Every finding on record at Eastgate Health Care Center

Based on medical record review, staff interview, and review of online medication resources, the facility failed to ensure adequate monitoring for a medication with a potential for toxicity. This affected one (Resident #162) of three reviewed for medication monitoring. The facility census was 160 residents.Findings include: Review of the medical record for Resident #162 revealed an admission date of [DATE] with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, diabetes, malignant neoplasm to lung, metastatic cancer to the brain, atrial fibrillation, heart disease, and obstructive sleep apnea. Resident #162 was discharged to the hospital on [DATE] and expired at the hospital. Review of the Minimum Data Set (MDS) for Resident #162 dated [DATE] revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #162 revealed an order dated [DATE] for 125 micrograms (mcg) of digoxin daily for diastolic congestive heart failure. There were no orders entered to monitor the resident's digoxin level. Review of lab results for Resident #162 dated [DATE] revealed there was no digoxin level included. Review of the nurse progress note for Resident #162 dated [DATE] at 1:47 P.M. revealed stat (immediate) labs were to be drawn due to change in the resident's mental status and the resident's complaint of not feeling well. Review of the stat lab results for Resident #162 dated [DATE] revealed there no digoxin level included. Review of the progress note for Resident #162 dated [DATE] revealed the resident was sent out to the hospital with a change of condition including mental status changes and a critical potassium level. Review of the Medication Administration Records (MAR) for Resident #162 dated [DATE] revealed the resident received four doses of digoxin on the following dates: [DATE], [DATE], [DATE], [DATE] Review of the progress note for Resident #162 dated [DATE] revealed the resident went into cardiac arrest in the emergency department and was admitted to the hospital. Interview on [DATE] at 11:08 A.M. with the Director of Nursing (DON) confirmed Resident #162 was ordered digoxin upon admission with no orders implemented to monitor digoxin levels. The DON verified Resident #162 received digoxin on [DATE], [DATE], [DATE] and [DATE] and when the resident exhibited a change in condition on [DATE] a digoxin level was not included in the stat laboratory blood work performed for the resident. Interview on [DATE] at 12:57 P.M. with Medical Doctor (MD) #753 with the county coroner's office confirmed she was working on Resident #162's case. MD #753 stated Resident #162's autopsy was not complete but based on laboratory data received from the hospital dated [DATE], one of the concerns was that the resident was suffering with digoxin toxicity at the time of her death. MD #753 verified Resident #162 had multiple other serious medical conditions, and no cause of death had yet been determined. Review of online reference Medscape at https://reference.medscape.com/drug/lanoxin-digoxin-342432?_gl=1*wg2rsc*_gcl_au*NTQ4OTEzMTgyLjE3ODIzMTk5NzI revealed residents receiving digoxin should be monitored for signs and symptoms of digoxin toxicity and clinical response with doses adjusted based on toxicity, efficacy, and blood levels. There was a very narrow margin between effective therapeutic and toxic dosages. Serum digoxin levels of less than 0.5 nanograms per milliliter (ng/mL) have been associated with diminished efficacy, while levels greater than 2.0 ng/mL have been associated with increased toxicity without increased benefit This deficiency represents noncompliance investigated under Complaint Number 3110292.

Based on medical record review and staff interview, the facility failed to provide and administer necessary respiratory care. This affected one (Resident #162) of three residents investigated for respiratory care as ordered by the physician. The facility census was 160 residents. Findings include: Review of the medical record for Resident #162 revealed an admission date of [DATE] with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, diabetes, malignant neoplasm to lung, metastatic cancer to the brain, atrial fibrillation, heart disease, and obstructive sleep apnea. Resident #162 was discharged to the hospital on [DATE] and expired at the hospital.Review of the Minimum Data Set (MDS) for Resident #162 dated [DATE] revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #162 revealed an order dated [DATE] for the resident to wear a bilevel positive airway pressure (BIPAP) machine at night and as needed for shortness of breath. Review of the Treatment Administration Record (TAR) for Resident #162 dated [DATE] revealed the BIPAP was signed off as provided on nightshift on [DATE] and on dayshift on [DATE]. There were no other dates and times signed off, and the record indicated to see the progress notes for details. Review of the progress note for Resident #162 dated [DATE] revealing the resident's daughter was going to bring in the resident's breathing equipment and the facility were waiting for it to arrive. Review of the progress note for Resident #162 dated [DATE] revealed the resident was sent out to the hospital with a critical potassium level. Review of the progress note for Resident #162 dated [DATE] revealed the resident was admitted to the hospital with a diagnosis of cardiac arrest. Review of the progress notes for Resident #162 dated [DATE] through [DATE] revealed the notes did not include documentation regarding the resident's BIPAP machine. Interview on [DATE] at 11:08 A.M. with the Director of Nursing (DON) confirmed Resident #162 was admitted to the facility with orders for a BIPAP and the resident's medical record indicated the resident's daughter was to bring in the resident's breathing machine from home and there were no follow up notes. The DON confirmed the TAR only had two dates in which the BIPAP was checked off but she couldn't confirm if the resident received a BIPAP on those dates as the facility was awaiting the family to bring in the machine. This deficiency represents noncompliance investigated under Complaint Number 3110292.

Based on observation, staff interview, facility document review, and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all the residents who received nourishment from the kitchen.Findings include:Observation on 08/18/25 at 9:40 A.M. of the walk-in refrigerator revealed it included the following: a large container of pancake batter with an open date of 08/12/25 and a discard date of 08/17/25, a large, opened container of sour cream without an open date, a large, opened container of canola oil without an open date. Interview on 08/18/25 at 9:44 A.M. with the Corporate Chef (CC) confirmed items in the refrigerator should have an open date and a discard date and items should be discarded by the discard date. The CC confirmed the sour cream and canola oil lacked open dates, and the pancake batter should have been discarded by the discard date on the label. 2. Observation on 08/18/25 at 9:43 A.M. of the dry storage revealed there were 21 boxes of salt which appeared to be damaged by liquid, and the contents inside were hardened. Interview on 08/18/25 at 9:49 A.M. with the Executive Chef (EC) confirmed damaged foods should be thrown away. The EC stated the boxes of salt had liquid damage, the contents were hardened, and the boxes of salt should have been discarded. Review of the facility policy titled Safe Food Handling and Storage dated June 2015 revealed the proper storage and handling of all foods, whether potentially hazardous or not, was essential in preventing chemical, physical or biological contamination.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to maintain its environment in a sanitary manner on Health Care 2, one of the four halls where residents resided. This had the potential to affect the residents residing on Health Care 2. Findings include: Review of a work order dated 08/17/24 revealed there was mold on ceiling tiles in the Administrator's office. The work order indicated the ceiling tiles were replaced and the pipes were wrapped.Review of a work order dated 09/21/24 revealed there was a moldy hole in the ceiling of room [ROOM NUMBER]. The work order indicated the hole in the ceiling was being fixed.Review of a work order dated 09/12/24 revealed there was mold in the corner of the floor by the window in room [ROOM NUMBER]. Review of a work order dated 12/16/24 revealed there was mold/mildew in the bathroom of room [ROOM NUMBER]. The work order indicated there was no mold or mildew seen, but the bathroom had just been cleaned.Review of a work order dated 07/01/25 revealed a visitor saw and smelled mold in room [ROOM NUMBER]. The work order indicated that the air conditioning (A/C) unit was cleaned.Review of a work order dated 07/09/25 revealed there was mold on ceiling tiles in the administrator's office. The work order indicated the ceiling tiles were replaced.Review of a work order dated 07/20/25 revealed there was mold in room [ROOM NUMBER]. The work order indicated the mold was cleaned.Review of a work order dated 07/25/25 revealed there was a moldlike substance on the ceiling by the window of room [ROOM NUMBER]. The work order indicated the resident stated they had mold on their ceiling above the window, and the dry wall was cut out and replaced with new dry wall.Review of a work order dated 07/29/25 revealed there was mold on top of the ceiling of the bathroom in room [ROOM NUMBER]. The work order indicated the ceiling was treated.Review of a work order dated 07/30/25 revealed there was water damage and mold under the sink in room [ROOM NUMBER]. The work order indicated the room was getting a new vanity which had already been ordered. Review of a work order dated 08/01/25 revealed there was mold on the ceiling of dry storage in the kitchen. The work order indicated the area was treated and got rid of mold.Review of a work order dated 08/01/25 revealed there was mold on the ceiling in Health Care 1 medication room. The work order indicated the area was cleaned and treated. Review of a work order dated 08/13/25 revealed there was mold in the A/C unit of room [ROOM NUMBER]. The work order indicated the area was cleaned and treated.Review of a work order dated 08/14/25 revealed there was possible mold in the register of room [ROOM NUMBER]. The work order indicated the area was cleaned and treated.Observation on 08/18/25 at 1:21 P.M of resident room [ROOM NUMBER] located on HC2 revealed there was a black area on the left wall by the ceiling behind the resident's bed. Observation on 08/21/25 at 9:49 A.M. of room [ROOM NUMBER] located in hall HC2 revealed the black area at the top of the wall was no longer there. Observation on 08/21/25 at 10:00 A.M. revealed the ceiling tiles in the dining room adjacent to room [ROOM NUMBER] were stained brown and black. Interview on 08/21/2025 at 11:41 A.M. with Maintenance Director (MD) #16 stated that he was not aware of mold in the facility. He stated that there was a black substance that appeared on the walls and ceilings, but it was able to be wiped off easily. MD #16 confirmed Housekeeper #15 was able to wipe off the black area in room [ROOM NUMBER]. Interview on 