Every finding on record at Eliza Jennings Home

Based on record review, observation, interview, and facility policy review, the facility failed to provide timely incontinence care and/or facial hair grooming to prevent hair growth. This affected two residents (Resident #65 and #82) of two residents reviewed for activities of daily living (ADL) care. The facility census was 116.Findings include:1. Record review for Resident #65 revealed an admission date of 08/20/24 with a diagnosis of Parkinsonism.Review of the care plan dated 12/05/25 revealed Resident #65 required assistance with ADL related to impaired functional ability/mobility, osteoarthritis of bilateral hips, morbid obesity and essential tremors. Resident #65 was always incontinent with bowel and bladder and had been unsuccessful on a toileting program. Interventions included checking and changing routinely and as needed, and when incontinence occurred, providing reassurance, maintaining dignity and assisting with hygiene care. Resident #65's level of required assistance fluctuated. Staff were to encourage independence as able and provide assistance as needed. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was always incontinent with bowel and bladder, required partial/moderate assistance for bed mobility and chair/bed to chair transfers and was dependent for toileting and personal hygiene. Observation and interview on 08/03/26 at 11:18 A.M. with Resident #65 revealed the resident lying in bed and complained of not being up out of bed yet or receiving incontinence care, stating, I am soaked. Resident #65 revealed having asked a couple of staff members to change her, putting her call light on, but staff only sticking their head in to say they will let someone know. The resident emphasized she had been wet with urine for a few hours. Resident #65 had a visible long beard and mustache approximately one half inch in length. Resident #65 continued to complain of staff not shaving her enough identifying it as once in a while but not as much as it was needed. Resident #65 stated not liking hair on her face and not being happy about being left in bed so long because staff say they have mechanical lifts to do first. Interview on 08/03/26 at 11:27 A.M. with Certified Nursing Assistant (CNA) #848 confirmed she was Resident #65's primary CNA and revealed she started her shift at 7:00 A.M. CNA #848 went on to state her assignment included five residents who required a mechanical lift to transfer, and she was required to care for them first, which was why she had not checked or changed Resident #65 yet on her shift. CNA #848 confirmed Resident #65 required assistance to be changed and to get out of bed. Observation at the time of the interview with CNA #848 of incontinence care for Resident #65 revealed the resident was soaked with urine through her brief, through a disposable pad, through a cloth pad underneath and onto the sheets. Resident #65 had a strong odor of urine, and her buttocks skin was a deep red with multiple creases embedded in the skin from the wrinkled pads she was lying on. Additional interview with CNA #848 who verified the observation, revealed it was the usual time of day, sometimes sooner, depending on who she worked with if she was able to assist Resident #65 any sooner with care and confirmed she did not shave Resident #848 because, Night shift is supposed to shave her. Observation on 08/04/26 at 3:53 P.M. with Unit Manager (UM) #708 revealed Resident #65's facial hair remained unshaven. Interview with Resident #65 at the time of the observation confirmed she did not like facial hair. Interview with UM #708 at the time of the observation revealed residents should not have to ask staff to shave them, staff should offer. 2. Record review for Resident #82 revealed an admission date of 12/16/21. Diagnoses included hemiplegia and hemiparesis, cerebral infarction, type two diabetes mellitus, vascular dementia, and muscle weakness. Review of the care plan dated 12/27/21 revealed Resident #82 was always incontinent with bowel and bladder. She was unaware of when she needed to use the bathroom and would not benefit from a toileting program. Interventions included checking and changing Resident #82 routinely and as needed, and when incontinence occurred, providing reassurance, maintaining dignity and assisting with hygiene care. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #82 was severely cognitively impaired, always incontinent of bowel and bladder, used a wheelchair for mobility, and was dependent for toileting hygiene, bed mobility, and chair/bed to chair transfers. Observation on 08/05/26 at 8:30 A.M. revealed Resident #82 was sitting up in her chair in the dining room. Observation on 08/05/26 at 11:00 A.M. revealed Resident #82 remained sitting in her chair in the dining room. Interview at the time of the observation with CNA #843 after requesting incontinence care be provided for the resident responded she would not be providing incontinence care for Resident #82 until after lunch at approximately 12:30 P.M. Observation on 08/05/26 at 12:30 P.M. revealed Resident #82 was sitting up in her chair next to the dining room table. Resident #82's lunch plate was empty of food and Resident #82 was resting her head on the back of the chair. CNA #843 was sitting in the nurses' room. Interview at the time of the observation with CNA #843 revealed she could not change Resident #82 yet because all the residents had to be done eating before they were allowed to change residents and by then, it would be time for bingo. Resident #82 would want to go to bingo so she could not change her until after bingo, about 2:30 P.M. Interview on 08/05/26 at 2:45 P.M. with CNA #843 revealed she had started her shift at 7:00 A.M. Resident #82 was assisted out of bed into her chair about 7:30 A.M. CNA #843 confirmed she had not checked or changed Resident #82 for incontinence since 7:30 A.M. She had planned on doing it after lunch about 12:30 or 1:00 P.M, but because the resident liked bingo and has not returned yet, it would not happen until after the next shift at 3:00 P.M. Interview on 08/05/26 at 3:05 P.M. with Director of Life Enrichment #813 revealed bingo was held on this date from 1:30 P.M. to between 2:30 to 2:45 P.M. Interview on 08/05/26 at 3:09 P.M. with UM #708 verified Resident #82 should be checked and changed for incontinence every two hours. Observation on 08/05/26 at 3:11 P.M. revealed Resident #82 was sitting up in her chair in the dining room. Interview on 08/05/26 at 3:12 P.M. with Assistant Director of Nursing (ADON) #663 verified Resident #82 should be checked and changed for incontinence every two hours and as needed. Interview and observation on 08/05/26 at 3:27 P.M. with CNA #804 confirmed she was Resident #82's primary CNA starting at 3:00 P.M. CNA #804 stated not usually laying Resident #82 down until 4:30 P.M., and then walked over to Resident #82 who remained sitting in the dining room and stated to Resident #82, Do you want to lay down now? Resident #82 said, Yes. CNA #804 then stated to Resident #82, Do you want to lay down at 4:30? Resident #82 said, Yes. CNA #804 then stated, Ok so you want to lay down at 430. Resident #82 said, Yes. CNA #804 then stated she would lay Resident #82 down at 4:30 P.M. to check and change her. Upon interview with Resident #82, the resident responded to any question asked with the one word of yes.Observation on 08/05/26 at 4:30 P.M. revealed Resident #82 was lying in bed. Interview at the time of the observation with CNA #804 who reported not waiting to allow incontinence care to be observed because the resident wanted to go to bed. Observation after the interview of Resident #82's peri area with Registered Nurse (RN) #701 and CNA #804 revealed Resident #82's right upper thigh, peri area and buttocks were deep red. Interview on 08/05/26 at 5:23 P.M. with ADON #663 revealed CNAs were not permitted to change residents during meals. They were supposed to be passing trays, supervising residents in the dining room and feeding residents. If a resident was incontinent and it was not everywhere, then the resident had to wait until after the meal was over. Review of facility policy titled, Activities of Daily Living, undated revealed it was the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring each staff honor and support the principals of quality of life for each resident; and that the care and services provided were person-centered, and honor and support each resident's preferences, choices, values and beliefs. This deficiency represents non-compliance investigated under Complaint Numbers 2706321, 1366909 (OH00163826), and 1366908 (OH00163104).

