Every finding on record at Forest Hills Center

Based on record review, interview, personnel file review, observation, and review of Quality Assurance and Performance Improvement (QAPI) documentation, the facility failed to implement and maintain an effective QAPI program by failing to identify, monitor, and implement effective corrective actions regarding deficiencies in the facility's activity program. The facility identified concerns related to activity programming and staffing through its QAPI process; however, residents continued to experience limited activity programming and the facility failed to ensure the individual directing the activity program met required qualifications. This had the potential to affect all 74 residents residing in the facility.Findings Included:Interview with the Administrator on 06/08/26 at 2:23 P.M. revealed the facility's QAPI committee routinely reviewed quality measures, resident concerns, staffing concerns, activity programming, employee retention, and operational issues affecting resident care. The Administrator stated activity programming and staffing concerns were areas currently being monitored through the facility's QAPI process.The Administrator stated concerns were identified through resident and family complaints, audits, quality measure data, staffing concerns, and trends identified by department managers. The Administrator further stated the facility evaluates the effectiveness of corrective actions through follow-up audits, review of quality measure data, monitoring of trends, resident and family feedback, and subsequent QAPI reviews.When informed of concerns identified during the current survey regarding activity programming and qualifications of activity staff, the Administrator stated the facility was aware of the concerns and reported they were currently working with certified activity personnel and obtaining additional assistance and support for the activity department.Review of personnel records revealed the individual functioning as Activities Director did not possess documentation demonstrating the qualifications required for the position.Observations conducted throughout the survey revealed residents on multiple units were frequently observed sitting in common areas with limited to no staff-facilitated engagement, individualized programming, one-to-one activities, or organized activity programming occurring despite activities scheduled on the facility calendar.Interview with Activities Director #192 revealed one-to-one activity visits were not being consistently documented, weekend activities were not being tracked, and resident-specific activity programming was not being completed consistently.Despite the facility's awareness of concerns involving activity programming and staffing through its QAPI process, observations, interviews, and record review revealed continued deficiencies related to resident activity services and qualifications of activity personnel. The facility failed to implement effective corrective actions to identify, monitor, and resolve the concerns. This deficiency represents non-compliance investigated under Complaint Numbers 2748921, 2739488, 2699816, and 2614048.

Based on personnel file review, facility record review, staff interviews, and facility policy review, the facility failed to ensure the activities program was directed by a qualified activities professional. This had the potential to affect all 74 residents residing in the facility. The facility census was 74. Findings include:Review of the facility Activity Director job description revealed the primary purpose of the position was to plan, organize, develop, direct, and implement the overall operation of the activity department to ensure an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of each resident. Continued review revealed the Activity Director must be a qualified therapeutic recreation specialist, a licensed activities professional, possess qualifying experience in a patient activities program, be a qualified occupational therapist or occupational therapy assistant, or have completed an approved training course. Review of the personnel file for Activity Director #192 revealed the there was no documentation present to support the staff met the qualifications required to direct the facility's activities program. Review of facility staff roster revealed the facility only had one activity staff, Activity Director #192. Interview with the Administrator on 06/01/26 at 3:40 P.M. revealed his expectation was for Certified Nursing Assistants (CNA's) to assist residents to and from activities and follow the activity calendar. When the Administrator was informed of surveyor observations of residents sitting in common areas with limited engagement, the Administrator stated staff should know better. When asked how the facility verified scheduled activities were occurring during evenings and weekends, the Administrator acknowledged, That is a good point. We don't have anything. Interview with the Activities Director #192 on 06/02/26 at 2:18 P.M. confirmed she was not currently certified to serve as a Activity Director and had not received formal training specific to the Activities Director position. Activities Director #192 also revealed after 3:00 P.M. and on Saturdays/Sundays, the facility CNAs/Aids are responsible for resident engagement; however, confirmed there is no current process to verify or prove these activities are completed. The Activities Director #192 stated activity programming ideas are sourced from the internet and the final activity calendar is reviewed and approved by the Administrator. Activities Director #192 confirmed one-to-one activity visits were not being documented as required, stating To be honest, those 1:1 documents haven't been documented like they should be. We have the residents identified, but the paperwork isn't there. When asked how weekend activities were tracked, Activity Director #192 stated, Activities are not being tracked on the weekend right now. It really just depends on which staff are on the floor and if they have time. It's not consistent. Interview with Human Resources Director (HRD) #210 on 06/02/26 at 2:33 P.M. revealed the facility did not provide formal activity-related training courses or modules for Activity Aides or CNA's responsible for resident engagement. HRD #210 further confirmed the facility had not employed a CNA since 04/07/26 and the position remained vacant. Review of the facility Activities policy dated 06/01/24 revealed the facility was expected to provide an ongoing program of activities based upon each resident's comprehensive assessment, care plan, interests, and preferences. The policy further indicated activities may be provided through group programming, individualized activities, and one-to-one programming designed to meet resident needs and preferences.This deficiency represents non-compliance investigated under Complaint Numbers 2739488, 2730063, 2994932, and 2748921.