08/21/25 at 1:52 P.M. with Housekeeper #15 confirmed she worked every other weekend on HC 2 located on the first floor, which included Rooms 151-181. Housekeeper #15 stated that there was a black stain in room [ROOM NUMBER] on the wall which she was able to remove. Interview on 08/21/25 at 1:58 P.M. with Environmental Services Supervisor (ESS) #17 stated that if a staff member saw a black substance and they wiped it off and put in a work order, she followed up. She stated she was not an expert but during high humidity days if residents did not have their air on, the black areas would appear, but the black areas would wipe off and not come back. Interview on 08/21/25 at 2:49 P.M. with MD #16 stated that he first became aware of the black substance in room [ROOM NUMBER] through work orders from the previous day. Interview on 08/22/25 at 2:11 P.M. with the Director of Nursing (DON) confirmed if staff saw mold they should report it to maintenance staff via work order. The DON stated she thought they would hire a contractor to come out and test or evaluate the situation. The DON stated that her expectation was that concerns with black areas be reported right away so that they could be addressed. Interview on 08/22/25 at 2:17 P.M. with the Administrator if staff saw a black substance in the environment which appeared to be mold it should be reported to the maintenance staff via work order so it could be addressed immediately. The Administrator stated the facility had not made any attempts to determine the origin of the black substances in the environment detailed on the work orders. Review of the facility policy titled Environmental Services-Homelike Environment dated January 2025 revealed the facility would maintain a high standard of cleanliness in all areas of the facility. The environmental service department worked diligently in conjunction with the other departments to maintain a comfortable homelike atmosphere that was clean and odor free for the residents.This deficiency represents noncompliance that was investigated under Complaint Number 2592171.

Based on medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the state survey agency (SSA). This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder. Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident’s attention. Review of the medical record for Resident #156 revealed an admission date of 09/20/23 with a diagnosis of dementia with behavioral disturbances and a discharge date of 05/12/25. Review of the Minimum Data Set (MDS) assessment for Resident #156 dated 05/06/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #156 dated 05/01/25 at 7:41 P.M. per Registered Nurse (RN) #14 revealed the the resident’s power of attorney (POA) expressed concern about an interaction they reportedly saw between Resident #156 and another resident and asked if the incident was documented. RN #14 told the POA that they could not release any information until they spoke to their supervisor to ensure there were no privacy violations. Review of the progress note for Resident #156 dated 05/02/25 at 12:05 PM revealed the facility held a care conference with a family member to discuss the resident’s escalated verbal and physical behaviors. The note did not address any resident-to-resident incidents. Review of the progress note for Resident #156 dated 05/12/25 at 1:21 P.M. revealed the facility held a care conference with the resident’s representative where they discussed the resident’s care. The note did not address any resident-to-resident incidents. Interview on 08/21/25 at 7:35 P.M. with Resident #156’s representative, Resident Representative (RR) #23 confirmed on 04/26/25 at approximately 7:00 P.M. Resident #156 was watching television when Resident #52 approached Resident #156’s room door with their pants down. RR #23 stated Resident #52’s belt was unbuckled, their pants were unbuttoned, the zipper was down, and the resident’s pants were down to the resident’s knees. RR #23 stated they intervened before Resident #52 pulled down their (Resident #52’s) brief. RR #23 stated they told Resident #52 to leave Resident #156’s room, and once Resident #52 left, RR #23 asked Resident #156 what happened. RR #23 stated that Resident #156 told them that Resident #52 was going to show the resident their genitalia. RR #23 stated they went to the nurses’ station at approximately 7:00 P.M. and notified the outgoing and incoming nurses of the interaction between Resident #156 and Resident #52. RR #23 stated staff told them they would keep an eye on the residents and would ensure they were separated. RR #23 stated they contacted the facility on 05/01/25 and spoke with an RN to ensure the facility administration was notified of the interaction. RR #23 stated that on 05/02/25 they called and notified a social worker who stated they would notify the Administrator. RR #23 stated on 05/02/25, they received a return call from the Administrator, the Director of Nursing (DON), and the Social Services Designee (SSD). RR #23 stated that during the phone call, they informed the facility staff of the incident and requested an in-person meeting. RR #23 stated that on 05/12/25 an in-person meeting was held with RR #23, the Administrator, the DON, the SSD, and the Assistant Director of Nursing (ADON), and RR #23 discussed the incident during the meeting. Interview on 08/22/25 at 10:53 A.M. with RN #14 confirmed RR #23 had mentioned an incident about Resident #52 exposing themself but stated he did not remember whether RR #23 had reported the incident to him. RN #14 further confirmed if RR #23 had reported something to him, he would have notified the Administrator immediately. Interview on 08/22/25 at 10:20 A.M. with RN #8, who was the former ADON, stated she was notified of the incident between Resident #52 and Resident #156 on 05/01/25. RN #8 stated RR #23 had wanted to speak with management regarding an incident between Resident #156 and Resident #52. RN #8 stated she spoke with RR #23 who stated Resident #156 was sitting on their bed watching television when RR #23 witnessed Resident #52 approaching the room with their pants down to their hips. RN #8 that RR #23 reportedly told Resident #52 that it was not their room, and the resident turned and left. Interview on 08/21/25 at 3:49 P.M. with the SSD confirmed during a meeting with RR #23, the Administrator, and the DON on 05/12/25, RR #23 alleged Resident #52 exposed themself to Resident #156. The SSD revealed the meeting was documented in a progress note, but the allegation of possible resident-to resident abuse was not documented. Interview on 08/21/25 at 4:00 P.M. with the DON confirmed she attended a meeting where RR #23 alleged Resident #52 attempted to expose their genitals to Resident #156. Interview on 08/21/25 at 5:14 P.M. with the Administrator confirmed he was the Abuse Coordinator for the facility and recalled a meeting was held regarding Resident #156’s behaviors. The Administrator confirmed during the meeting, RR #23 reported that Resident #52 attempted to expose themself to Resident #156 on 04/26/25. The Administrator confirmed the facility did not report the incident to the SSA. 2. Review of the medical record for Resident #120 revealed and admission date of 11/07/24 with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and major depressive disorder. Review of the MDS for Resident #120 date 06/04/25 revealed the resident had severe cognitive impairment and required supervision with activities of daily living (ADLs.) Review of the medical record for Resident #117 revealed and admission date of 03/22/25 with diagnoses including unspecified dementia without behavioral disturbance, adjustment disorder with anxiety, and hypertension. Review of the MDS assessment for Resident #117 dated 06/13/25 revealed the resident had severe cognitive and was ambulatory and wandered daily. Review of the care plan for Resident #117 undated revealed the resident had behavioral problems that included hitting others. Interventions included the following: provide a room change, intervene as necessary to protect the rights and safety of others, approach/speak to the resident in a calm manner, divert the resident's attention, take the resident to an alternate location as needed, monitor behavior episodes and attempt to determine the underlying cause, considering the location, time of day, persons involved, and situation, document the behavior and potential causes. Review of the progress note for Resident #120 dated 04/02/25 at 1:30 A.M. per Licensed Practical Nurse (LPN) #10 revealed staff heard the resident yelling and requesting staff get him/her off of me. LPN #10 observed Resident #120 lying in bed, and their roommate was standing over the resident hitting Resident #120 on the arm with a plastic cup. Resident #120 stated they had also been hit on the left arm and left leg. Review of the progress note for Resident #117 dated 04/02/25 at 1:31 A.M. per LPN #10 revealed Resident #117 was standing over their roommate hitting the roommate on the arm with a plastic medicine cup. LPN #10 asked Resident #117 why they were hitting their roommate and the resident stated they did not know. Review of the Interdisciplinary Team (IDT) note for Resident #117 dated 04/13/25 revealed a resident-to-resident incident occurred. Staff observed Resident #117 standing over their roommate and hitting them with a plastic cup. The note indicated the new behavioral intervention for the resident was a room change. Interview on 08/20/25 at 8:37 P.M. with LPN #10 confirmed on 04/02/25 she heard yelling out from a resident room and found Resident #117 standing at Resident #120's bedside hitting them with a plastic cup. LPN #10 stated she informed the charge nurse and the Director of Nursing (DON) of the resident-to resident incident. Interview on 08/22/25 at 11:00 A.M. with the DON confirmed the IDT met two times per week to review incidents. She stated that she deferred to the Administrator to decide which incidents should be reported to the SSA. Interview on 08/22/25 at 12:23 P.M. with LPN #9 confirmed she was a night shift team leader, and staff were to report all falls and incidents to her. LPN #9 confirmed she immediately notified the on-call person, the DON or Administrator of resident-to-resident altercations, which required two-hour reporting. She further stated the staff were to write witness statements about the incidents. LPN #9 stated that she did not recall an incident involving Resident #117 in an altercation with another resident Interview on 08/22/25 at 1:58 P.M. with RN #8 confirmed incidents were discussed during IDT meetings, and the Administrator made the decision on which incidents were to be reported to the SSA. She stated that resident-to-resident altercations were to be reported to the SSA within two hours of being notified of them. Interview on 08/22/25 at 3:06 P.M. with the Administrator confirmed the facility did not report the resident-to-resident incident between Resident #120 and #117 to the SSA. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property revised September 2022 revealed the facility would report all allegations of abuse to the SSA. This deficiency represents noncompliance investigated under Complaint Number 1301484 (Complaint OH00165616.)