Based on record review, observation, and interview, the facility failed to ensure fall interventions were in place per the plan of care. This affected one resident (Resident #10) of five residents reviewed for accidents. The facility census was 116.Findings include:Record review for Resident #10 revealed an admission date of 05/01/17. Diagnoses included syncope and collapse, schizoaffective disorder bipolar type, cognitive communication deficit, Parkinsonism, tremors, repeated falls, displaced intertrochanteric fracture of left femur, anxiety disorder and nightmare disorder. Review of the care plan dated 03/23/26 revealed Resident #10 was at increased risk for unavoidable falls and injury related to psychotropic med use for management of schizoaffective disorder and poor safety awareness. Interventions included to place Resident #10's bed in the lowest position when Resident #10 was in bed. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact, was always incontinent of bowel and bladder, and was dependent with chair/bed transfers. Review of the progress note dated 06/21/26 at 11:42 A.M. completed by Registered Nurse (RN) #701 revealed Resident #10 yelled for assistance and was found on the floor sitting upright on his buttocks up against the bed and leaning toward the left with a bolster pad dislodged and hanging off the side of the bed. Review of the fall risk assessment dated [DATE] revealed Resident #10 had a history of falls in the past three months and was considered a high risk for falls. Observation on 08/03/26 at 4:44 P.M. with Licensed Practical Nurse (LPN) #694 revealed Resident #10 was lying in bed. The bed was in a high position while no staff were present to monitor and/or assist him. Interview at the time of the observation with LPN #694 confirmed Resident #10's bed was in a high position, and the nurse verified the resident could not raise it himself. Interview on 08/03/26 at 4:46 P.M. with Certified Nursing Assistant (CNA) #964 who confirmed Resident #10 was on her assignment and stated she was from agency and saw the resident in bed upon her arrival at 3:00 P.M. CNA #964 verified Resident #10's bed was in a high position and had also been at that time. She denied knowing if it should be lower because she was only told who needed checks and changes, not who was at high risk for falls.Observation on 08/04/26 at 5:48 P.M. revealed Resident #10 was lying in bed with no staff present and the bed was in a high position. Interview at the time of the observation with CNA #846 confirmed Resident #10's bed was in a high position while being left alone and stated, We always keep his bed like that. Observation and interview on 08/04/26 at 5:52 P.M. with Assistant Director of Nursing (ADON) #663 confirmed Resident #10's bed was not in the lowest position per his plan of care.This deficiency represents non-compliance investigated under Master Complaint Number 2992896 and Complaint Numbers 2706321 and 2684754.

Based on record review, observation, staff interview, review of facility policy and review of manufacturer's instructions for administering insulin using an insulin pen, the facility failed to administer physician ordered insulin by manufacturer's instructions. This affected two residents (Resident #88 and #131) of two residents reviewed for insulin administration. The facility identified 17 residents (Residents #1, #4, #5, #17, #23, #24, #34, #36, #53, #60, #72, #74, #87, #98, #112, #114 and #129) who received insulin pen injections. The facility census was 116.Findings include:1. Record review for Resident #88 revealed an admission date of 08/27/21. Diagnosis included diabetes mellitus (DM) due to underlying condition with diabetic polyneuropathy. Review of Resident #88's physician orders revealed an order dated 09/23/25 for insulin aspart flexpen subcutaneous solution pen injector 100 units/milliliter (ml). Inject as per sliding scale: if 150 to 200 (blood sugar check) give 2 units; 201 to 250 give 4 units; 251 to 300 give 5 units; 301 to 350 give 6 units; 351 to 400 give 7 units; 401 or greater call physician and give 9 units subcutaneously before meals and at bedtime for DM. Review of the care plan dated 10/27/25 revealed Resident #88 had a diagnosis of diabetes with polyneuropathy. Interventions included administering medication as ordered. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact, required assistance with activities of daily living, and had DM. Observation on 08/04/26 at 8:29 A.M. of medication administration for Resident #25 revealed Licensed Practical Nurse (LPN) #719 confirmed Resident #88's blood sugar was 154. LPN #719 placed the needle on the aspart insulin pen, turned the dial to a dosage of 2 units and then administered the insulin to Resident #88. LPN #719 did not prime the insulin pen before administering the 2 units of insulin. Interview at the time of the observation with LPN #719 verified not priming the insulin pen prior to administration and stated she did not prime the insulin pen because it was not brand new as she only primed insulin pens if they were brand new. 2. Record review for Resident #131 revealed an admission date of 11/21/24. Diagnosis included type two DM with diabetic chronic kidney disease. Review of the care plan dated 02/05/25 revealed Resident #131 had a diagnosis of DM. Interventions included administering medication as ordered. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #131 was severely cognitively impaired, required assistance with activities of daily living, and was diagnosed with DM. Review of the current physician orders for August 2026 revealed Resident #131 had an order for Humalog subcutaneous solution pen-injector 100 units/ml. Inject 10 units subcutaneously before meals related to type two DM with diabetic chronic kidney disease. Give with sliding scale and inject as per sliding scale: if 151 to 200 give 2 units; 201 to 250 give 3 units; 251 to 300 give 4 units; 301 to 350 give 5 units; 351 to 400 give 6 units subcutaneously before meals. Observation on 08/05/26 at 8:31 A.M. of medication administration for Resident #131 revealed LPN #693 placed the needle on the Humalog insulin pen, dialed 10 units on the insulin pen, and then administered the insulin to Resident #131. LPN #693 did not prime the pen prior to administering the insulin to Resident #131. Interview at the time of the observation with LPN #693 confirmed she did not prime the insulin pen prior to administering the insulin.Review of facility policy titled, Medication Administration Policy revised 2023 revealed all medications will be administered safely, accurately, and in accordance with the resident's comprehensive assessment, plan of care and prescribers' orders. Licensed staff shall follow the rights of medication administration, including right resident, right medication, right dose, right route, right time, right documentation, right reason and right response. Review of the manufacturer's instructions for priming insulin pens titled, Instructions for Use undated revealed priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps but not more than four times.This deficiency represents non-compliance investigated under Complaint Number 1366909 (OH00163826).

Based on observation, interview, record review and review of the facility policy revealed the facility failed to maintain a clean and homelike environment. This affected one resident (Resident #9) of one resident observed for environment. The facility census was 116.Findings include:Record review for Resident #9 revealed an admission date of 02/01/19. Diagnoses included malignant neoplasm of liver, neuromuscular dysfunction of the bladder, anxiety disorder, neuropathy, and mild intellectual disabilities. Review of Significant Change MDS assessment dated [DATE] revealed Resident #9 was severely cognitively impaired. Resident #9 had no impairment of the upper or lower extremities, had an indwelling urinary catheter, was always incontinent of stool, was dependent for toileting hygiene, required substantial/maximal assist for bed mobility and chair/bed to chair transfers. Review of the care plan dated 07/16/26 revealed Resident #9 needed assistance with activities of daily living related to impaired functional abilities and was always incontinent of bowel. Interventions included Resident #9 required max assist with bed mobility, required EBP due to the bacteria Providencia stuartii, Klebsiella pneumonia ESBL, Enterobacter cloacae and Enterococcus faecalis and an indwelling urinary catheter, maintain dignity and provide support, reassurance and assistance with hygiene if incontinence occurs.Review of Resident #9's physician orders revealed August 2026 orders for EBP related to an indwelling urinary catheter, urinary catheter care every shift and as needed, check and clean the indwelling urinary catheter insertion site, and ensure it is draining without difficulty. Observation on 08/03/2026 at 3:45 P.M. revealed Resident #9 was lying in bed and had a large amount of stool on both his hands covering the fingers and palms. Stool was on the sheets, splattered on both sides of the floor from the headboard to the foot of the bed and was tracked into the entrance of the bathroom door. Resident #9 was rambling and asking for assistance. The catheter bag was lying on the floor on top of splattered stool. Observation and interview on 08/03/2026 at 3:46 P.M. of Resident #9 with CNA #829 verified the findings of Resident #9's stool incontinence and stated Resident #9 did not walk so he would not have been able to track the stool throughout the room as it was. CNA #829 put on disposable gloves and used a towel to clean a circular area on the floor next to the resident's right side of the bed and then stood in the cleaned area. Stool remained splattered and tracked on the other remaining areas of the floor. CNA #829 proceeded to clean Resident #9's body. Licensed Practical Nurse (LPN) #694 then entered Resident #9's room and assisted CNA #829 to finish care for Resident #9. Interview with CNA #829 revealed housekeepers left for the day at 3:00 P.M. Interview with LPN #694 verified the stool on Resident #9's floor.Observation on 08/04/26 at 5:19 P.M. with CNA #829 of Resident #9's room revealed the floor still had stool splattered and tracked on the floor from the previous day and had not yet been cleaned. The stool was now dried and remained except for the small area CNA #829 had cleaned with a towel the previous day. Interview at the time of the observation with CNA #829 verified the findings. Interview on 08/05/2026 at 8:24 A.M. with Administrator revealed she spoke with the housekeeper who was assigned to Resident #9's room on 08/04/26, and the housekeeper did not get to Resident #9's room that day, so it was not cleaned up.Review of facility policy titled, Environmental Cleaning revised April 2026 revealed the resident care environment throughout the facility will be maintained in a state of cleanliness that meets professional standards to protect residents and healthcare personnel from potentially infectious microorganisms. Environmental cleaning was a team effort. This deficiency represents non-compliance investigated under Master Complaint Number 2992896 and Complaint Number 1366909 (OH00163826).

