progress notes as provided to the resident on 11/02/24 at 9:45 A.M., 11:00 A.M., 12:00 P.M., 1:30 P.M., 2:30 P.M., 2:35 P.M., 3:30 P.M., and 5:30 P.M. The Oxycodone five mg was documented as removed from the medication cart at the following times which were not documented on the MAR as administered to the resident or documented in the progress notes as provided to the resident on 11/03/24 at 9:30 A.M., 11:00 A.M., 12:00 P.M., 1:30 P.M., 2:45 P.M., 4:45 P.M., and 5:30 P.M. This is 15 doses of the narcotic pain medication not documented as provided to the resident over these two days. Review of a facility self-reported incident dated 11/04/24, indicated during review of the Controlled Substance Record (CSR) it was discovered an agency nurse Registered Nurse (RN) #100 administered 19 doses of Oxycodone (opioid) five milligram (mg) on the CSR record for Resident #01 over two days. Only four of those 19 doses were recorded on the medication administration record (MAR) as provided to Resident #01. Resident #01 normally does not receive as needed doses of the medications. While reviewing cameras footage for a period of four hours, this nurse was not observed medicating Resident #01, despite the medication having been documented as having been administered. Attempts to contact RN #100 were unsuccessful as she failed to return any phone calls or calls from the staffing agency, who was her employer. Staff interviews revealed Resident #01 had no behaviors out of his ordinary over the time frame. Staff further stated they had not witnessed RN #100 medicate Resident #01. Staff interviewed further stated RN #100 would not be available at times during the three shifts, but none reported feeling she had been impaired. Review of the facility investigation revealed five like residents had been interviewed. None had any concerns with not receiving medications. The facility additionally interviewed two nurses and the two Certified Nursing Assistants (CNA) who had worked with RN #100, and all denied any knowledge of misappropriation. The [NAME] County Sheriff's office, the Ohio Board of Nursing, the facility pharmacy, and the staffing agency were all notified on 11/04/24 by the Administrator. Resident #01's physician was notified by the nurse who discovered the concern on 11/04/24. Review of Licensed Practical Nurse (LPN) #120's typed statement, dated 11/05/24, revealed on 11/02/24, while receiving report from RN #100, RN #100 appeared to be disorganized and unable to focus on anything for more than a few seconds. LPN #120 documented RN #100 kept reporting Resident #01 had been very combative with cares and stated Resident #01 had been hitting and kicking staff. After report the controlled substances were counted and RN #100 stated I hope I can stay awake long enough to drive home. When LPN #120 asked her why, she had stated she had been working a lot, in a defensive tone. LPN #120 reported she had told RN #100 to be careful and she would see her in the morning. LPN #120 reported RN #100 returned on 11/03/24 and during report kept trying to change the subject. LPN #120 reported she returned at 7:00 P.M. and once again RN #100 appeared very disorganized. When RN #100 reported on Resident #01 she stated she had contacted the provider as his medication was getting low and she had not wanted him to be without. RN #100 once again stated Resident #01 had been very combative with care during the day. After RN #100 left, LPN #120 asked the CNA if Resident #01 had been more combative throughout the day and she said, no more than normal. As LPN #120 was reviewing the documentation she noted Resident #01 had received the oxycodone every hour over the last two days. LPN #120 documented Resident #01 was alert and acting his normal behaviors. LPN #120 documented informing the Administrator and Director of Nursing of her concerns on 11/04/24. Review of the summary of investigation indicated the allegation of misappropriation by RN #100 towards Resident #01 was substantiated. Review of the Ohio Board of Nursing licensure verification revealed RN #100 held an active license as of 10/24/22. RN #100 was from a contracted staffing agency. Interview on 11/21/24 at 8:15 A.M. with the Administrator revealed RN #100 was never to return to the facility and no further incidents of misappropriation were discovered. The Administrator confirmed the facility conducted an investigation and substantiated that RN #100 misappropriated Resident #01's medications. Review of the policy titled Controlled Substance Administration & Accountability, undated, revealed the facility will have safeguards in place in order to prevent loss or diversion. The policy was followed in the events surrounding the misappropriation of Resident #01's narcotic medication by RN #100. As a result of the incident, the facility took the following actions to correct the deficient practice by 11/21/24: Immediate removal of RN #100 from the schedule on 11/04/24. All resident narcotic records and Narcotic medications were audited on 11/04/24 with no deficient practice noted. Five like residents were interviewed on 11/04/24 and had no concerns related to misappropriation. Three staff members were interviewed on 11/04/24 and one on 11/05/24 and were not aware of any misappropriation occurring while working with RN #100. All staff in the facility were in-serviced by the Administrator and the Director of Clinical Operations on the facility's abuse, neglect, and misappropriation policy by 11/21/24. RN #100 has been placed on a Do Not Return list on 11/04/24. All resident narcotic records continue to be audited weekly by the Director of Nursing and Unit Managers indefinitely. This deficiency represents non-compliance investigated under Complaint Number OH00159761.