Based on record review, staff interview, and facility policy review, the facility failed to maintain medical records that were complete and accurate. This affected one (Resident #154) of 48 sampled residents. Findings include: Review of the medical record for Resident #154 revealed an admission date of [DATE] with a diagnoses of protein-calorie malnutrition and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #154 revealed the resident had severe cognitive impairment. Review of the do not resuscitate (DNR) order form for Resident #154 dated [DATE] revealed the physician signed an order for DNR comfort care indicating staff would not perform cardiopulmonary resuscitation (CPR.) Review of the order recap report for Resident #154 revealed an order dated [DATE] for the resident's code status as DNR comfort care. Review of the social service assessment for Resident #154 dated [DATE] per Social Worker (SW) #12 revealed the resident was a full code Review of the progress notes for Resident #154 dated [DATE] and [DATE] per Physician #25 revealed the resident was a full code. Interview on [DATE] at 10:49 A.M. with SW #12 confirmed she completed Resident #154's social service assessment on [DATE] and had documented the resident was a full code. SW #12 stated that she did not review the physician's orders prior to completing the social services assessment. She stated it was her error, which resulted in incorrect documentation of the resident's code status. Interview on [DATE] at 2:47 P.M. with Physician #25 confirmed she documented Resident #154's code status in error on [DATE] and [DATE] in the physician progress notes. Physician #25 stated the code status was one of the fields in the electronic notes which was prepopulated. Review of the facility policy titled Medical Records System revised [DATE] revealed the facility would ensure medical records were complete, accurately documented, readily accessible, and systematically organized.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide nail care for one (Resident #13) of four residents reviewed who were dependent on facility staff for activities of daily living (ADL). Findings include: Review of the medical record for Resident #13 revealed an admission date of 05/23/22 with diagnoses including dementia without psychotic disturbance, type two diabetes mellitus, blindness to the right eye, and bilateral glaucoma. Review of the care plan for Resident #13 dated 05/05/23 revealed the resident had a self-care performance deficit and staff were to assist with ADLs as needed. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 07/08/25 revealed the resident had severe cognitive impairment, was dependent on staff for personal hygiene, and had not rejected care during the assessment look-back period. Observation on 08/20/25 at 8:05 A.M. revealed Resident #13's fingernails on both hands were three to four inches long, extending beyond the fingertips. Resident #13's nails were discolored (yellowish), rough, jagged, and there was a brown substance underneath the nails. Interview on 08/20/25 at 8:06 A.M. with Resident #13 confirmed they wanted their fingernails cleaned and trimmed. Interview on 8/20/25 at 8:16 A.M. with Certified Nursing Assistant (CNA) #4 confirmed Resident #13's fingernails were approximately four inches long and dirty, with dried food or another substance underneath the nail. She stated that because the resident had a diagnosis of diabetes, CNAs were not allowed to cut their nails but were expected to clean them daily and document the care in the resident's electronic medical record and on a shower sheet that was submitted to a nurse. Interview on 08/20/25 at 8:28 A.M. with CNA #5 confirmed Resident #13's nails were exceptionally long and dirty with debris underneath. She stated that nails should be cleaned to prevent scratching, infection, fungus, and germs. She stated that she could clean the resident's nails but could not cut them because the resident had diabetes. Interview on 08/20/25 at 9:01 A.M. with Licensed Practical Nurse (LPN) #3 confirmed Resident #13's nails were about four inches long with food underneath. She stated nurses were responsible for nail care, and long, jagged nails increased the risk of skin injury, infection, and skin tears. Interview on 08/20/25 at 9:12 A.M. with the Director of Nursing (DON) confirmed Resident #13's nails were exceedingly long and needed cleaning. She stated that nurses were responsible for cutting residents' nails, and direct care staff were expected to check residents' nails when providing care including baths, showers, and administration of medications. Review of the facility policy titled Bathing and General Hygiene dated April 2025 revealed staff should perform nail care for residents as needed.

Based on medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to thoroughly investigate allegations of resident abuse and ensure residents were protected from further potential abuse during the course of the investigation. This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder.Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident's attention. Review of the medical record for Resident #156 revealed an admission date of 09/20/23 with a diagnosis of dementia with behavioral disturbances and a discharge date of 05/12/25. Review of the Minimum Data Set (MDS) assessment for Resident #156 dated 05/06/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #156 dated 05/01/25 at 7:41 P.M. per Registered Nurse (RN) #14 revealed the the resident's power of attorney (POA) expressed concern about an interaction they reportedly saw between Resident #156 and another resident and asked if the incident was documented. RN #14 told the POA that they could not release any information until they spoke to their supervisor to ensure there were no privacy violations. Review of the progress note for Resident #156 dated 05/02/25 at 12:05 PM revealed the facility held a care conference with a family member to discuss the resident's escalated verbal and physical behaviors. The note did not address any resident-to-resident incidents. Review of the progress note for Resident #156 dated 05/12/25 at 1:21 P.M. revealed the facility held a care conference with the resident's representative where they discussed the resident's care. The note did not address any resident-to-resident incidents. Interview on 08/21/25 at 7:35 P.M. with Resident #156's representative, Resident Representative (RR) #23 confirmed on 04/26/25 at approximately 7:00 P.M. Resident #156 was watching television when Resident #52 approached Resident #156's room door with their pants down. RR #23 stated Resident #52's belt was unbuckled, their pants were unbuttoned, the zipper was down, and the resident's pants were down to the resident's knees. RR #23 stated they intervened before Resident #52 pulled down their (Resident #52's) brief. RR #23 stated they told Resident #52 to leave Resident #156's room, and once Resident #52 left, RR #23 asked Resident #156 what happened. RR #23 stated that Resident #156 told them that Resident #52 was going to show the resident their genitalia. RR #23 stated they went to the nurses' station at approximately 7:00 P.M. and notified the outgoing and incoming nurses of the interaction between Resident #156 and Resident #52. RR #23 stated staff told them they would keep an eye on the residents and would ensure they were separated. RR #23 stated they contacted the facility on 05/01/25 and spoke with an RN to ensure the facility administration was notified of the interaction. RR #23 stated that on 05/02/25 they called and notified a social worker who stated they would notify the Administrator. RR #23 stated on 05/02/25, they received a return call from the Administrator, the Director of Nursing (DON), and the Social Services Designee (SSD). RR #23 stated that during the phone call, they informed the facility staff of the incident and requested an in-person meeting. RR #23 stated that on 05/12/25 an in-person meeting was held with RR #23, the Administrator, the DON, the SSD, and the Assistant Director of Nursing (ADON), and RR #23 discussed the incident during the meeting. Interview on 08/22/25 at 10:53 A.M. with RN #14 confirmed RR #23 had mentioned an incident about Resident #52 exposing themself but stated he did not remember whether RR #23 had reported the incident to him. RN #14 further confirmed if RR #23 had reported something to him, he would have notified the Administrator immediately. Interview on 08/22/25 at 10:20 A.M. with RN #8, who was the former ADON, stated she was notified of the incident between Resident #52 and Resident #156 on 05/01/25. RN #8 stated RR #23 had wanted to speak with management regarding an incident between Resident #156 and Resident #52. RN #8 stated she spoke with RR #23 who stated Resident #156 was sitting on their bed watching television when RR #23 witnessed Resident #52 approaching the room with their pants down to their hips. RN #8 that RR #23 reportedly told Resident #52 that it was not their room, and the resident turned and left. Interview on 08/21/25 at 3:49 P.M. with the SSD confirmed during a meeting with RR #23, the Administrator, and the DON on 05/12/25, RR #23 alleged Resident #52 exposed themself to Resident #156. The SSD revealed the meeting was documented in a progress note, but the allegation of possible resident-to resident abuse was not documented.Interview on 08/21/25 at 4:00 P.M. with the DON confirmed she attended a meeting where RR #23 alleged Resident #52 attempted to expose their genitals to Resident #156. Interview on 08/21/25 at 5:14 P.M. with the Administrator confirmed he was the Abuse Coordinator for the facility and recalled a meeting was held regarding Resident #156's behaviors. The Administrator confirmed during the meeting, RR #23 reported that Resident #52 attempted to expose themself to Resident #156 on 04/26/25. The Administrator confirmed the facility did not report the incident to the SSA nor did the facility conduct a thorough investigation to include measures to protect residents during the course of the investigation. 