Based on medical record review, facility electronic mail communication with local health department, and interview the facility failed to timely report rashes of unknown origin which were suspicious of scabies to the local health department. This affected five residents (Resident #207, #213, #245, #284 and #298) of 19 residents residing in the memory care unit (#201, #202, #207, #213, #220, #225, #228, #230, #232, #233, #245, #257, #274, #279, #284, #296, #297, #298, and #308). The facility census was 118. Findings include: Review of the medical record for Resident #207 revealed an admitted [DATE]. Diagnoses included but were not limited to allergic contact dermatitis (10/05/23), paranoid schizophrenia, vascular dementia, and anxiety disorder. Resident #207 was noted to have severe cognitive impairment and required supervision for activities of daily living. Review of the facility's infection control log for the past six months revealed concerns were logged and identified. Following a dermatologist appointment for Resident #207, on 06/25/24, for a rash of unknown origin, four additional residents (#213, #245, #284 and #298), who resided in memory care, were identified with rashes of unknown origin. Interview on 07/24/24 at 12:27 P.M. with the Director of Nursing (DON) revealed Resident #207 was identified as having a prickly rash and was sent to the dermatologist on 06/25/24 and returned with an order to treat scabies empirically. Resident #207 did not have a scraping completed while at the appointment to confirm scabies due to having previously been treated with oral and topical steroids. Following the dermatologist's order treatment for scabies for Resident #207, the facility completed skin sweeps 06/25/24 and identified four other residents that had a rash of unknown origin and began to treat the additional four residents first and then two days later the remaining 14 residents were treated. Review of the Fax correspondence from the facility to the local health department dated 07/24/24 timed at 5:16 P.M. revealed the facility reported the five residents (#207, #213, #245, #284 and #298) as suspected cases of scabies, 30 days after the suspected cases of scabies were identified. Phone interview on 07/25/24 at 10:02 A.M. with County Health Department Nurse #24 revealed the health department wanted suspected cases of scabies reported within 24 business hours to monitor and prevent further potential outbreak. Review of the guidance from the Centers for Disease Control (CDC) website Public Health Strategies for Scabies Outbreaks in Institutional Settings | Scabies | related to scabies revealed when the characteristic symptoms of itching and rash were absent, it was easy to misdiagnose scabies, which could lead to outbreaks. Maintain a high index of suspicion that scabies could be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scraping. If there were multiple cases, the guidance indicated to notify the local health department of the outbreak. Review of the Ohio Department of Health (ODH) guide titled; Know Your ABCs: A Quick Guide to Reportable Infection Diseases in Ohio from the Ohio Administrative Code Chapter 3701-3 effective August 1, 2019, revealed under Class C: Report an outbreak, unusual incident or epidemic of other diseases (e.g. histoplasmosis, pediculosis, scabies, staphylococcus infections) by the end of the next business day. This deficiency represents non-compliance investigated under Complaint Number OH00155236.

Based on observation and staff interview, the facility failed to maintain a clean, safe, sanitary and well-maintained environment in resident common areas and resident rooms. This had the potential to affect all 115 residents living in the facility. Findings include: Interview was conducted on 12/04/23 at 12:30 P.M. with the Director of Environmental Services (DES) #422 who revealed the housekeeping staff were to make sure all floors in the resident common areas and resident rooms were kept clean. DES #422 explained the floor scrubber was broke so the staff were to use whatever equipment they had to keep the floors clean. Observations of the general facility environment and resident rooms were conducted on 12/05/23 from 12:00 P.M. and 12:25 P.M. with the Director of Maintenance (DM) #359 and revealed carpeted areas in resident rooms and common areas throughout the facility were covered in stains and/or various debris indicating the carpet was not being maintained in a clean manner. In addition, the following findings were observed: Resident #52's bathroom door had a wire clothing hanger bent in half and stuck into the door in place of a functional door handle. The only way to open the door to the bathroom was to grab the bent, wire hanger. Observation of the common area on the second floor revealed dried food and food crumbs on the table by the common area computer for resident use. The table lamp was unplugged and the electrical cord was laying on the open ground where the plug prongs were exposed to the environment and any traffic near the lamp. Observation of the bottom of the door going into Resident #91's room and facing into the hallway revealed a moderate build up of brown, dried stains looking like dried on coffee stains. Observation of Resident #108's room revealed broken, missing window blinds. Observation of Resident #101's room revealed a beside dresser drawer had a metal staple plate affixed onto it and an old, hinged metal hasp (parts used with a pad lock) approximately three to four inches long was sticking straight out posing risk for injury by the metal hasp. There was no pad lock in use on the drawer so the metal hasp with just sticking out at a 90 degree angle from the drawer. DM#359 verified the above findings at the time of the observations on 12/05/23 from 12:00 P.M. to 12:25 P.M. Review of the facility policy titled Safe Environment, revised 11/28/16, revealed the facility would provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This deficiency represents non-compliance investigated under Complaint Number OH00148425 and continued noncompliance from the survey dated 11/16/23.

Based on observation and staff interview the facility failed to maintain a clean, safe, sanitary and well-maintained environment. This had the potential to affect all residents. The facility census was 113. Findings include: An environmental tour was conducted on 11/16/23 between 10:45 A.M. and 11:20 A.M. with the Administrator. The following was observed and verified with the Administrator at the time of discovery. Carpeted areas throughout the facility in resident rooms and common areas were noted with stains and debris throughout. The unit three air purifier had a thick coating of dust and debris covering every part of its filter. The window unit air conditioners throughout the facility were noted to be not affixed to the window and were held up against the windows with tape. The room occupied by Resident #43 was noted with a non-hospital grade power strip with four outlets in use plugged in to the wall. The poles used to hang intravenous (IV) medication used by Residents #53 and #219 were not clean. The bathroom in Resident #52's room and had noticeable cobwebs on the light fixture about the mirror. The recliner chair in Resident #36's room was dirty and with numerous unknown debris on it. The footboard on the bed used by Resident #220 was detached from one side. The bathroom in Resident #224's room contained an open yellow biohazard bag. The rooms occupied by Residents #1,#75 and #76 had noticeable water stains on the ceiling. The room occupied by Resident #69 had a significant crack in the wall. The tube feed poles utilized by Residents #25,#69 and #73 were stained with residual tube feed and other debris. 2. Observation of the laundry area on 11/16/23 at 11:30 A.M. revealed the area behind the washer and dryer was dirty and full of numerous debris, lint and other items. A pile of towels was noted to be behind the washer and was discolored brown and full of unknown dirt and debris. Observations of the back panels of dryers revealed significant lint build up. Laundry Aide (LA) #897 11/16/23 verified the above findings at the time of observations.

Based on observation and interview the facility failed to provide dignified feeding assistance to Resident #15 and Resident #217. This affected two residents (#15 and #217) of four residents observed for feeding assistance. The facility identified eight residents (#15, #19, #32, #34, #64, #76, #87, and #217) who required feeding assistance. The facility census was 113. Findings include: 1. Review of Resident #15's medical records revealed an admitted [DATE]. Diagnoses included dementia, anorexia and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to Resident #15 was rarely understood. Resident #15 required extensive assistance with eating. Review of the care plan dated 11/03/23 revealed Resident #15 was at risk for nutritional deficits. Interventions included provide assistance at meals. Observation was conducted on 11/14/23 at 8:43 A.M. of the breakfast meal for Resident #15. The observation revealed State tested Nursing Assistant (STNA) #972 was providing feeding assistance to Resident #15 in a common dinning area. STNA #972 stood next to Resident #15 while feeding and did not engage Resident #15 with conversation or eye contact while providing feeding assistance. Interview with STNA #972 at the time of the observation confirmed she was standing up next to Resident #15 and had not tried to engage the resident. Resident #15 was not interviewable. 2. Review of Resident #217's medical records revealed an admitted [DATE]. Diagnoses included Alzheimer's and macular eye degeneration. Review of MDS assessment dated [DATE] revealed no recorded cognition score due to Resident #217 was rarely understood. Resident #217 required extensive assistance with eating. Review of the care plan dated 11/08/23 revealed Resident #217 was at risk for nutritional deficits. Interventions included provide assistance at meals. Observation was conducted on 11/14/23 at 8:47 A.M. of the breakfast meal for Resident #217. The observation revealed STNA #973 was providing feeding assistance to Resident #217 in the residents room. STNA #973 was observed to have been standing up next to Resident #217 and did not engage Resident #217 with conversation or eye contact while providing feeding assistance. Interview with STNA #973 at time of observation confirmed she standing up next to Resident #217 and had not tried to engage the resident. Resident #217 was not interviewable. Review of facility policy titled Feeding of Residents revised 07/28/21 revealed staff should engage with resident and maintain eye contact and conversation to create a pleasant dining experience.