Based on record review and staff interviews, the facility failed to ensure residents were free of potential hazards and accidents. This affected one (#60) resident and had the ability to affect 19 additional residents (#7, #8, #11, #14, #28, #29, #30, #34, #36, #39, #40, #41, #48, #50, #51, #53, #56, #58, and #59) in the memory unit who were cognitively impaired and independently mobile. The facility census was 64. Findings include: Review of medical record for Resident #60 revealed admitted [DATE]. The resident was admitted with diagnoses including dementia with severe psychotic disturbances, type two diabetes mellitus, anxiety, Bipolar Disease, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He was independent or required supervision only for activities of daily living. Review of the progress note on 03/07/24 at 9:29 P.M., revealed Licensed Practical Nurse (LPN) #104 documented she had been informed by an unidentified State tested Nursing Assistant, that Resident #60 had gotten into staffs' bag and took a lighter and cigarette. Staff had been able to get the lighter, but Resident #60 refused to give them the cigarette. Attempts to redirect Resident #60 were unsuccessful, and his family was called. Resident #60's son-in-law came to the facility and the incident was deescalated. Interview on 04/04/24 at 8:42 A.M., with LPN #104 revealed she had gotten in report at shift change Resident #60 had been having increased moodiness. She was alerted by staff around shift change Resident #60 had gotten into a staff members coat which had been hanging in a common area at the end of the unit. Staff had been able to get the lighter from him. However, multiple attempts to get the cigarette were unsuccessful. The family was then called to inform them of the incident and increased behaviors. Resident #60's son in law came to the facility and after walking Resident #60 outside the facility for a bit, he was able to get Resident #60 to turn over the cigarette. LPN #104 then explained, normally the staff's personal items would be locked in the nursing office, however, the area was under construction at the time of the incident.

Based on observation, staff interview and review of the product insert instructions, the facility failed to ensure insulin pen needles were primed after a new needle was applied. This affected one (#24) of two residents observed for insulin administration. The facility census was 64. Findings include: Review of the medical record of Resident #24 revealed an admitted [DATE]. Diagnoses include hypertension, diabetes mellitus type II, and schizoaffective disorder. Review of the physician order dated 11/20/23 revealed Insulin Aspart (with Niacinamide) eight (8) units routinely and additional units as necessary related to sliding scale to be injected subcutaneously four times daily related to diabetes mellitus type II. Observation on 04/03/24 at 10:20 A.M., revealed Licensed Practical Nurse (LPN) #114 placed a new needle onto the Aspart insulin pen for Resident #24. LPN #114 dialed the pen to 18 units and injected Resident #24 with the insulin, LPN #114 verified he had not primed the needle stating I thought that was just with a new pen. Review of the manufacturer's product insert revealed instructions to check the flow of medication through the needle before every injection.