2. Review of the medical record for Resident #120 revealed and admission date of 11/07/24 with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and major depressive disorder. Review of the MDS for Resident #120 date 06/04/25 revealed the resident had severe cognitive impairment and required supervision with activities of daily living (ADLs.) Review of the medical record for Resident #117 revealed and admission date of 03/22/25 with diagnoses including unspecified dementia without behavioral disturbance, adjustment disorder with anxiety, and hypertension. Review of the MDS assessment for Resident #117 dated 06/13/25 revealed the resident had severe cognitive and was ambulatory and wandered daily. Review of the care plan for Resident #117 undated revealed the resident had behavioral problems that included hitting others. Interventions included the following: provide a room change, intervene as necessary to protect the rights and safety of others, approach/speak to the resident in a calm manner, divert the resident's attention, take the resident to an alternate location as needed, monitor behavior episodes and attempt to determine the underlying cause, considering the location, time of day, persons involved, and situation, document the behavior and potential causes. Review of the progress note for Resident #120 dated 04/02/25 at 1:30 A.M. per Licensed Practical Nurse (LPN) #10 revealed staff heard the resident yelling and requesting staff get him/her off of me. LPN #10 observed Resident #120 lying in bed, and their roommate was standing over the resident hitting Resident #120 on the arm with a plastic cup. Resident #120 stated they had also been hit on the left arm and left leg. Review of the progress note for Resident #117 dated 04/02/25 at 1:31 A.M. per LPN #10 revealed Resident #117 was standing over their roommate hitting the roommate on the arm with a plastic medicine cup. LPN #10 asked Resident #117 why they were hitting their roommate and the resident stated they did not know. Review of the Interdisciplinary Team (IDT) note for Resident #117 dated 04/13/25 revealed a resident-to-resident incident occurred. Staff observed Resident #117 standing over their roommate and hitting them with a plastic cup. The note indicated the new behavioral intervention for the resident was a room change. Interview on 08/20/25 at 8:37 P.M. with LPN #10 confirmed on 04/02/25 she heard yelling out from a resident room and found Resident #117 standing at Resident #120's bedside hitting them with a plastic cup. LPN #10 stated she informed the charge nurse and the Director of Nursing (DON) of the resident-to resident incident. Interview on 08/22/25 at 11:00 A.M. with the DON confirmed the IDT met two times per week to review incidents. She stated that she deferred to the Administrator to decide which incidents should be reported to the SSA. Interview on 08/22/25 at 12:23 P.M. with LPN #9 confirmed she was a night shift team leader, and staff were to report all falls and incidents to her. LPN #9 confirmed she immediately notified the on-call person, the DON or Administrator of resident-to-resident altercations, which required two-hour reporting. She further stated the staff were to write witness statements about the incidents. LPN #9 stated that she did not recall an incident involving Resident #117 in an altercation with another resident Interview on 08/22/25 at 1:58 P.M. with RN #8 confirmed incidents were discussed during IDT meetings, and the Administrator made the decision on which incidents were to be reported to the SSA. She stated that resident-to-resident altercations were to be reported to the SSA within two hours of being notified of them. Interview on 08/22/25 at 3:06 P.M. with the Administrator confirmed the facility did not report the resident-to-resident incident between Resident #120 and #117 to the SSA nor did the facility conduct a thorough investigation to include measures to protect residents during the course of the investigation. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property revised September 2022 revealed the facility would investigate all allegations of abuse and would ensure residents were protected from further potential abuse during the course of the investigation. This deficiency represents noncompliance investigated under Complaint Number 1301484 (Complaint OH00165616.)

Based on record review, interview, and facility policy review, the facility failed to prevent a significant medication error that placed 1 (Resident #132) of 1 resident reviewed for insulin administration at risk for hypoglycemia. Specifically, Resident #132 received short-acting insulin (Humalog) instead of long-acting insulin (Lantus) and required transfer to a hospital emergency department for observation.The findings included: Review of the medical record for Resident #132 revealed an admission date of 07/11/25 with diagnoses including myocardial infarction, chronic kidney disease, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #132 dated 07/17/25 revealed the resident had intact cognition. Review of the care plan for Resident #132 revealed the resident had diabetes mellitus with diabetic polyneuropathy. Interventions directed staff to administer diabetes medication as ordered by clinicians. Review of the physician's orders for Resident #132 revealed an order dated 07/11/25 for Lantus insulin subcutaneously 95 units at bedtime. Review of the physician's orders for Resident #132 revealed an order dated 07/24/25 for Humalog insulin 15 units with meals, hold if the blood sugar is below 150. Review of the progress note for Resident #132 dated 07/24/25 at 10:08 P.M. revealed Resident #132 was given 60 units of Humalog instead of 95 units of Lantus by mistake. Staff called the resident's physician and the resident showed no signs or symptoms of hypoglycemia. Review of the progress note for Resident #132 dated 07/24/25 at 11:00 P.M. revealed the physician gave an order to send the resident to the hospital for an evaluation. Review of the hospital after visit summary for Resident #132 dated 07/24/25 revealed the resident was seen for an accidental medication error. The hospital performed point of care glucose testing 10 times for Resident #132. Interview on 08/18/2025 at 2:27 P.M. with Resident Representative (RR) #6 confirmed she received a call from a facility nurse reporting Resident #132 had been given the wrong insulin and was being sent to the hospital for observation. Interview on 08/19/25 at 5:45 P.M. with Licensed Practical Nurse (LPN) #2 confirmed on 07/24/25 she mistakenly administered 60 units of Humalog insulin to Resident #132 instead of Lantus insulin. Interview on 08/20/25 at 9:43 A.M. with LPN #1 stated LPN #2 reported the medication error involving Resident #132 immediately and stayed with the resident until emergency medical services (EMS) transported the resident to the hospital. Interview on 08/20/25 at 10:27 A.M. with the Director of Nursing (DON) confirmed LPN #2 reported a medication error with Resident #132 on 07/24/25 in which the resident received Humalog insulin instead of Lantus insulin Interview on 08/21/25 at 3:59 P.M. with the Medical Director confirmed the facility notified him on 07/24/25 that Resident #132 received the wrong insulin. MD confirmed he gave an order for Resident #132 to be transferred to the emergency department for monitoring in a controlled environment. Review of the facility policy titled Medication Error dated May 2025 revealed medication errors would be prevented and reported. This deficiency represents noncompliance investigated under Complaint Number 2579530.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure the residents were treated with dignity and respect at meal service. This affected one (Resident #120) of 11 residents whom were eating lunch in the dining room. The facility census was 148. Findings include: Record review for Resident #120 revealed Resident #120 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 had no cognitive deficits and required supervision during eating. Observation of lunch service on 05/02/22 from 12:15 P.M. to 12:45 P.M. revealed State tested Nursing Assistant (STNA) #46 brought Resident #120 into the dining room and placed Resident #120 at the table with Resident #20. Resident #20 was served her lunch at 12:15 P.M. and STNA #46 continued to serve the other nine residents (#14, #25, #31, #35, #41, #48, #59, #124, and #149) in the dining room and then started to set up room trays while Resident #120 was still waiting for her tray. Interview on 05/02/22 at 12:45 P.M. with STNA #46 verified Resident #120 had not been served her lunch and STNA #46 explained she had been forgotten. STNA #46 stated she went into the kitchenette and found Resident #120's meal ticket tucked under a tray and that was why she was forgotten. Review of the facility's Meal Service Policy, dated 05/2021, revealed the Registered Dietician/RD and nursing personnel will assist with the dining room seating charts for each unit. The charts will identify where the residents will be served and help ensure the delivery of the appropriate diet. It also assures that each resident at any given table is served before moving onto the next table, and all residents at one table will be served before moving to the next table. If a resident sits at a table where the tablemates are already eating, his/her tray will be obtained as quickly as possible. This deficiency substantiates Complaint Number OH 887 and OH 637.