Based on medical record review, interview, and facility policy review the facility failed to ensure resident's wishes regarding advanced directives were accurate and clearly identified in a resident's medical record. This affected one resident (Resident #76) of five residents reviewed for advanced directives. The facility census was 113. Findings include: Review of Resident #76's medical record revealed an admitted [DATE] and a facility re-entry date of [DATE] with diagnoses including myositis ossificans traumatica, adult failure to thrive, severe protein calorie malnutrition, anorexia, dementia, stage three chronic kidney disease, and longstanding persistent atrial fibrillation. Review of physician orders for Resident #76 dated [DATE] revealed a Do Not Resuscitate Comfort Care Arrest (DNR CC-Arrest) order which instructed Do Not intubate Protocol is activated when the patient experiences cardiac or respiratory arrest and further clarifies all other necessary treatments should be initiated prior to arrest. Review of Resident #76's electronic medical record on [DATE] revealed no code status and no advanced directive paperwork and review of the hard chart revealed no indication of code status or documentation of advanced directives. Interview on [DATE] at 10:25 A.M. with Licensed Practical Nurse (LPN) #970 and Central Supply/Medical Records staff (CSMR) #912 confirmed resident code status and any advanced directive documents could be found in the front of the hard chart but both LPN #970 and CSMR #912 were unable to find it. CSMR #912 further confirmed she would be printing and placing a copy of Resident #76's DNRCC-Arrest paperwork in the hard chart and presented the surveyor with what she referred to as a unit report which contained resident code statuses and pointed out the nurses can see from this printed report that Resident #76 was a DNRCC-A. LPN #970 acknowledged she was aware of this form and noted it gets updated whenever the unit census changes. Interview on [DATE] at 10:40 A.M. with LPN #971 confirmed she would look at the order summary report for code status orders and follow accordingly if resident code status was not readily found in the front of the hard chart or profile in the electronic medical record. Interview on [DATE] at 03:17 P.M. with State tested Nurse Aide (STNA) #907 confirmed there was a printed nursing report on each nursing unit containing important resident information, including resident code statuses. Interview on [DATE] at 08:40 A.M. with Medication Technician #893 confirmed if she needed to know a resident code status, she could find it on the team report sheet, which she pulled out of a drawer on the unit to show the surveyor the report sheet contained code status orders for each unit resident. Interview on [DATE] at 09:57 A.M. with STNA #839 confirmed she did not know Resident #76's code status. When asked how she would find code status, she said to ask one of the nurses. Interview on [DATE] at 02:32 P.M. with the Administrator confirmed there was no advanced directive paperwork in Resident #76's electronic medical record. She further stated there was no DNR paperwork uploaded to the electronic medical record due to an issue from Resident #76's last hospital admission. The administrator proceeded to present an order in the medical record date [DATE] indicating Resident #76 was a full code and added Resident #76 was not a DNRCC-A. Interview on [DATE] at 02:50 P.M. with the Director of Nursing (DON) confirmed Resident #76 was a full code. The DON further confirmed the code status in Resident #76's profile was blank and the order for a full code was dated [DATE]. The DON also confirmed there was a code status order for a DNRCC-A effective from [DATE] to [DATE] and no signed advanced directive documentation, adding staff would have performed cardiopulmonary resuscitation (CPR) even if the order for a DNR was present if they did not have the signed DNR paperwork because that was the way we do it here. Review of admission paperwork from re-entry to the facility on [DATE] revealed hospital discharge orders indicated Resident #76 was a full code. Review of the undated Advanced Directive Procedure revealed the facility will determine whether the resident has any advanced directive upon admission, resident wishes will be communicated with facility staff, and all advanced directive document copies will be obtained and located with the resident's medical record.

Based on observation, record review and interview the facility failed to ensure physician orders were followed for the use of Prevalon boots. This affected one resident (#7) of two residents observed for Prevalon boots. The facility census was 113. Findings include: Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a memory problem, inattention, altered level of consciousness, and was a two-person total dependence for activities of daily living (ADLs). Review of the care plan dated 9/21/23 revealed Resident #7 medical conditions required monitoring and managed as ordered and interventions included to administer medications and treatments as ordered. Review of the physician orders dated 06/21/22 revealed an order for Prevalon boots every shift. Observation on 11/13/23 at 10:12 A.M. revealed Resident #7 was in bed with her Prevalon boots located on the floor near the bathroom entrance. Observation and interview on 11/16/23 at 8:44 A.M. with Registered Nurse (RN) #814, revealed Resident #7 was in bed without her Prevalon boots on. Resident #7 had multiple signs posted in her room that indicated her Prevalon boots were to be put on in the morning. RN #814 verified and confirmed Resident #7's Prevalon boots were not on and were located on the floor next to a reclining chair.

Based on record review, observation and interview the facility failed to ensure flammable materials were not left in resident rooms. This affected one resident (#21) of four residents reviewed for accident hazards. The facility census was 113. Review of Resident #21's medical records revealed an admitted [DATE]. Diagnoses included schizoaffective disorder and anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Resident #21 required supervision with transfers, ambulation and personal hygiene. Review of the care plan dated 09/20/23 revealed Resident #21 was an independent smoker. Review of smoking assessment dated [DATE] revealed Resident #21 was safe to smoke unsupervised. Observation on 11/15/23 at 7:53 A.M. revealed Resident #21 had a pack of cigarettes, lighter and a canister of lighter fluid on his dresser. Interview on 11/15/23 at 11:29 A.M. with State tested Nursing Assistant (STNA) #949 confirmed Resident #21 was an independent smoker and was able to keep his smoking materials in his room. Observation of Resident #21's room with STNA #949 at time of interview confirmed the canister of light fluid and STNA #949 stated Resident #21 should not have that substance in his room. Interview on 11/15/23 at 2:11 P.M. with Administrator revealed Resident #21 should not have had light fluid in his room and she stated she had educated Resident #21 on not having hazardous material in his room.

Based on record review and interview, the facility failed to notify Resident #8's family representative a change in resident's pressure ulcer condition. This finding affected one (Resident #8) of three residents reviewed for notification of changes. Findings include: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, diabetes and anemia. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #8's progress note dated 08/04/23 at 8:35 A.M. revealed the wound to the sacrum had a moderate amount of odorous serosanguinous drainage. Interview with Licensed Practical Nurse (LPN) #803 at 09/07/23 at 1:09 P.M. confirmed she left a message on Certified Nurse Practitioner (CNP) #830's notification board for him to address the odor in Resident #8's sacral wound. LPN #803 confirmed she did not notify Resident #8's family representative of the odor in the resident's sacral wound on 08/04/23 because the resident was her own person. Interviews on 09/07/23 at 1:33 P.M. with Resident #8's emergency contact number one and emergency contact number two confirmed they were not notified by the facility on 08/04/23 of odor in the resident's sacral wound during a dressing change. Review of the undated Notification of Changes Policy indicated it was the policy of the facility that changes in a resident's condition or treatment were immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. This deficiency represents non-compliance investigated under Complaint Numbers OH00145703 and OH00145705.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 105 of the 107 residents. Two Resident's (#17 and #260) did not receive food from the facility. The facility census was 107. Findings include: Observations during the initial tour on 06/28/21 at 8:40 A.M. revealed the oven door had dried on spills down the front. The control knobs on the oven and stove top were dirty. The hood and overhead vents were greasy and dusty, the spigots for fire suppression system were greasy and dusty. These findings were verified by Dietary Manager #401 at the time of the observation.