Based on observation, record review, staff and resident interviews, interview with respiratory care provider, and policy review, the facility failed to ensure a resident's noninvasive ventilator such as bi-level positive airway pressure (BiPap), average volume-assured pressure support (AVAPS), or continuous positive airway pressure was administered as ordered. This affected one (#25) resident of four residents reviewed for noninvasive ventilators. The facility identified four residents had noninvasive ventilators. The facility census was 64. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE], with medical diagnoses of chronic obstructive pulmonary disease, morbid obesity, chronic kidney disease stage III, and congestive heart failure. Review of the medical record for Resident #25 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/11/24 which indicated Resident #25 was cognitively intact and required moderate staff assistance for bed mobility, maximum staff assistance for transfers and toilet hygiene, and was dependent for bed mobility. Review of the MDS revealed the use of oxygen and noninvasive mechanical ventilator. Review of the medical record for Resident #25 revealed a physician order dated 07/19/22, for BiPap mode with setting at eight minimum pressure support, six maximum pressure, 18 target rate, and 14 bleed in three liters of oxygen every night shift. Review of the medical record for Resident #25 revealed the March and April 2024 Treatment Administration Record (TAR) revealed no documentation to support the Bipap was administered as ordered on 03/25/24 - 03/31/24 and on 04/01/24. Review of the medical record for Resident #25 revealed a nurse progress note, dated 03/25/24 at 6:03 A.M., which stated the Bipap mask was broken-blue plastic loop that connects the mask straps. The note stated the respiratory company was called but could not reorder parts due to after hours and would pass it on to the dayshift nurse to order. Review of the order form from the respiratory company dated 03/25/24 revealed the facility ordered the mask for Resident #25. Interview on 04/03/24 at 9:50 A.M., with Registered Nurse (RN) #106 stated she called the respiratory company and ordered the part for resident on the morning on 03/25/24. RN #106 stated Resident #25 had two Bipap masks in her room and was not sure if either mask worked. Observation with interview on 04/03/24 at 10:00 A.M., with Resident #25 stated she has not worn her Bipap machine since 03/25/24 because her mask was broken. Resident #25 confirmed she had two Bipap masks sitting on the bedside table but was not sure if either of the masks worked properly. Observation revealed two Bipap masks sitting on her bedside table near the Bipap machine. Interview on 04/03/24 at 11:05 A.M., with a representative from the respiratory company confirmed the facility ordered Resident #25 a new Bipap mask on 03/25/24 and stated the new mask was delivered to the facility on [DATE]. Interview on 04/03/24 at 4:11 P.M., with Director of Nursing (DON) confirmed the new Bipap mask for Resident #25 arrived on 03/27/24. DON confirmed staff has not administered the Bipap machine as ordered for 03/27/24 through 04/02/24. Review of the undated policy titled, Noninvasive ventilation (CPAP, Bipap, AVAPS, Trilogy), stated the facility was to provide noninvasive ventilation as per physician's order and current standards of practice. The policy stated Bipap or bi-level positive airway pressure was a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. The policy stated to replace equipment immediately or when equipment is available, when it was broken and malfunctions, or if visible soiling remains after cleaning. This deficiency represents non-compliance in regards to the allegations for Complaint Number OH00151883.

Based on observation of wound care, record review, resident interview, staff interview, and review of policy, the facility failed to ensure residents did not acquire pressure ulcers from medical devices in place. This affected one (#32) of three residents reviewed for pressure ulcers. The current census is 64. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #32 include fracture of right femur, transverse fracture of right fibula, acute kidney injury, diabetes type 2, asthma, heart disease, and pressure ulcers of bilateral buttocks. Review of the comprehensive Minimum Data Set (MDS) assessment dated revealed the resident had intact cognition, had pressure ulcer upon admission, and was a 2-person assist for Activities of Daily (ADL). Review of Resident #32's care plans dated 02/19/24 revealed a focus for cellulitis of the lower extremities, open area right lower leg. Interventions include on 02/26/24 keep right leg immobile, Unna boot with Profore wraps to bilateral leg, apply every other day using a 2-3 person assist to keep right leg immobile. Further review of the care plans revealed a focus for acute pain related to fracture of right femur. Interventions include pad splint and casting at the top of upper thigh and heel on the right lower leg with gauze pads to protect from skin breakdown. Keep splint on right leg, remove only for pulse and skin checks. Review of Resident #32's physician orders for the right leg revealed on 02/26/24 at 7:00 A.M., the