Based on observation, staff interview, and policy review, the facility failed to ensure the resident's foods were handled in a manner to prevent the potential spread of food borne illness. This affected three residents (Residents #7, #29, and #60) observed during the afternoon meal. The facility census was 148. Findings include: 1. Observations on 05/02/22 at 12:48 P.M. revealed the residents were being served their afternoon meal. The residents were receiving hamburgers on bun with condiments and toppings consisting of lettuce, tomatoes, mayonnaise and mustard in individual packs. State tested Nursing Assistant (STNA) #63 was assisting Resident #60 with meal set up. STNA#60 asked Resident #60 what they wanted on their hamburger. The STNA opened the packs of mayonnaise and mustard put on the top bun. STNA# 63 then picked up the lettuce, and tomatoes with her bare hand and placed them on the hamburger, the STNA then wiped her hands on her scrub top and picked up the top bun placed it on the hamburger, used her bare hand to smash the sandwich down and then cut it with the knife. During the same observation on 05/02/22 at 12:50 P.M., STNA #124 was assisting Resident #7 with adding condiments to the resident's hamburger. STNA#124 put mustard and ketchup from individual packets on the sandwich and then placed the top bun on the hamburger with her bare hand then held the sandwich with one bare hand while using the knife to cut the sandwich in half. STNA #124 picked up half the sandwich with her bare hand and handed it to Resident #7. Interview with STNA #124 on 05/02/22 at 1:00 P.M. verified she did touch Resident #7's food with her bare handed and she should have used the resident's eating utensils to apply and cut the food. Interview on 05/02/22 at 1:05 P. M. with STNA #63 verified she applied the condiments with her bare hand and she should have used gloves or utensils when setting Resident #60's meal tray. 2. Observation on 05/02/22 at 12:45 P.M. revealed the residents were being served their afternoon meal. The residents were receiving hamburgers on bun with condiments and toppings consisting of lettuce, tomatoes, mayonnaise and mustard in individual packs. STNA #5 was assisting Resident #29 with meal set up. STNA#5 asked Resident #29 what they wanted on their hamburger. STNA# 5 then picked up the lettuce and tomatoes with her bare hand and placed them on the hamburger, used her bare hand to smash the sandwich down, and then cut it with the knife. During an interview with STNA #5, she verified she touched Resident #29's food with her bare hands. She stated she sanitized her hands but stated she should have applied gloves to touch the food. Review of the facility's policy titled Meal Service dated 05/2021 revealed staff is to serve meals using proper hand techniques. No direct contact with food.

Based on record review, staff interview, review of facility Self-Reported Incidents (SRI's) and review of facility policy, the facility failed to conduct thorough investigations regarding possible resident to resident abuse. This affected four (#25, #30, #66 and #62) residents of five SRI's reviewed during the survey. The census was 142. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #25 dated 11/05/21 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of nurse progress note for Resident #25 dated 11/16/21 revealed nurse was in nurses' station and heard yelling, so nurse went into the dining room and saw aides trying to get resident to sit in her wheelchair. Resident #30 was holding the side of her head and stated Resident #25 had thrown a cup at her. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for Resident #30 dated 11/19/21 revealed resident had moderately impaired vision, cognitive status was not assessed, and resident required extensive assistance of one staff with ADL's. Review of nurse progress note for Resident #30 dated 11/16/21 revealed nurse was in nurses' station and heard yelling, so nurse went into the dining room and saw aides trying to get resident to sit in her wheelchair. Resident #30 was holding the side of her head and stated Resident #25 had thrown a cup at her. Nurse assessed Resident #30 for injuries and found none. Interview on 12/21/21 at 10:28 A.M. with the Administrator confirmed the incident between Resident #25 and #30 was not reported to her but if it had been, she would have reported it as an SRI and investigated. Interview on 12/21/21 at 10:28 A.M. with the Director of Nursing (DON) confirmed the nurse notified her by telephone of the incident but felt it did not need to be reported or investigated further because Resident #30 told the nurse when Resident #25 threw the cup at her she was startled because Resident #30 is legally blind. DON stated the nurse told her the cup did not contact Resident #30 and therefore did not need to be reported/investigated as an SRI. 2. Review of the medical record for Resident #66 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #66 dated 10/09/21 revealed resident was cognitively impaired and required extensive assistance of one staff with ADL's. Review of the nurse progress note for Resident #66 dated 12/11/21 revealed Resident #66 (a male resident) was observed lying in female resident's room with clothes off and having a bowel movement from the waist down. Further review of the note revealed Resident #66 and a female resident were observed touching each other above the waist. The residents were separated and redirected. Review of the medical record for Resident #62 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #62 dated 09/17/21 revealed resident was cognitively impaired and required extensive assistance of two staff with ADL's. Review of the nurse progress note for Resident #62 dated 12/11/21 nurse observed Resident #62 (a female resident) and a male resident touching each other inappropriately above the waist. The male resident was in Resident #62's bed with feces covering him from the waist down. Nurse separated the resident's and attempted redirection with resident and stated this is inappropriate. Further review of the note revealed Resident #62 stated, I love him. Nurse attempted to contact Resident #62's representative regarding the incident but was unable to reach her. Interview on 12/21/21 at 10:40 A.M. with the Administrator and the DON confirmed the nurse called the DON on the phone on 12/11/21 regarding the incident between Residents #66 and #62. DON confirmed she did not think of the incident as possible abuse because the nurse told her on the phone there was no inappropriate touching, and the residents were not distressed and said they loved one another. Administrator confirmed she learned of the incident on 12/12/21 and did not think it should be considered a potential abuse. Administrator and DON confirmed Residents #62 and #66 are both cognitively impaired and unable to consent to sexual activity. The Administrator and DON confirmed there was SRI reported and no further investigation into the incident involving Resident #66 and #62. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property dated November 2016 revealed all allegations of possible abuse should be reported and thoroughly investigated and if event that caused the allegation involved abuse it should be reported to the state survey agency immediately but not later than two (2) hours after the allegation was made. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview, review of facility Self-Reported Incidents (SRI's) and review of facility policy, the facility failed to immediately report allegations of potential resident abuse to the Ohio Department of Health (ODH). This affected four (#25, #30, #66 and #62) residents of five SRI's reviewed during the survey. The census was 142. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #25 dated 11/05/21 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of nurse progress note for Resident #25 dated 11/16/21 revealed nurse was in nurses' station and heard yelling, so nurse went into the dining room and saw aides trying to get resident to sit in her wheelchair. Resident #30 was holding the side of her head and stated Resident #25 had thrown a cup at her. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for Resident #30 dated 11/19/21 revealed resident had moderately impaired vision, cognitive status was not assessed, and resident required extensive assistance of one staff with ADL's. Review of nurse progress note for Resident #30 dated 11/16/21 revealed nurse was in nurses' station and heard yelling, so nurse went into the dining room and saw aides trying to get resident to sit in her wheelchair. Resident #30 was holding the side of her head and stated Resident #25 had thrown a cup at her. Nurse assessed Resident #30 for injuries and found none. Interview on 12/21/21 at 10:28 A.M. with the Administrator confirmed the incident between Resident #25 and #30 was not reported to her but if it had been, she would have reported it as an SRI and investigated. Interview on 12/21/21 at 10:28 A.M. with the Director of Nursing (DON) confirmed the nurse notified her by telephone of the incident but felt it did not need to be reported or investigated further because Resident #30 told the nurse when Resident #25 threw the cup at her she was startled because Resident #30 is legally blind. DON further confirmed the nurse told her the cup did not contact Resident #30 and therefore did not need to report/investigate as an SRI. 2. Review of the medical record for Resident #66 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #66 dated 10/09/21 revealed resident was cognitively impaired and required extensive assistance of one staff with ADL's. Review of the nurse progress note for Resident #66 dated 12/11/21 revealed Resident #66 (a male resident) was observed lying in female resident's room with clothes off and having a bowel movement from the waist down. Further review of the note revealed Resident #66 and a female resident were observed touching each other above the waist. The residents were separated and redirected. Review of the medical record for Resident #62 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #62 dated 09/17/21 revealed resident was cognitively impaired and required extensive assistance of two staff with ADL's. Review of the nurse progress note for Resident #62 dated 12/11/21 nurse observed Resident #62 (a female resident) and a male resident touching each other inappropriately above the waist. The male resident was in Resident #62's bed with feces covering him from the waist down. Nurse separated the resident's and attempted redirection with resident and stated this is inappropriate. Further review of the note revealed Resident #62 stated, I love him. Nurse attempted to contact Resident #62's representative regarding the incident but was unable to reach her. Interview on 12/21/21 at 10:40 A.M. with the Administrator and the DON confirmed the nurse called the DON on the phone on 12/11/21 regarding the incident between Residents #66 and #62. DON confirmed she did not think of the incident as possible abuse because the nurse told her on the phone there was no inappropriate touching, and the residents were not distressed and said they loved one another. Administrator confirmed she learned of the incident on 12/12/21 and did not think it should be considered a potential abuse. Administrator and DON confirmed Residents #62 and #66 are both cognitively impaired and unable to consent to sexual activity. The Administrator and DON confirmed there was SRI reported and no further investigation into the incident involving Resident #66 and #62. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property dated November 2016 revealed all allegations of possible abuse should be reported and thoroughly investigated and if event that caused the allegation involved abuse it should be reported to the state survey agency immediately but not later than two (2) hours after the allegation was made. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview, review of facility policy, and review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC), the facility failed to ensure staff wore personal protective equipment properly to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected one (#49) of three residents observed for quality of care. The census was 142. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #49 dated 12/14/21 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's.). Observation on 12/20/21 at 1: 40 P.M. revealed Housekeeper #350 was mopping Resident #49's floor and conversing with the resident who was in her bed. Housekeeper #350 was wearing an N-95 mask pulled down below her nose while talking to Resident #49 and was at times closer than six feet to Resident #49. Interview on 12/20/21 at 1:45 P.M. with Housekeeper #350 confirmed her mask had been below her nose while she was cleaning Resident #49's room with resident in the room. Housekeeper #350 confirmed she had not been fit tested for the N-95 mask and complained it kept slipping down below her nose. Housekeeper #350 confirmed she had not reported to the facility management that her mask did not fit properly. Interview on 12/20/21 at 2:48 P.M. with the Director of Nursing (DON) confirmed the facility was requiring all staff to wear N-95 masks in resident areas because facility was in outbreak mode and all staff were required to wear N-95 masks covering their nose, mouth, and chin in resident areas. Interview on 12/20/21 at 5:10 PM. with the Administrator confirmed the facility had not been able to conduct recent fit testing due to company which conducts tests not available until January 2022. Administrator further confirmed approximately two weeks ago nursing management provided N-95 masks to all staff including housekeepers and demonstrated ensuring the mask fit properly over the mouth, nose, and chin and that the mask was not too loose. Administrator further confirmed the facility had four different type of N-95 masks so staff could choose a mask that fit best for them and staff were supposed to notify their supervisor immediately if the mask did not fit properly. Review of the facility policy titled Fit Testing undated revealed team members were responsible to wear his or her N-95 mask when and where required and in the manner in which they were trained, inform their supervisor if it no longer fitted well and should request a new one that fits properly. Review of an online resource from the CDC (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care-strategies.html) revealed the following guidance regarding facemasks: ensure all healthcare care personnel (HCP) wear a facemask while in the facility. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high spread (red) of COVID 19 with a positivity rate of 13.5% for the week ending in 12/14/21. This deficiency substantiates Complaint Number OH 354.

Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to perform dressing changes and skin treatments as ordered by the physician. This affected one (#49) of three residents reviewed for quality of care. The census was 142. Findings include: 1. Review of the medical record for Resident #49 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] surgical aftercare for surgery on the digestive system. Review of the Minimum Data Set (MDS) for Resident #49 dated 12/14/21 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's.). Review of the hospital records for Resident #49 revealed the discharge instructions dated 12/08/21 revealed resident had a peripherally inserted central catheter (PICC) line in place for administration of intravenous (IV) antibiotics. Further review of the instructions revealed the PICC line dressing should be changed at least once a week or whenever the dressing was loose, wet, or dirty to prevent infection. Review of the admitting orders for Resident #49 dated 12/08/21 revealed an order to change the PICC line dressing once a week and as needed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress notes on 12/20/21 revealed notes contained no documentation regarding completion of PICC line dressing change and/or resident refusal of dressing change. Observation on 12/20/21 at 1:50 P.M. of Resident #49 revealed she had a PICC line to right arm with a soiled dressing with edges slightly peeling. Resident #49's PICC line dressing to the right arm was dated 12/05/21. Interview on 12/20/21 at 1:50 P.M. with Resident #49 confirmed the PICC line dressing had been changed on 12/05/21 but had not been changed since she was admitted to the facility on [DATE]. Interview on 12/20/21 at 1:55 P.M. with Licensed Practical Nurse (LPN) #300 confirmed Resident #49's PICC line dressing looked like it needed to be changed and it was dated 12/05/21 and she did not recognize the initials. LPN #300 confirmed the PICC line dressing change was done on night shift and she was not aware of any resident refusals. Interview on 12/20/21 at 2:48 P.M. with the Director of Nursing (DON) confirmed Resident #49's PICC line dressing was supposed to be changed weekly and as needed. Review of late entry nurse progress note created on 12/20/21 at 6:59 P.M. revealed Resident #49 had refused her dressing change on 12/19/21. Further review of the late entry note revealed it did not include any attempts to reapproach resident or educate resident regarding risk of infection. The record did not include an assessment of the dressing and/or physician notification of resident refusal. Review of facility policy titled PICC Lines dated June 2017 revealed dressing to PICC lines should be changed weekly and if the integrity of the dressing is compromised. 2. Review of the December 2021 monthly physician orders for Resident #49 revealed resident had orders for the following daily treatments: cleanse skin tear to abdomen with normal saline, pat dry, apply triple antibiotic ointment and cover with clean dry dressing every night, apply dry dressing to Jackson-[NAME] (JP) surgical drain site and cover with [MEDICATION(S)] check site and change dressing daily. Review of the December 2021 Treatment Administration Record (TAR) for Resident #49 revealed the treatment to skin tear and the surgical drain were scheduled to be completed on night shift and the TAR was marked with a code to see the nurse notes for 12/13/21 and 12/15/21. Review of nurse progress notes for Resident #49 dated 12/14/21 and 12/16/21 revealed the treatments to resident's skin tear and to resident's JP drain were not completed on these dates due to inadequate staffing. Interview on 12/21/21 at 10:45 A.M. with the DON confirmed the facility had adequate staffing and the treatments for Resident #49 should have been completed as ordered. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations, staff interview, review of facility policy, review of online resources from the Centers for Disease Control (CDC) and the Ohio Department of Health (ODH), and review of a Director's Order from ODH, revealed three randomly observed facility staff (Dietary Aide (DA) #100, Registered Dietician (RD) #200 and Registered Nurse (RN) #300) failed to appropriately wear/utilize facemask's to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). Facility census was 151. Findings include: 1. Observation on 08/24/20 at 8:42 A.M. revealed DA #100 walked through the front lobby and entered the administration area and was not wearing a mask. Further observation revealed DA #100 exited the administration area at approximately 8:43 A.M. carrying an N-95 mask in a plastic wrapper. DA #100 walked through the front lobby and the first-floor hallway and got on the elevator. DA #100 was still carrying the N-95 mask in a plastic wrapper as he got on the elevator and he had not donned or unwrapped the N-95 during the elevator ride to the second floor. Interview on 08/24/20 at 8:45 A.M. with DA #100 confirmed he had obtained an N-95 mask from the administrator before getting on the elevator but had not donned or unwrapped the N-95 mask yet. DA #100 further confirmed he would don the mask prior to entering the kitchen. 2. Observation on 08/24/20 at 8:46 A.M. revealed RD #200, RN #300, and Therapy Director (TD) #250 were meeting in a closed conference room. RD #200 was not wearing a mask. RN #300 and TD #250 were wearing facemask's. Further observation revealed RD #200 held a mask up over her face as she walked past the surveyor and the administrator and exited the conference room at approximately 8:46 A.M. Once RD #200 was in the hallway she dropped the mask from her face and carried it with her down the hallway. Observation on 08/24/20 at 8:52 A.M. revealed RD #200 and RN #300 were meeting in a closed office and neither were wearing masks. Interview on 08/24/20 at 8:52 A.M. with RN #300 confirmed she was not wearing a facemask during the meeting with RD #200 on 08/24/20 at approximately 8:52 A.M. Interview on 08/24/20 at 8:53 A.M. with RD #200 confirmed she was not wearing a facemask during the meeting in the conference room with RN #300 and TD #250 on 08/24/20 at approximately 8:46 A.M. nor was she wearing a facemask during the meeting with RN #300 on 08/24/20 at approximately 8:52 A.M. Interview on 08/25/20 at 9:02 A.M. with RN #900, the facility's infection preventionist, confirmed all staff had been educated to wear facemask's anywhere inside the facility to prevent the spread of COVID-19. RN #900 further confirmed the only exception to wearing a facemask inside the facility would be for an individual working alone in an enclosed office. Review of the undated facility policy titled Protocol for COVID 19 dated revealed the facility would follow the guidance and information published by the CDC and state health departments regarding management of the COVID-19. Review of online resource from the CDC regarding preventing the spread of COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html) revealed the following guidance: COVID-19 can be spread to others even if you do not feel sick, everyone should wear a mask in public settings and when around people who don't live in the same household to prevent infecting others, continue to maintain a distance of about six feet between yourself and others, a mask is not a substitute for social distancing. Review of an online resource from ODH (https://coronavirus.ohio.gov/wps/portal/gov/covid-19/public-health-advisory-system/) on 08/25/20 revealed Clermont County, the county in which the facility was situated, was experiencing a very high exposure and spread of COVID 19 at the time of the survey. Review of ODH Director of Health order dated 07/23/20 revealed facial coverings were required at all times in the state of Ohio in any indoor space that was not a private residence.