Based on observation, interview and policy review, the facility failed to implement an ongoing infection prevention and control program related to COVID 19. This affected six Resident's (#76, #84, #158, #159, #160 and #161) who resided on the observation for COVID 19 unit out of 107 residents in the facility. Findings include: Interview with the Administrator on 06/28/21 at 9:00 A.M. reported the facility had no residents with COVID 19 but had one staff test positive so they were in outbreak testing. She reported the observation unit was located on the second floor and this was where new admissions spend their first 14 days. She indicated full personal protective equipment had to be worn in the resident rooms. On 06/28/21 at 10:00 A.M. during the initial tour of the facility, a small unit on the second floor had the double doors at both ends of the unit closed. Signs were posted for authorized employees only and had N95 masks at the entrance to the unit. There was no eye protection available and staff working the unit were not observed wearing eye protection. Resident's in the general population were observed congregating in the dining room or in areas where group activities were being held. No residents were observed wearing masks. On 06/28/21 at 3:25 P.M. Resident #160's sister was standing outside of his room calling out for help. The call light above his door was illuminated. The sister was wearing a surgical mask and no other personal protective equipment. The daughter was in the room with the resident explaining they had called for assistance but the staff did not come timely enough so she tried to assist him to the bathroom and he had an accident on the floor, his bed was wet with urine, there was medication residue on the carpet from where he spit out his medication. She found him wet and in need of toileting for the last two days and was very upset. The daughter reported she visited daily to help him eat and to explain things to him since he spoke little English. The daughter wore no personal protective equipment. On 06/29/21 at 3:21 P.M. the daughter was observed in his room not wearing any personal protective equipment. She was asked how she was educated when entering the building. She said she was told to wear a surgical mask. She pulled it out of her purse and said she removed it when in the room with her father. She acknowledged seeing the signs on the entry doors but did not think that was related to her father. Resident #76 also had a visitor at that time who wore no personal protective equipment. Interview on 06/29/21 at 3:25 P.M. with the infection preventionist Registered Nurse (RN) #408 reported the front desk didn't know where the visitors were going in the facility and told all to wear a surgical mask. She initially reported that was all that was necessary when visiting the observation unit. But was asked why the signage indicated to wear an N95, eye protection and gown when entering the resident rooms. She admitted then that the resident's families should be wearing the gown, gloves, eye protection when in the room. She was informed the direct care staff wore no eye protection for two days and today's State tested Nurse Aide (STNA) also was not wearing a gown or gloves when going into resident rooms. She was informed Residents #76 and #160 had visitors wearing no personal protective equipment. On 06/29/21 at 4:06 P.M. Residents #76's and #160's visitors had N95 masks and gowns on. Interview with Resident #160's daughter said she was educated to wear mask and gown when in the room and was upset she was not told this earlier because she did not want to bring COVID 19 home to her family. Further interview with RN #408 and the Administrator on 07/01/21 at 10:03 A.M. reported all staff and visitors were to complete screening upon entering the facility. This was a computerized system that could print out the screening logs. They reported visitors going to the observation unit were provided a leaflet on how to don and doff personal protective equipment. Staff and visitors were to wear N95 masks, goggles, and gowns. They call families weekly with updates and have a website for information. They reported 83% of residents were vaccinated for COVID 19 but only 64% of the staff were vaccinated. They reported residents on the observation unit should wear personal protective equipment when they left the unit and residents in the general population should wear a surgical mask when out of their rooms, but they could not force them. Review of the facility's policies on COVID 19 were based on the Centers for Disease Control. This deficiency substantiates Complaint Number OH 256.

Based on observation, interview and record review, the facility failed to provide personal hygiene for Resident #95. This affected one of three Resident's (#67, #95 and #160) reviewed for activities of daily living. The facility census was 107. Findings include: Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change comprehensive assessment (MDS 3.0) dated 06/02/21 indicated he was alert, oriented and independent in daily decision making. No behaviors were identified. He required the extensive assistance of one staff for personal hygiene. Review of the activities of daily living plan of care dated 03/22/21 indicated he required extensive assistance of one staff for personal hygiene. Review of the electronic aide task section on bathing revealed he was provided one bath/shower in the last 30 days on 06/28/21. His preference was marked that he preferred a bath/shower once weekly. Interview and observation of Resident #95 on 06/28/21 at 3:25 P.M. revealed he had extremely long fingernails and some were jagged and had black substance underneath. Resident #95 verified his nails were too long and not of his preference. Resident #95 was observed with his fingernails in the same condition on 06/29/21 at 1:46 P.M. and at 3:40 P.M. Interview with State tested Nurse Aide (STNA) #402 on 06/29/21 at 3:40 P.M. confirmed Resident #95's nails were long and dirty. STNA #402 reported the nurse was responsible for clipping fingernails and she would let the nurse know. On 06/29/21 at 3:51 P.M. STNA #402 informed Licensed Practical Nurse (LPN) #403 who requested STNA #402 soak his nails with denture tablets. Interview with LPN #403 on 06/29/21 at 3:55 P.M. reported the denture tables were very effective at cleaning under the nails and would not harm the resident. On 06/30/21 at 7:49 A.M. Resident #95's nails were observed in the same condition, and Resident #95 confirmed he was not provided nail care. On 06/30/21 at 9:34 A.M. Registered Nurse (RN) #404 verified Resident #95's nails were long, jagged with black substance underneath.

Based on observation, interview, record and policy review, the facility failed to identify, evaluate and monitor Resident #95's new onset pain and notify the physician to manage his pain. This affected one of two Resident's (#75 and #95) reviewed for pain management. The facility census was 107. Findings include: Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He entered palliative care on 06/16/21. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He received the medication on 06/25/21 at 3:05 P.M. for pain level 5, 06/26/21 at 5:41 A.M. for pain level 10, 06/27/21 at 9:43 P.M. for pain level 5, 06/28/21 at 5:39 A.M. for pain level 5, 06/29/21 at 9:51 P.M. for pain level 8 and on 06/30/21 at 7:45 A.M. for pain level 8. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the order administration notes revealed he was provided [MEDICATION(S)] on 06/25/21 at 3:05 P.M. for complaints of pain. On 06/26/21 at 5:41 A.M. for shortness of breath or pain. On 06/27/21 at 9:43 P.M. for shortness of breath or pain. On 06/28/21 at 5:39 A.M. for complaints of leg and indwelling catheter pain. It was noted the catheter was draining tea colored urine. On 06/29/21 at 9:51 P.M. for general pain. On 06/30/21 at 7:45 A.M. for complaints of scrotum pain. The notes lacked specific identification of the type of pain, location and non-pharmacological interventions attempted. Review of the corresponding progress notes lacked consistent indication of where the pain was located, the type, level, and no notification to the physician of his increased level of pain that began on 06/25/21. Review of the significant change comprehensive assessment (MDS 3.0) dated 06/02/21 indicated he was alert, oriented and independent in daily decision making. No behaviors were identified. He required extensive assistance of one staff for toilet use and hygiene. He had an indwelling urinary catheter and was incontinent of bowel. He was identified to have frequent pain affecting his sleep and limiting his day to day activities. He rated his pain as an eight out of 10 being the worst pain imaginable. Review of the pain plan of care dated 03/22/21 indicated he had pain/discomfort related to peripheral [CONDITION(S)] and liver failure. Review of the interventions indicated to monitor for verbal and nonverbal signs of pain/discomfort every shift and provide pain interventions as needed. Notify the physician if the pain was not being relieved with the current regimen and offer non-pharmacological interventions such as positioning, relaxation and breathing, diversional activities, heat or cold packs and/or warm shower/bath. Interview with Resident #95 on 06/28/21 at 3:48 P.M. reported he had unrelieved groin pain he thought from his catheter. Observation of Resident #95 on 06/29/21 at 3:53 P.M. revealed a full urinary catheter bag that contained 2000 cubic centimeters (cc's) of orange colored urine, further observation revealed the resident had a piece of tape securing his urinary catheter tubing to his leg. Interview with Licensed Practical Nurse (LPN) #403 at time of observation revealed the resident should have had a leg strap and confirmed the amount of urine, further observation with LPN #403 revealed Resident #95 had a very swollen scrotal area and resident moaned in pain when area was touched. LPN #403 reported his scrotum had been edematous for a few weeks and confirmed there was no documentation related to his swollen and painful scrotum. Interview with LPN #407 on 06/30/21 at 7:49 A.M. reported he had not worked in a couple of days and had no idea his scrotum was swollen. Interview with State tested Nurse Aide (STNA) #405 on 06/30/21 at 7:55 A.M. reported she worked on Saturday and noticed his scrotum was swollen and tender, so she informed LPN #406. Interview with Registered Nurse (RN) #404 and observation of Resident #95 on 06/30/21 at 9:34 A.M. verified the scrotal area was very swollen and his urine was dark with sediment in the tubing. Resident #95 complained of pain from the catheter. RN #404 reported no awareness of the resident's swollen scrotum and he would be notifying the physician of the pain and inquired about getting a urinalysis. On 06/30/21 at 11:24 A.M. the nurse noted the resident had a new onset of hydrocele with reports of discomfort to the scrotum/lower back that he rated a nine out of 10. [MEDICATION(S)] was administered with minimal effect. The urinary catheter bag had amber colored urine with moderate amounts of sediment. The nurse called the physician who ordered the resident be sent out to the hospital. On 07/01/21 at 4:16 A.M. he returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/02/21 at 11:30 A.M. the nurse practitioner was made aware he was requesting [MEDICATION(S)] for scrotal pain and gave a new order to discontinue [MEDICATION(S)] and utilize [MEDICATION(S)] (an opioid analgesic) 50 milligrams every eight hours as needed for complaints of generalized pain/discomfort. Review of the pain management policy dated 02/01/21 indicated to evaluate the resident for pain by asking the resident to rate the intensity of his/her pain using a numerical scale or a visual descriptor, identify key characteristics of the pain (duration, frequency, location, onset, pattern and radiation), descriptors of pain (aching, burning, throbbing, tingling, stabbing), determine factors that make the pain better or worse, how does the pain impact the quality of life, use non pharmacological and/or pharmacological interventions, effectiveness of the medication or treatments, if not controlled the practitioner should be notified, reassess the resident regularly.