resident was to have Unna boot with Profore wraps to bilateral legs every other day using a 2-3 person assist to keep right leg immobile, every other shift every other day. The order was discontinued on 03/01/24. Review of the order dated 03/01/24 the wound dressing order changed to cleanse open areas with Dakin's 0.125%, pat dry, apply Urgotul silver, followed by ABD pad, wrap full leg from toes to bend of knee with gauze/kerlix, then wrap with Ace wrap. Change daily and as needed every night shift for wound care. This order was discontinued on 03/04/24. Review of the order dated 03/05/23 the wound dressing order changed right lower leg cleanse open areas with Dakin's 0.125% pat dry, apply Urgotul silver, followed by ABD pad, wrap full leg from toes to bed of knee with gauze/kerlix, then wrap with Ace wrap every day shift once a day. This order was discontinued on 03/28/24. Review of Resident #32's progress notes dated 03/01/24 at 8:30 A.M., revealed the Certified Nurse Practitioner (CNP) #350 documented Resident #32's right posterior leg had a fluid filled blister. The right medial lower leg has an open area. The anterior ankle is noted to have a purple, non-blanchable area and a superficial open area at the center. Per the note the CNP documented her impression as a suspected deep tissue injury to the right anterior ankle related to a medical device and a suspected deep tissue injury and stage two pressure injury to the right upper posterior thigh. Review of Resident #32's wound assessments dated 03/01/24 to 04/01/24 revealed the upper posterior thigh suspected deep tissue injury was staged at a pressure ulcer stage 2 had healed as of 03/28/24. The right anterior ankle suspected deep tissue injury was staged as a pressure ulcer stage 2 and was improving. Further review of Resident #32's progress notes revealed on 03/06/24 at 12:52 P.M., Registered Nurse (RN) #411 documented in a progress note the nurse observed and evaluated Resident #32's braces were not applied correctly, the Unna boots were not on correctly, the skin was cool to touch on the left leg and toes. Resident #32's right leg was warm to tough. Pressure ulcers present related to missing placement of the braces. Per the note the nurse updated CNP #350 and the provider ordered to send the resident to the hospital for evaluation and treatment. Interview on 04/01/24 at 3:40 P.M., with Resident #32 revealed the resident was alert and oriented. Resident #32 stated he has had a lot of issues with his legs and recently he was notified he had some more wounds due to the braces not being applied correctly. Resident #32 stated he did not have any increased pain with the new wounds. Resident #32 did state he had to go to the hospital, at the beginning of 03/2024, to be treated for possible blood clots due to the braces being too tight. Resident #32 stated he returned the same day and stated the hospital staff told him he did not have any blood clots. Resident #32 stated he did not have concerns regarding his wound care at the facility at the time he had the different dressings he understood the nursing staff were unsure of how to apply his braces to prevent new ulcers. Interview on 04/03/24 at 1:57 P.M., with RN #411 revealed the nurse was caring for Resident #32 prior to and after 03/01/24 when the pressure ulcers to his right leg were discovered. RN #411 stated she believed and notified Certified Nurse Practitioner (CNP) #350 the resident had new skin issues due to the staff not applying the boots and splints to his bilateral legs. RN #411 stated the CNP #350 ordered for Resident #32 to be sent to the hospital for treatment of the new wounds caused by the splints and boots. Interview on 04/04/24 at 10:20 A.M., with CNP #350 stated when she was assessing Resident #32's legs on 03/01/24 she noted the resident had two suspected deep tissue injuries from improper placements of the splints on the resident's right leg. Per CNP #350, both the wounds she observed did develop into stage two pressure ulcers. CNP #350 stated upon discovery of the Unna boots being applied too tightly on 03/01/24 she ordered new dressings for the resident. CNP #350 stated on 03/06/24 she was notified by the nurse the resident's legs and toes showed decrease signs of circulation so she ordered the resident to be seen at the hospital. CNP #350 verified she felt the pressure ulcers to the right leg on the thigh and the ankle were due to the improper placement and improper wrapping of the dressing. Observation of 04/04/24 at 10:30 A.M., of Resident #32's wound dressing revealed the right thigh wound appeared to be healed with no open areas. The right ankle wound appeared to be as described in the wound documentation, a stage two pressure ulcer. CNP #350 was observed measuring and documenting the conditions of the resident's wounds. CNP #350 was observed applying the wound dressing as prescribed. Resident #32 denied any issues with his wounds at the time of the observation. Review of the undated facility policy titled, Pressure Injury Prevention and Management, revealed the facility will assess and revised any interventions which may cause avoidable pressure ulcers. This deficiency represent the noncompliance investigated under Complaint Number OH00151812 and OH00151833.