Based on medical record review, staff interview, review of a facsimile (fax) confirmation form and review of facility policy, the facility failed to complete a discharge summary for a resident transferred to another facility and failed to send resident clinical documentation to the receiving facility upon a resident's transfer. This affected one (#1) of three residents sampled during the survey. The census was 147. Findings include: Review of record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed resident was cognitively impaired, required extensive assistance of two staff with bed mobility, transfer, and toilet use, and was coded for refusal of care and for frequent bladder and bowel incontinence. Review of MDS dated [DATE] for Resident #1 revealed resident was discharged with a return not anticipated. Review of care plan for Resident #1 dated 11/18/19 revealed discharge plans for resident were uncertain. Interventions included the following: encourage family discussion of long range plans, inform family of resident's plan of care and goals to assist with making decisions related to long range plans, provide resident and family with possible community referrals to assist in decision making. Review of nurse progress note for Resident #1 dated 11/27/19 per Licensed Practical Nurse (LPN) #90 revealed resident was transferred to another nursing facility and was transported per outside transport service and that resident left with her son and her personal belongings. Review of the record for Resident #1 revealed there was no evidence regarding any additional documentation including the provision of information to the the new facility upon transfer to ensure continuity of care. Review of the discharge summary for Resident #1 initiated on 11/27/19 revealed that the social services section had been completed but that the nursing section of the discharge summary was blank, and the following items were not addressed: skin integrity, continence status, lab work, radiology, outside consultations, discharge instructions, medication reconciliation, resident signature, resident representative signature. Review of fax confirmation sheet from facility dated 11/27/19 timed at 5:22 P.M. revealed a fax containing 19 pages of information was sent to the facility to which Resident #1 had been transferred. (The facility did not have evidence of the contents of the 19 pages of information.) Interview of on 12/03/19 at 11:56 [NAME]M. with Registered Nurse (RN) #10 confirmed that the discharge summary for Resident #1 had not been completed and had not been signed by the resident and/or resident representative and had not been provided to the resident's receiving facility when resident was discharged on [DATE]. Interview on 12/03/19 at 3:07 P.M. with Licensed Practical Nurse (LPN) #90 confirmed Resident #1 was transferred to another nursing facility at approximately 4:00 P.M. on 11/27/19 accompanied by her son, that she did not send any resident information to the receiving facility upon discharge, that she had not completed the discharge summary for resident, and that she had not had resident nor resident's representative sign the discharge summary. LPN #90 further confirmed that the receiving facility called the facility after Resident #1 had arrived there and requested information regarding the resident as no information had been sent. LPN #90 further confirmed that she then gave a verbal report to the nurse and faxed information to the receiving facility at approximately 5:20 P.M. on 11/27/19. Review of facility policy titled Discharge Planning dated 11/2016 revealed the facility would provide the following information to the receiving provider upon resident discharge: contact information of practitioner responsible for care of the resident, resident representative information including contact information, advanced directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, all other necessary information including a copy of the resident's discharge summary as applicable to ensure a safe and effective transition of care. This deficiency substantiates Complaint Number OH 641.

Based on medical record review, review of facility self-reported incidents (SRI's), staff interview, and review of facility policy, the facility failed to immediately report an allegation of verbal and physical abuse to the state survey agency. This affected one (#1) of three residents reviewed for abuse concerns. The census was 147. Findings include: Review of record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed resident was cognitively impaired, required extensive assistance of two staff with bed mobility, transfer, and toilet use, and was coded for refusal of care and for frequent bladder and bowel incontinence. Review of MDS dated [DATE] for Resident #1 revealed resident was discharged with a return not anticipated. Review of care plan for Resident #1 dated 11/18/19 revealed resident was resistive to care related to agitation. Interventions included the following: allow the resident to make decisions about treatment regime to provide a sense of control, educate resident and family members of possible outcomes of not complying with treatment or care, provide resident with choices during care provision. Review of care plan for Resident #1 dated 11/18/19 revealed the resident had the potential to be verbally and physically aggressive with staff related to anger and poor impulse control and the resident would yell, curse, and scream at staff and would attempt to hit, pinch, and grab at staff and accuse others of trying to hurt her. Interventions included the following: administer medications as ordered, analyze times of day, places, circumstances, triggers and what deescalates behavior, assess and address for contributory sensory deficits, assess and anticipate resident's needs. Review of facility SRI's dated 11/01/19-12/03/19 revealed no reports were filed related to Resident #1 Interview on 12/03/19 at 2:27 P.M. with Licensed Practical Nurse (LPN) #60 confirmed that on 11/25/19 at approximately 7:00 P.M. Resident #1 was tearful and reported to him that State tested Nursing Assistant (STNA) #50 had been aggressive when providing perineal care, that resident had been incontinent of stool and that STNA had held a washcloth full of stool in resident's face and said she had to get stool out of her vagina. LPN #60 further confirmed that Resident #1 refused to get her ice when requested, and told her she was going to shut her door so other patients didn't have to listen to her scream. LPN #60 confirmed that he took the following actions in response to Resident #1's concerns: he assessed resident for injuries and found none, he assured the resident that STNA #50 would not care for her anymore, he interviewed STNA #50 who confirmed she had provided peri care to Resident #1 but that she denied any abuse or mistreatment, he reported the resident's concerns to the unit manager Registered Nurse (RN) #70 the next morning. Interview on 12/03/19 at 2:16 P.M. with RN #70 confirmed that LPN #60 had reported to him at approximately 7:00 [NAME]M. on 11/26/19 that the LPN had removed STNA #50 from caring for Resident #1 due to resident had expressed concerns about provision of perineal care. RN #70 confirmed that he then interviewed Resident #1 who alleged that STNA #50 was providing perineal care on 11/25/19 with STNA #80 in the room assisting and that during the course of the care STNA #50 had held stool in the resident's face, had made threatening statements suggesting that the resident better not go to sleep because the aide would be back, and that the aide had intentionally put her knee upon top of the resident's knee to cause pain to the resident. RN #70 confirmed that he took the following actions in response to Resident's #1's concerns: he assessed resident for injuries and found none and he reported the resident's allegations to the Administrator and Director of Nursing (DON) immediately. Interview on 12/03/19 at 3:16 P.M. with STNA #80 confirmed that he had assisted STNA #50 when she provided perineal care to Resident #1 on 11/25/19. STNA #80 further confirmed that the Administrator had also interviewed him about the incident and that Resident #1 had been incontinent of stool and some of it had gotten in the resident's vagina and that STNA #50 had cleaned her up, and that he did not feel any of STNA #50's actions were abusive or inappropriate. Interview on 12/03/19 at 2:53 P.M. with the Administrator confirmed that on the morning of 11/26/19 she received a verbal report from RN #70 that Resident #1 was unhappy with how STNA #50 had touched her privates the night before and that she wanted to talk to somebody in administration, and that she didn't want STNA #50 to be her aide anymore. Administrator confirmed that based upon the report she received, she had not considered the resident's concerns to be an allegation of physical and/or verbal abuse and that she had not reported the allegation to the state agency via a SRI. Administrator confirms she investigated the incident as a resident concern but did not feel it was an allegation of abuse. Review of facility policy titled Abuse, Neglect, and Misappropriation of Property dated 11/2016 revealed the facility would identify, report, and investigate all allegations of verbal and physical abuse towards residents. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, review of facility self-reported incidents (SRI's), staff interview, and review of facility policy, the facility failed to implement its abuse policy by failing to immediately report an allegation of verbal and physical abuse to the state survey agency. This affected one (#1) of three residents reviewed for abuse concerns. The census was 147. Findings include: Review of record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed resident was cognitively impaired, required extensive assistance of two staff with bed mobility, transfer, and toilet use, and was coded for refusal of care and for frequent bladder and bowel incontinence. Review of MDS dated [DATE] for Resident #1 revealed resident was discharged with a return not anticipated. Review of care plan for Resident #1 dated 11/18/19 revealed resident was resistive to care related to agitation. Interventions included the following: allow the resident to make decisions about treatment regime to provide a sense of control, educate resident and family members of possible outcomes of not complying with treatment or care, provide resident with choices during care provision. Review of care plan for Resident #1 dated 11/18/19 revealed the resident had the potential to be verbally and physically aggressive with staff related to anger and poor impulse control and the resident would yell, curse, and scream at staff and would attempt to hit, pinch, and grab at staff and accuse others of trying to hurt her. Interventions included the following: administer medications as ordered, analyze times of day, places, circumstances, triggers and what deescalates behavior, assess and address for contributory sensory deficits, assess and anticipate resident's needs. Review of facility SRI's dated 11/01/19-12/03/19 revealed no reports were filed related to Resident #1 Interview on 12/03/19 at 2:27 P.M. with Licensed Practical Nurse (LPN) #60 confirmed that on 11/25/19 at approximately 7:00 P.M. Resident #1 was tearful and reported to him that State tested Nursing Assistant (STNA) #50 had been aggressive when providing perineal care, that resident had been incontinent of stool and that STNA had held a washcloth full of stool in resident's face and said she had to get stool out of her vagina. LPN #60 further confirmed that Resident #1 refused to get her ice when requested, and told her she was going to shut her door so other patients didn't have to listen to her scream. LPN #60 confirmed that he took the following actions in response to Resident #1's concerns: he assessed resident for injuries and found none, he assured the resident that STNA #50 would not care for her anymore, he interviewed STNA #50 who confirmed she had provided peri care to Resident #1 but that she denied any abuse or mistreatment, he reported the resident's concerns to the unit manager Registered Nurse (RN) #70 the next morning. Interview on 12/03/19 at 2:16 P.M. with RN #70 confirmed that LPN #60 had reported to him at approximately 7:00 [NAME]M. on 11/26/19 that the LPN had removed STNA #50 from caring for Resident #1 due to resident had expressed concerns about provision of perineal care. RN #70 confirmed that he then interviewed Resident #1 who alleged that STNA #50 was providing perineal care on 11/25/19 with STNA #80 in the room assisting and that during the course of the care STNA #50 had held stool in the resident's face, had made threatening statements suggesting that the resident better not go to sleep because the aide would be back, and that the aide had intentionally put her knee upon top of the resident's knee to cause pain to the resident. RN #70 confirmed that he took the following actions in response to Resident's #1's concerns: he assessed resident for injuries and found none and he reported the resident's allegations to the Administrator and Director of Nursing (DON) immediately. Interview on 12/03/19 at 3:16 P.M. with STNA #80 confirmed that he had assisted STNA #50 when she provided perineal care to Resident #1 on 11/25/19. STNA #80 further confirmed that the Administrator had also interviewed him about the incident and that Resident #1 had been incontinent of stool and some of it had gotten in the resident's vagina and that STNA #50 had cleaned her up, and that he did not feel any of STNA #50's actions were abusive or inappropriate. Interview on 12/03/19 at 2:53 P.M. with the Administrator confirmed that on the morning of 11/26/19 she received a verbal report from RN #70 that Resident #1 was unhappy with how STNA #50 had touched her privates the night before and that she wanted to talk to somebody in administration, and that she didn't want STNA #50 to be her aide anymore. Administrator confirmed that based upon the report she received, she had not considered the resident's concerns to be an allegation of physical and/or verbal abuse and that she had not reported the allegation to the state agency via a SRI. Administrator confirms she investigated the incident as a resident concern but did not feel it was an allegation of abuse. Review of facility policy titled Abuse, Neglect, and Misappropriation of Property dated 11/2016 revealed the facility would identify, report, and investigate all allegations of verbal and physical abuse towards residents. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the failed to notify the attending physician of multiple doses of insulin which were not administered as ordered by the physician. This affected one (#1) of three residents sampled during the survey. The census was 147. Findings include: Review of record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed resident was cognitively impaired, required extensive assistance of two staff with bed mobility, transfer, and toilet use, and was coded for refusal of care and for frequent bladder and bowel incontinence. Review of MDS dated [DATE] for Resident #1 revealed resident was discharged with a return not anticipated. Review of (MONTH) 2019 physician orders for Resident #1 revealed orders for the following: [MEDICATION NAME]90 units subcutaneously every morning, regular insulin 60 units subcutaneously two times daily with lunch and dinner. Review of nurse progress note for Resident #1 dated 11/21/19 timed at 5:31 P.M. revealed resident's regular insulin 60 unit dose was not given as ordered but was held per nursing judgment due to resident's blood sugar was 98. Review of nurse progress note for Resident #1 dated 11/22/19 timed at 5:08 P.M. revealed resident's regular insulin 60 unit dose was not given as ordered but was held per nursing judgment due to resident's blood sugar was 98. Review of nurse progress note for Resident #1 dated 11/24/19 timed at 9:28 [NAME]M. revealed resident's [MEDICATION NAME]90 unit dose was not given as ordered and that resident's blood sugar was 78. Review of nurse progress note for Resident #1 dated 11/25/19 timed at 8:45 [NAME]M. revealed resident's [MEDICATION NAME]90 unit dose was not given as ordered and that resident's blood sugar was 101. Review of nurse progress note for Resident #1 dated 11/26/19 timed at 8:51 [NAME]M. revealed resident's [MEDICATION NAME]90 unit dose was not given as ordered but was held per nursing judgment due to resident's blood sugar was 114. Review of nurse progress note for Resident #1 dated 11/26/19 timed at 12:42 P.M. revealed resident's regular insulin 60 unit dose was not given as ordered but was held per nursing judgment due to resident's blood sugar was 117. Review of nurse progress notes dated 11/21/19-11/27/19 for Resident #1 revealed there was no documentation regarding physician notification that insulin doses were not administered as ordered on [DATE], 11/22/19, 11/24/19, 11/25/19 and twice on 11/26/19. Review of physician assistant progress notes for Resident #1 dated 11/21/19 and 11/25/19 revealed resident had insulin ordered for her diabetes, that prior to resident's admission to the facility, resident's blood sugar had been uncontrolled while she was in the hospital, and that the facility should monitor the resident's blood sugar for control. The notes did not contain information regarding the doses of insulin being held by the facility. Interview on 12/03/19 at 12:19 P.M. with Registered Nurse (RN) #10 confirmed that the insulin was not administered to Resident #1 as ordered on [DATE], 11/22/19, 11/24/19, 11/25/19 and twice on 11/26/19, and that the record did not contain information regarding physician notification of the missed doses. Review of facility policy titled Practitioner Notification dated 11/2016 revealed the facility would communicate to practitioners regarding resident concerns in a timely manner via phone call or fax communication. Review of policy titled Administration of Insulin dated 08/2008 revealed insulin would be administered in a safe manner as prescribed by the physician. This deficiency is based on incidental findings discovered during the course of this complaint investigation.