Based on observation and staff interview, the facility failed to properly contain garbage in the outside dumpster. This had the potential to affect all 107 residents living in the facility. Finding include: Observations during the initial tour on 06/28/21 at 8:40 A.M. revealed the side doors of two dumpsters were open. The dumpsters had debris around them, including numerous plastic gloves, a brief, and disposable plastic cups. This was verified by Dietary Manager #401 at the time of the observation.

Based on interview, record review and policy review, the facility failed to provide one resident (Resident #3) with appropriate supervision and /or use of a gait belt while she was standing at the parallel bars during therapy. Actual harm occurred when Resident #3 was left unattended and was unable to stand any longer. The rsident lost her balance, falling to the floor and hitting her head. This resulted in Resident #3 sustaining a hematoma to her head (collection of blood outside a blood vessel) and a nondisplaced fracture involving the middle third of the left scaphoid (bone in the wrist area by the thumb). This affected one resident (Resident #3) of three residents reviewed for accidents. The facility census was 116. Findings include: Review of the medical record revealed Resident #3 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 10/12/19 revealed Resident #3 was at increased risk for falls and injury related to impaired mobility and right-side weakness because of a cerebral infarction (stroke). Interventions included: assistance of one person with transfers with a pyramid cane and enabler bars to assist with bed mobility and transfers. An intervention dated 11/02/19, as a result of a fall, revealed Resident #3 was to be assisted with proper positioning and balance before assisting onto the toilet or changing of clothes. An intervention dated 12/03/19, as a result of a fall in therapy, revealed nursing contacted the therapy manager and therapy staff was to be in-serviced regarding the supervision of Resident #3 that required assistance and supervision with ambulation and transfers. Review of the Physical Therapy Evaluation dated 10/29/19 revealed Resident #3's long-term goal was to complete functional sit to stand with grab bar with contact guard (patient requires light physical contact from staff) assistance demonstrating proper safety awareness in order to improve function and decrease risk of falls. The evaluation indicated Resident #3 felt unsteady when standing, and she was worried about falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and required extensive assist of one staff with bed mobility and transfers and was unable to ambulate. Review of facility form labeled, Patient Incident Report revealed on 12/03/19 at 10:45 A.M. Resident #3 was participating in physical therapy. She was standing at the parallel bars. Physical Therapy Assistant (PTA) #[AGE]8 walked to the other end of the parallel bars to set-up another resident with a walker. PTA #[AGE]8 went to walk back over to Resident #3 as she lost her balance and fell to her right side hitting her head on the therapy gym floor. Nursing was called to the therapy room to evaluate Resident #3. Resident #3 had a hematoma to her head. The incident report revealed a gait belt was not used while Resident #3 was standing at the parallel bars during the incident. Resident #3 had pain rated a five out of ten on a pain scale. Resident #3 was sent to the hospital for evaluation. The incident report revealed after the incident Rehabilitation Director #[AGE]6 educated PTA #[AGE]8 on the need to maintain contact guard/ touching assist, and the need to use a gait belt with all residents during therapy sessions. The incident report revealed PTA #[AGE]8 would sign off that she would always demonstrate safety in the therapy gym. Rehabilitation Director #[AGE]6 also educated all therapy staff on safety and fall prevention during all therapy sessions. The therapy staff was to participate in formal education and training sessions on safety and fall preventions. Rehabilitation Director #[AGE]6 would document weekly that safe procedures were followed during therapy sessions. Review of the witness statement dated 12/02/19 at 10:45 A.M. (this is inaccurate date as should be 12/03/19) completed per PTA #[AGE]8 revealed Resident #3 was standing on the outside of the parallel bars nearest the sink. PTA #[AGE]8 then assisted another resident by setting her up with a rolling walker and she was walking back over to Resident #3 when Resident #3 lost her balance and fell hitting her head on the carpeted area of the therapy gym floor. PTA #[AGE]8 notified nursing. Review of the nursing note dated 12/03/19 at 11:55 A.M. authored by Registered Nurse (RN) #[AGE]9 revealed Resident #3 was in therapy. PTA #[AGE]8 stated Resident #3 was using the parallel bars when PTA #[AGE]8 went to obtain a rolling walker that was at the other end of the parallel bars. When returning, Resident #3 lost her balance and fell on her right side hitting her head. Her left forearm had bruising and swelling to the distal portion. Resident #3 was transported to the hospital for evaluation. Review of Emergency Department progress note dated 12/03/19 authored by Physician Assistant #612 revealed Resident #3 had pain, swelling, and bruising to her left wrist. X-ray of the wrist was without acute fracture dislocation. Resident #3 was placed in a thumb Spica splint (a type of splint used to immobilize the thumb and wrist) because of concern for possible scaphoid (bone in the wrist area by the thumb) fracture. Review of facility form labeled, Fall Assessment- V2 dated 12/05/19 revealed the resident was at high risk for falls due to Resident #3 had impaired mobility, she was incontinent, she required an assistive device, she had a history of [REDACTED]. Review of Orthopedic #611 progress note dated 02/07/20 revealed Resident #3 returned to his office for an evaluation and was now nine weeks status [REDACTED]. She was transitioned to a wrist brace with thumb extension on the last visit. Resident #3 had a component of carpometacarpal arthritis and had pain along the base of the thumb. He documented a [DIAGNOSES REDACTED]. Interview on 02/18/20 at 12:23 P.M. with Resident #3 revealed she was unable to move her right side as she had a stroke. She revealed a couple months ago she was in therapy and PTA #[AGE]8 had her stand up on the outside of the parallel bars. She revealed PTA #[AGE]8 then left her standing without any assistance holding onto the parallel bars as she went to assist another resident. She revealed she had never stood unassisted previously as she was weak especially on her right side. She revealed she was unable to hold her weight any longer and got dizzy. She stated she fell to her right side to the ground hitting her head and broke her wrist. Resident #3 stated PTA #[AGE]8 did not use a gait belt. She stated she was now scared staff would leave her alone again when they transferred her as she can not stand by herself and needed assistance. Interview on 02/18/20 at 4:43 P.M. with Rehabilitation Director #[AGE]6 revealed Resident #3 was receiving therapy as she had right sided weakness and had frequent falls. She verified PTA #[AGE]8 did not have a gait belt on Resident #3 as she assisted Resident #3 to stand at the parallel bars. She verified it was therapy policy for all therapists during therapy sessions to use a gait belt for transfers and ambulation. She verified Resident #3 required contact guard assistance, which meant during Resident #3's transfers and while standing, the therapist should have been providing assistance at all times by touching Resident #3 during her transfer and while she was standing on the parallel bars. She revealed she educated PTA #[AGE]8 on safety and the use of a gait belt as well as all the other therapy staff. She revealed she had been auditing the therapy department to ensure safety. Interview on 0[DATE] at 2:27 P.M. with the Administrator and the Director of Nursing verified PTA #[AGE]8 should not have left Resident #3 without maintaining contact while Resident #3 was standing and verified PTA #[AGE]8 should have been using a gait belt during the therapy session. They revealed the therapy staff was educated, but the facility had not educated any nurses or state tested nursing assistants (STNA's) on safe transfers. They revealed the therapy department had a policy on use of gait belts to be used for all transfers, but that the facility did not have a policy on gait belt use. They stated they had only trained the therapy department on gait belt use and did not have any education after Resident #3's fall regarding education for nurses and STNAs on the use of gait belts. Review of facility policy labeled, Falls Preventions Procedures dated June 2016 revealed the nursing staff in conjunction with the physician, nurse practitioner, consultant pharmacist, therapy staff and others will identify and document resident's risk for falls. Review of therapy policy labeled, Safety- Environmental and Physical dated 12/15/16 revealed it was the responsibility of all rehabilitation personnel to ensure a safe environment for the patients, staff and visitors in the rehabilitation area. The policy revealed all employees involved assisting residents would use a gait belt on all transfers, pre-gait and gait activities. Any employee providing direct care to a resident would be required to utilize a gait belt with the resident regardless of a resident's functional status unless the resident had a medical condition documented to prevent this safety interventions. The policy also included not to leave a patient alone in the treatment area and when transfers, pre-ambulation, ambulation and balance activities were performed gait belts must be used to ensure proper supervision and control of all potential situations. This deficiency substantiates Complaint Number OH 998.