Based on observations, staff and resident interviews, revealed the facility failed to maintain a homelike environment in completing repairs. This affected one (#60) of 23 resident rooms observed. The facility census was 64. Findings include: Review of medical record for Resident #60 revealed admitted [DATE]. The resident was admitted with diagnoses including dementia with sever psychotic disturbances, type two diabetes mellitus, anxiety, bipolar disease, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He was independent or required supervision only for activities of daily living. Interview on 04/03/24 at 8:34 A.M., with Resident #60, revealed he pointed out the drywall which was damaged from his recliner and his bathroom faucet dripped. He stated he placed paper towels in the sink to muffle the sound of the dripping. Observation on 04/03/24 at 8:34 A.M., revealed there were four damaged drywall areas approximately four feet from the floor and directly behind the top of the recliner. Three of the areas were approximately one inch () by (x) one eighth (1/8) inch. One of the areas was approximately 3.0 x one quarter (1/4) inch. Observation of the bathroom sink revealed the faucet had a slow, steady drip of water. This was verified with State tested Nursing Assistant #231. Interview on 04/03/24 at 11:05 A.M., with Maintenance Director #319 revealed he was unaware Resident #60's faucet was leaking, but it would not be a concern if it was leaking directly into the sink. He also denied knowledge of the drywall damage to the wall behind Resident #60's recliner and stated it would be something fixed after the resident moved out and the room would be redone. This deficiency represent the noncompliance investigated under Complaint Number OH00151833.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. This affected one (#15) of the six residents reviewed for personal fund accounts. The facility census was 64. Findings included: Review of the medical record for Resident #15 revealed an admitted [DATE], with medical diagnoses of diabetes mellitus, hyperlipidemia, anemia, and dementia. Review of the medical record for Resident #15 revealed an annual Minimum Data Set (MDS) assessment, dated 01/08/24, which indicated Resident #15 had moderate cognitive impairment and required moderate staff assistance with toilet hygiene and bathing and set-up assistance with transfers and bed mobility. Review of the medical record for Resident #15 revealed a Resident Fund Statement, dated 12/30/23 through 03/29/24 which indicated Resident #15 had a personal fund account with the facility. Further review of the medical record for Resident #15 revealed no documentation to support the resident or resident representative who had signed a personal fund account authorization form. Interview on 04/04/24 at 3:31 P.M., with Business Office Manager (BOM) #321 confirmed the medical record for Resident #15 did not contain documentation to support the resident or resident representative had signed an authorization form for a personal fund account. Review of the undated policy titled, Resident Personal Funds, stated if the resident chooses to deposit personal funds with the facility, upon written authorization of the resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited in the facility.

Based on medical record review, staff interview, and review of policy, the facility failed to monitor blood pressure prior to the administer of medications as ordered. This affected for one (#24) of five residents observed for medication administration. The facility census was 64. Findings include: Review of the medical record of Resident #24 revealed an admitted [DATE]. Diagnoses include hypertension, diabetes mellitus type II, and schizoaffective disorder. Review of the physician order dated 07/09/23 revealed metoprolol tartrate 50 milligrams (mg) by mouth two times daily for hypertension, hold in SBP (systolic blood pressure) is less than 110 mm/Hg (milliliters of mercury) or heart rate less than 60 beats per minute. A second order dated 07/11/23 for amlodipine 10 mg once daily for acute kidney injury and hold if SBP less than 110 mm/Hg. Observation of medication administration on 04/03/24 at 10:20 A.M., revealed Licensed Practical Nurse (LPN) #114 removed a 50 milligram (mg) tablet of metoprolol and a 10 mg tablet of amlodipine (both for hypertension) to administer to Resident #24. Both medications had instructions to hold if the systolic blood pressure was less than 110 milliliters of mercury (mm/Hg) and for the metoprolol hold if the heart rate was less than 60 beats per minute. LPN #114 administered both medications without obtaining a blood pressure or heart rate value. Interview with LPN #114 immediately following the administration provided verification LPN #114 had not obtained a blood pressure or heart rate value prior to administering the medications. Review of the undated policy titled Medication Administration revealed to obtain and record vitals signs when applicable and or ordered by the physician. This deficiency represents non-compliance in regards to the allegations for Complaint Number OH00151883 and OH00151405.

Based on observation, staff interview, and review of policy, the facility failed to ensure personal protective equipment (PPE) was utilized during a procedure for one resident (#04) of two residents with Enhanced Barrier Protection (EBP) in place. The facility also failed to ensure staff performed proper hand hygiene when performing tracheostomy care for one (#04) resident out of the two residents reviewed for tracheostomy care. Furthermore, the facility failed to ensure a sanitary environment was provided during meal service. This directly affected one resident (#20) and had the possibility to affect five males (#13, #17, #20, #24, and #61) who eat in their rooms. The facility census was 64. Findings included: 1. Review of the medical record for Resident #04 revealed an admitted [DATE], with medical diagnoses of chronic obstructive pulmonary disease, heart failure, traumatic subarachnoid hemorrhage, and hypertension. Review of the medical record for Resident #04 revealed a quarter Minimum Data Set (MDS) assessment, dated 02/18/24, which indicated Resident #04 had moderate cognitive impairment and required maximum staff assistance for bathing, bed mobility, and transfers and was dependent upon staff for toilet hygiene. Further review of the MDS revealed Resident #04 had a colostomy, tracheostomy, and indwelling catheter. Observation on 04/03/24 at 12:45 P.M., of Registered Nurse (RN) #106 providing catheter care for Resident #04 revealed RN #106 pulled down the front of Resident #04's pants and adult incontinence briefs with ungloved hands. RN #106 then donned a plastic isolation gown and gloves. RN #04 obtained a basin of water and two wash cloths. RN #106 wet one wash cloth with soapy water and cleansed the insertion site of the suprapubic catheter using aseptic technique. RN #106 removed her gloves and placed a split four-inch by four-inch gauze around the catheter and taped it in place. Interview with RN #106 immediately after the procedure provided verification, she had not used proper enhanced barrier precautions when providing catheter care for Resident #04. Observation on 04/04/24 at 10:07 A.M., of RN #109 complete tracheostomy care for Resident #04 revealed RN #109 washed her hands prior to donning gown and gloves. RN #109 removed Resident #04's inner tracheostomy cannula and dressing around the tracheostomy site then removed her gloves. RN #109 then donned new gloves and inserted the new clean inner cannula. RN #109 proceeded to remove her gloves and opened a tracheostomy kit to get the normal saline and cotton tipped applicators from the kit. RN #109 continued to open both bedroom and bathroom drawers with her bare hands looking for additional supplies prior to applying new gloves and using the supplies to clean around Resident #04's tracheostomy site. RN #109 applied new tracheostomy ties and sponge drainage dressing around the tracheostomy site. RN #109 removed her gloves and handed Resident #04 his water pitcher. RN #109 washed her hands prior to leaving Resident #04's room. Interview on 04/04/24 at 10:25 A.M., with RN #109 confirmed she did not perform hand hygiene after removing her gloves at any time during the tracheostomy care or prior to handing Resident #04 his water pitcher. RN #109 confirmed Resident #04 was under EBP and she did not wear a mask when performing the tracheostomy care. Review of the policy titled, Enhanced Barrier Precautions dated 03/20/24 revealed personal protective equipment for enhanced barrier precautions is necessary only when performing high-contact activities. The policy stated EBP would be obtained for residents with wounds and/or indwelling devices (central lines, indwelling catheter, tracheostomy/ventilator tubes). Review of the undated policy titled, Tracheostomy Care stated the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-center care plan and resident goals and preferences. Policy stated tracheostomy care would be provided per physician orders. The policy stated to perform hand hygiene per facility policy, put exam gloves on both hands, masks and eye wear should be work if there is a likelihood of splashes and splattering. The policy state to remove old dressing and remove gloves and discard dressing and gloves. Perform hand hygiene, apply gloves, insert new inner cannula, clean stoma with normal saline moistened cotton-tipped applicators, change trach ties, and replace split dressing. The policy continued to state to dispose of equipment and perform hand hygiene. 2. Observation on 04/03/24 at 12:45 P.M., of Registered Nurse (RN) #106 providing catheter care for Resident #04 revealed RN #106 pulled down the front of Resident #04's pants and adult incontinence briefs with ungloved hands. RN #106 then donned a plastic isolation gown and gloves. RN #04 obtained a basin of water and two wash cloths. RN #106 wet one wash cloth with soapy water and cleansed the insertion site of the suprapubic catheter using aseptic technique. RN #106 removed her gloves and placed a split four-inch by four-inch gauze around the catheter and taped it in place. Interview with RN #106 immediately after the procedure provided verification she had not used proper enhanced barrier precautions when providing catheter care for Resident #04. 3. Observation on 04/01/24 at 11:48 A.M., revealed State tested Nursing Assistant (STNA) #233 sat a tray of food on the overbed table of Resident #20. A urinal was on one end of the table with approximately 200 milliliters of urine in it. This surveyor interviewed STNA #233 after she exited the room about the urinal placed on the overbed table, near the food. STNA #233 stated That is where he likes it and gets upset if it is not there. STNA #233 verified there was urine in the urinal and then emptied it in the toilet and replaced the urinal on the over bed table. Review of the policy titled Enhanced Barrier Precautions dated 03/20/24, revealed personal protective equipment for enhanced barrier precautions is necessary only when performing high-contact activities. This deficiency represents non-compliance investigated under Complaint Number OH00151883 and OH00151938.