Based on interview and record review, the facility failed to timely notify Resident #4's and #5's physician and/ or guardian of their change in condition of the development of their pressure ulcers. This affected two residents (Residents #4 and #5) of three residents reviewed for change in condition. The facility census was 118. Findings included: 1. Review of medical record for Resident #5 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the facility form labeled, Braden Scale for Predicting Pressure Sore Risk, dated 01/26/20, revealed Resident #5 was at moderate risk for developing pressure ulcers. She was slightly limited with sensory perception, she was occasionally moist, she was bedfast, she was slightly limited with mobility, her nutrition was probably inadequate, and she had a potential for friction and shear. Review of the baseline care plan, dated 01/26/20, for revealed no indication Resident #5 was at risk for pressure ulcers, and the baseline care plan did not include any interventions to prevent pressure ulcers. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had impaired cognition and required extensive assist of two person with bed mobility and was totally dependent of two people with transfers. She was at risk for developing pressure ulcers but had no pressure ulcers on admission. Review of the nursing note dated 02/02/20 at 1:14 A.M. completed by Licensed Practical Nurse (LPN) #616 revealed Resident #5 had a fluid filled blister to her right heel. She revealed Resident #5 had difficulty elevating her heels due to resident rests on her side. There was no documentation of measurements of the area, or documentation the physician was contacted regarding treatment orders or any interventions implemented. Review of nursing notes and wound assessments dated 02/02/20 to [DATE] revealed no further documentation regarding notification to physician, interventions implemented, treatment ordered, or assessment of Resident #5's pressure injury to her right heel. Review of facility form labeled, Wound- Weekly Observation Tool- V3, dated [DATE], revealed Resident #5 had a deep tissue injury (a pressure-related injury to subcutaneous tissue under intact skin) to her right heel that measured three centimeters (cm) in length by 3.8 cm width, and the depth was unable to be determined. The wound was described as dark purple area with a blister in the center of wound. The assessment revealed the date the wound was acquired was on 02/02/20. The assessment revealed the Nurse Practitioner #615 was notified on [DATE] of the pressure injury, and a treatment to apply skin prep every night was obtained. Review of care plan dated [DATE] revealed Resident #5 had a pressure injury (deep tissue injury) located on her right heel due to pressure. This pressure ulcer was acquired at the facility per the care plan. Interventions included float heels using a heel manager, no shoes to the right foot, measure the pressure area weekly, and pressure injury treatment as ordered. Interview on 02/18/20 at 3:53 P.M. with Registered Nurse (RN)/ Wound Nurse #613 revealed the nurse had placed in a notebook that Resident #5 had a pressure injury to her right heel. She verified the wound was acquired on 02/02/20 but the wound was not measured, and the physician was not notified of the pressure ulcer until she assessed the wound on [DATE]. She revealed a treatment was not initiated for Resident #5 until [DATE] after she assessed Resident #5's wound. She verified this was a delay in treatment, and the nurse who found the pressure ulcer on Resident #5 should have assessed and documented measurements, contacted the physician to obtain treatment orders, and initiated treatment and interventions per physician recommendations timely. 2. Review of medical record for Resident #4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the facility form, Braden Scale for Predicting Pressure Sore Risk, dated 01/20/20, revealed Resident #4 was at moderate risk for developing pressure ulcers as he was slightly limited with sensory perception, he was very moist, he was chair fast, he was very limited with mobility, and he had a potential problem with friction and shear. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #4 had impaired cognition. He required extensive assistance of one staff with bed mobility and toileting and was totally dependent with two staff assist with transfers. He was at risk for pressure ulcers but had no pressure ulcers on admission. Review of the care plan dated 01/29/20 revealed Resident #4 was at increased risk for pressure injury related to impaired functional ability, [MEDICAL CONDITION] and incontinence. He was at moderate risk per the Braden scale. Interventions included: skin inspection once a week, turn and reposition every two hours, check skin daily and report any areas of discoloration, redness, excoriation, or open areas, and pressure reducing mattress. Review of the undated care plan revealed Resident #4 had an actual pressure injury of a stage two (partial-thickness skin loss) located on his coccyx due to pressure. He had left [MEDICAL CONDITION], impaired mobility and was non-ambulatory. The care plan revealed the pressure ulcer was facility acquired. Interventions included: limit the time he is sitting up in his chair and encourage frequent position changes, measure the pressure area weekly, air mattress, and turn and reposition every two hours. Review of the nursing notes and wound assessments dated 0[DATE] to 02/18/20 revealed no documentation of Resident #4's pressure ulcer that originated on 0[DATE]. Review of the nursing note dated 02/18/20 at 2:09 P.M. completed by RN/ Wound Nurse #613 revealed Resident #4 was examined on wound rounds for an open area on his coccyx that was facility acquired on 0[DATE]. The wound measured 0.4 cm in length by 0.4 cm in width by 0.2 cm depth. The wound was surrounded by a large field of scar tissue. Resident #4's guardian was notified on 02/18/20. Resident #4's Primary Care Physician #614 was also notified on 02/18/20 and ordered a low air loss mattress, wheelchair cushion, turn every two hours, and he ordered a treatment to cleanse with normal saline, apply wound gel and cover with [MED] daily. Review of facility form labeled, Wound-Weekly Observation Tool- V3, dated 02/18/20, completed by RN/ Wound Nurse #613 revealed Resident #4 had a pressure ulcer to his coccyx area that was acquired on 0[DATE]. The wound was a stage two that measured a 0.4 cm in length by 0.4 cm in width by 0.2 cm depth. RN/ Wound Nurse #613 contacted the physician on 02/18/20 and Resident #4's guardian was notified of his pressure ulcer. She obtained treatment orders and orders for low air loss mattress and wheelchair cushion. Review of physician's orders [REDACTED].#4 had an order dated 02/18/20 to cleanse his stage two pressure ulcer with normal saline, apply wound gel and [MED] daily. He also had a physician's orders [REDACTED]. Interview on 02/18/20 at 3:46 P.M. with RN/ Wound Nurse #613 revealed she worked one to three times a week. She revealed the nurse's documented any wounds that she should look at in a notebook. She verified the nurse had documented in a notebook on 0[DATE], which was not part of Resident #4's clinical record, that he had an open area that needed looked at. She verified that was why she put the date of Resident #4's facility acquired pressure ulcer as 0[DATE], but she was not able to evaluate the pressure ulcer until 02/18/20. She verified the nurse did not document in the clinical record any assessment of the wound to his coccyx, any notification to the physician of the wound, notification of Resident #4's guardian of the wound, and a treatment was not initiated or new interventions implemented when the wound was acquired on 0[DATE]. She verified Resident #4's wound was not assessed and documented until 02/18/20, the physician was not contacted until 02/18/20 when a treatment was ordered and initiated with new interventions per physician orders [REDACTED].#4's guardian was not notified until 02/18/20. She verified this was a delay in treatment. Interview with the Administrator and Director of Nursing on 0[DATE] at 2:27 P.M. verified Resident #5's deep tissue pressure ulcer to her right heel was originally found on 02/02/20, but the physician was not notified until [DATE], and a treatment was not ordered until [DATE] (two days later). They verified the nurse documented in a notebook that Resident #4 had a pressure ulcer to his coccyx area on 0[DATE]. They verified this was not part of Resident #4's clinical record as it was internal communication form to the wound nurse. They verified Resident #4's wound was not assessed and documented until 02/18/20 (five days later). They verified the physician was not notified until 02/18/20, and a treatment was not ordered until 02/18/20 as well as interventions were not implemented until 02/18/20. They verified this was a delay in treatment. Review of undated facility policy labeled, Notification of Changed Policy revealed it was the policy of the facility that changes in a resident's condition or treatment were immediately shared with the resident, resident representative, and the attending physician. The policy revealed the intent of the policy was to provide accurate and timely information relevant to a resident's condition who would make decisions about care, and treatment. Review of facility protocol labeled, Wound Treatment Protocol, dated 12/03/18, revealed the nurse was to ensure if they found a wound they were to measure the wound, document the wound, write an appropriate order, notify the family, notify the physician or nurse practitioner, document in the nursing notes and notify the wound nurse. This deficiency substantiates Complaint Number OH 998