Based on medical record review, observation, staff interview, and review of facility policies, the facility staff failed to maintain contact precautions during wound care, and failed to have a Legionella water management program in place. This directly affected one (#165) of three residents reviewed for transmission based precautions and had the potential to affect all 58 residents residing in the facility. The census was 58. Findings include: 1. Review of Resident #165's medical record revealed an admitted d of 12/22/22. Diagnoses included type two diabetes mellitus, right lower cellulitis, chronic foot ulcer, venous insufficiency, morbid obesity, methicillin-resistant staphylococcus aureus (MRSA), anxiety, and hallucinations. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 was assessed as cognitively intact. Review of physician orders revealed an order dated 01/16/23 for contact isolation related to (MRSA) in a right foot wound. Review of wound care physician office notes dated 03/01/23 revealed Resident #165's right foot wound was recently cultured and was still positive for MRSA. Observation of wound care for Resident #165 on 04/26/23 at 12:50 P.M. revealed Licensed Practical Nurse (LPN) #208 entered Resident #165's room and prepared wound care items. A sign posted on Resident #165's door frame read to, See nurse before entering. Further observation revealed personal protective equipment (PPE), including gowns, were hanging on the back of a closet door in the room. LPN #208 did not put on a gown. LPN #208 proceeded to provide wound care to Resident #165's right foot. LPN #208 helped reposition Resident #165's legs in bed and elevated his legs on pillows. LPN #165 then removed the old wound dressing and applied a new dressing. LPN #208 did not put on a gown at any time during Resident #165's wound care. During an interview on 04/26/23 at 1:07 P.M., LPN #208 confirmed Resident #165 was ordered to be on contact precautions for MRSA in his right foot. LPN #208 confirmed she did not put on a gown while providing wound care to Resident #165's right foot. Review of the facility's policy dated 12/01/20 revealed contact precaution refers to actions designed to reduce/prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. Healthcare personnel caring for residents in contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 2. Interview with Maintenance Director #254 on 04/26/23 at 11:50 A.M. stated he did not have proof of the facility assessment or surveillance plan for Legionella, and he was not able to find a program on his electronic maintenance system to follow. Interview with the Administrator on 04/26/23 at 11:56 A.M. verified there was no evidence of a facility assessment or surveillance plan for Legionella, and the facility did not have any knowledge it was not being completed. Review of the facility policy dated 12/01/22 revealed it is the the policy to establish primary and secondary strategies for the prevention and control of Legionella infections. The guidelines included Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. 36303

Based on observation, record review, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), and staff and family interviews, the facility failed to implement appropriate pressure ulcer preventative measures for Resident #87 who was identified as being at risk for skin breakdown. This resulted in actual harm when Resident #87 developed multiple avoidable stage II pressure ulcers on the right and left lower legs. This affected one (#87) of four residents reviewed for pressure ulcers. The facility identified a total of seven residents with in-house developed pressure ulcers. The facility census was 74 Findings include: Review of Resident #87's medical record revealed an admitted 09/13/13 with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as not having any current pressure ulcers but at risk with a pressure relieve mattress in place. The resident was assessed as requiring extensive assistance of two persons for bed mobility and transfers and had a functional limitation for range of motion in the upper extremity on one side. Review of Occupational Therapy discharge summary dated of 02/03/14 revealed the resident was discharge with good foot and leg support in the wheel chair while using foot supports attached to the leg rest. Review of Resident #87's nurse's notes dated 03/09/14 revealed a fluid filled blister was found measuring 1.6 centimeters (cm) by 1.2 cm. A physician order [REDACTED]. Review of Resident #87's pressure ulcer record documented a state two pressure ulcer was identified on the right lower outer extremity on 03/13/14. The pressure ulcer was described as a broken blister measuring 1.8 centimeter (cm) by 1.6 cm, red in color with drainage. On 03/18/14, the pressure ulcer measured 1.4 cm by 1.8 cm pink in color with drainage. Review of Resident #87's pressure ulcer record documented a stage two pressure ulcer was identified for the left lower extremity on 03/17/14. The pressure ulcer was described as an open blister measuring 2 cm in diameter, red in color with drainage. On 03/18/14, the left lower extremity was documented as measuring 1.2 cm by 2 cm and described as an open blister with 2.4 cm x 3.2 cm surrounding pinkness. The risk factors included decreased mobility. Review of Resident #87's care plan for pressure ulcer prevention revealed a lack of documentation of the fluid-filled blister identified by the facility on 03/09/14 and no documentation there were interventions put into place to prevent a skin breakdown. Further review revealed on 03/17/14, the resident had developed two Stage two pressure ulcers one located on the left lower outer aspect of the the leg and another on the right leg in the same location. Interventions documented at that time included foot supports were to be removed from the wheelchair and an attempt to use a broda chair would be tried. Observation on 03/17/14 at 11:00 A.M., revealed Resident #87 was observed with his bilateral lower outer legs resting against his wheelchair foot supports. On 03/17/14 at 2:00 P.M., a dressing change was observed for Resident #87 and was performed by Licensed Practical Nurse (LPN) #28. Resident #87 was sitting up in the wheelchair with his legs externally rotated and his stage two pressure ulcers located on the bilateral lower outer legs were resting on the wheelchair foot support. The nurse was observed physically moving the resident legs and repositioning them to do the dressing change. The physician orders [REDACTED]. The wounds appeared to be opened and pink with minimal drainage noted on old dressing. On 03/17/14 at 3:00 P.M., Resident #87 was observed sitting up in his wheel chair with his legs externally rotated and his stage two pressure areas located on the right and left outer aspect of his lower legs were noted to be resting on the wheelchair's foot supports. On 03/17/13 at 5:10 P.M., Resident #87 was observed sitting up in his wheel chair with his lower outer aspects of his legs resting on his wheel chair foot supports. On 03/17/14 at 5:05 P.M., interview with Resident #87's family member stated the resident's foot supports have been like that for a couple of weeks and she felt they had caused the blisters on his outer lower legs bilaterally. On 03/17/14 at 5:12 P.M., interview with Physical Therapy Assistant (PTA) #14 verified that Resident #87's wheelchair foot supports must have came loose and weren't appropriate for him anymore. She verified that his outer lower legs where his stage two pressure ulcers were located were in direct contact with the foot supports. She also stated the residents legs were externally rotated and he did not have enough control to reposition his legs himself. She denied being notified of any change in the resident posture or wheel chair. On 03/17/14 at 5:17 P.M., interview with the assistant Director of Nursing verified that Resident #87 foot supports for his wheel chair were not appropriate for him and his outer lower legs were lying against where his stage two pressure ulcers were located . On 03/18/14 at 8:10 A.M., Resident #87 was observed eating breakfast in his wheelchair at the table and his lower legs continued to rest on the foot supports of the wheel chair. Review of the facility's wound management program pressure prevention matrix (dated June 2006) revealed to position the resident with pillows, wedges, and/or cushions as long as they do not put any pressure on affected area(s). The matrix also revealed to limit the guest's time up in the chair per the physician's orders [REDACTED]. the floor, to place on a foot rest or foot stool. The facility did not provide any additional policies for pressure ulcers. Information from the NPUAP obtained at www.npuap.org <http://www.npuap.org> was reviewed. According to the NPUAP, consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers. The NPUAP provided preventative points which indicated to provide pressure redistribution when positioning persons in chairs or wheelchairs.