Based on interview and record review, the facility failed to implement a baseline care plan that included interventions to prevent the development of pressure ulcers for Resident #5 who was moderate risk for the development of pressure ulcers at the time of admission. This affected one resident (Resident #5) of three residents reviewed for pressure ulcers. The facility census was 118. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the facility form labeled, Braden Scale for Predicting Pressure Sore Risk, dated 01/26/20, revealed Resident #5 was at moderate risk for pressure ulcers. She was slightly limited with sensory perception, she was occasionally moist, she was bedfast, she was slightly limited with mobility, her nutrition was probably inadequate, and she had a potential for friction and shear. Review of the baseline care plan, dated 01/26/20, for revealed no indication Resident #5 was at risk for pressure ulcers, and the baseline care plan did not include any interventions to prevent pressure ulcers. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had impaired cognition and required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. She was at risk for developing pressure ulcers but had no pressure ulcers on admission. Review of the nursing note dated 02/02/20 at 1:14 A.M. completed by Licensed Practical Nurse (LPN) #616 revealed Resident #5 had a fluid filled blister to her right heel. She revealed Resident #5 had difficulty elevating her heels due to the resident rests on her side. There was no documentation of measurements of the area, no documentation the physician was contacted regarding treatment orders or any interventions implemented. Review of the nursing notes and wound assessments dated 02/02/20 to [DATE] revealed no further documentation regarding notification to the physician, interventions implemented, treatment ordered, or assessment of Resident #5's pressure injury to her right heel. Review of the facility form labeled, Wound-weekly Observation Tool- V3, dated [DATE], revealed Resident #5 had a deep tissue injury (a pressure-related injury to subcutaneous tissue under intact skin) to her right heel that measured 3.0 centimeters (cm) in length by of 3.8 cm width, and the depth was unable to be determined. The wound was described as dark purple area with a blister in the center of wound. The assessment revealed the date the wound was acquired was on 02/02/20. The assessment revealed Nurse Practitioner #615 was notified on [DATE] of the pressure injury and a treatment to apply skin prep every night was obtained. Review of the care plan dated [DATE] revealed Resident #5 had a pressure injury (deep tissue injury) located on her right heel due to pressure. The pressure ulcer was acquired at the facility per the care plan. Interventions included: float heels using a heel manager, no shoes to the right foot, measure the pressure area weekly, and pressure injury treatment as ordered. Interview on 02/18/20 at 3:53 P.M. with Registered Nurse (RN)/ Wound Nurse #613 revealed the nurse had documented Resident #5 had a pressure injury to her right heel in a notebook used to communicate to the wound nurse. She verified the wound was acquired on 02/02/20, but the wound was not measured, and the physician was not notified until she assessed the wound on [DATE]. She verified the care plan prior to [DATE] did not include any preventative measures to prevent pressure ulcers despite Resident #5 being assessed as at moderate risk for the development of pressure ulcers. Interview with the Administrator and Director of Nursing on 0[DATE] at 2:27 P.M. verified Resident #5's baseline care plan did not include that she was at risk for developing pressure ulcers, and her baseline care plan did not include any interventions to prevent pressure ulcers. The Director of Nursing verified a care plan with interventions to prevent pressure ulcers or that Resident #5 was at risk for pressure ulcers was not devolved until after Resident #5 developed a pressure area. Review of facility policy labeled, Pressure Ulcer Risk Assessment, dated September 2014, revealed the purpose of the procedure was to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers. The facility was to routinely assess and document the condition of a resident's skin and immediately report any signs of developing a pressure ulcer. A risk assessment would be completed on admission and quarterly to determine risk of pressure ulcers and appropriate interventions would be implemented according to the risk score. This deficiency substantiates Complaint Number OH 998

Based on record review, review of a facility self reported incident (SRI) and interview, the facility failed to ensure one resident (Resident #125) was free of verbal abuse. Actual Harm occurred when State tested Nurse Aide (STNA) #50 verbally abused Resident #125 by directing foul language and threatening comments toward the resident. This affected one of three residents reviewed in facility self reported incident investigations. Findings include: Review of the closed medical record for Resident #125 revealed the resident's [DIAGNOSES REDACTED]. Hospice services were initiated for the resident on [DATE]. The resident expired at the facility on [DATE] at 8:40 P.M. Review of the investigation report dated [DATE] for a facility SRI involving Resident #125 revealed an allegation of verbal abuse was made on [DATE]. The investigation report indicated that a few months prior to the incident of [DATE], the responsible party for Resident #125 had placed a web camera in the resident's room so she could check on the resident since the responsible party was not able to visit the resident often. Facility staff were not aware the resident's responsible party had placed the camera in the resident's room. Based on a video recording in the camera, STNA #50 entered the room of Resident #125 on two separate occasions on Sunday [DATE] in the early hours of the morning. STNA #50 was verbally abusive toward Resident #125. STNA #50 directed the following foul language and threatening comments toward Resident #125: you need to shut the hell up; shut the f** up; if you think you are in pain now just wait. STNA #50 also called Resident #125 a lying (expletive) saying the resident was inconsiderate and selfish and only thinks of himself. Resident #125's responsible party brought the video recording to the attention of facility staff on [DATE]. Review of a statement from the Assistant Director of Nursing (ADON) dated [DATE] revealed the ADON spoke to the responsible party for Resident #125 on [DATE] at 7:30 A.M. concerning the camera which had been placed in the resident's room. The responsible party expressed concerns about STNA #50 who had worked the night shift on the previous Saturday. The responsible party indicated this STNA was on the video using foul and threatening language toward the resident. The responsible party was able to then share with the ADON a small portion of the video showing STNA #50 entering the resident's room. STNA #50 was seen questioning the resident about the resident's behavior of yelling out and STNA #50 told the resident he was going to get in trouble since he was already in trouble. The audio level on the video was very quiet and it was difficult for the ADON to hear it on the responsible party's phone. Review of a statement dated [DATE] from the responsible party for Resident #125 revealed the responsible party reported the details of the video concerning the incident of [DATE] involving Resident #125 and STNA #50 to the ADON on [DATE]. The responsible party showed the ADON a portion of the video related to the incident. The responsible party had placed the video camera in the resident's room without the knowledge or involvement of facility staff. The responsible party had saved the video of the incident. Review of a statement dated [DATE] from the Director of Nursing (DON) revealed the responsible party for Resident #125 had sent a copy of the video of the incident of [DATE] to the DON on [DATE]. The DON and other pertinent facility management staff viewed the video of the incident on [DATE]. At the conclusion of the investigation, the facility substantiated verbal abuse by STNA #50 toward Resident #125. STNA #50 was terminated. Interview with the Administrator and the ADON on [DATE] at 5:00 P.M. verified verbal abuse occurred toward Resident #125 by STNA #50 on [DATE]. This deficiency is an incidental finding discovered during the course of the complaint investigation.