Based on observations, staff and resident interviews and policy review, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affected 72 out of 72 residents who receive their meals from the kitchen, the facility identified two (#9 and #55) residents who do not eat food from the kitchen. The facility census was 74. Findings include:Observation on 06/03/26 at 12:03 P.M. revealed food temperatures for the regular texture chicken was 191.7 degrees Fahrenheit (F), regular texture vegetable was 196 degrees F, and regular sweet potato was 197 degrees F. Observation on 06/03/26 from 12:19 P.M. to 1:00 P.M. revealed during tray line facility had warming shells (tops and bases) to keep food warm. It was observed staff were using only one piece (either the top or the bottom but not both). The staff also ran out of trays and had to wait for several trays to be collected from the dining room and washed before being used for another resident for lunch service. Observation and interview 06/03/26 at 12:55 P.M. revealed test tray was plated. Temperatures on the steam table included chicken had a temperature of 138 degrees F, the vegetables had a temperature of 160 degrees F and the sweet potato had a temperature of 140 degrees F. Kitchen Manager #137 confirmed the temperatures. Kitchen Manager #137 reported facility did not have enough warming shells for all the residents so they used either the top or the bottom pieces. Observation and interview on 06/03/26 from 1:08 P.M. to 1:50 P.M. revealed the test tray left the kitchen at 1:08 P.M. and arrived to the unit at 1:13 P.M. Staff was observed passing out trays with the last tray passed out at 1:35 P.M. The test tray was tested had temperatures taken at 1:35 P.M. with results for the chicken with a temperature of 120 degrees F, the sweet potato with a temperature of 100 degrees F and the vegetables with a temperature of 80 degrees F. Kitchen Manager #137 confirmed food should be served at the holding temperature of 135 degrees F or higher and should be passed out timely upon reaching the unit. She acknowledged the food on the test tray was cold and acknowledged surveyor assessment it tasted cold. She confirmed she had asked for more warming shells a few times and it had not been approved due to budget constraints and she only had enough to cover food but did not have enough to use a top and bottom shell for all residents. She confirmed the food was also delayed due to running out of trays and having to collect some and do dishes so they could be used again for residents on the last hallway. Kitchen Manager #137 confirmed delays with tray pass and staff having to track down bedside tables as residents were taken to an area with tables. The facility confirmed there are 72 residents who receive their meals from the kitchen and there are two (#9 and #55) residents who do not eat food from the kitchen. Interview on 06/03/26 at 1:45 P.M. with Resident #68 reported his food was cold and gross and tasted like jail food. Review of the facility policy titled Test Tray and Point of Service Food Temperatures, dated 11/29/23 revealed food shall be served at a palatable, attractive and appetizing temperature. Food must be held at 135 degrees F and should be served with an internal temperature of 125 degrees for hot items and below 45 degrees F for cold items. This deficiency represents non-compliance investigated under Complaint Number 2739488.

Based on observations, staff interviews, and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. In addition, the facility failed to ensure hand hygiene was completed during meal service. This affected 72 residents who received meals from the facility kitchen. The facility identified two Residents (#9 and #55) who do not eat food from the kitchen. The facility census was 74.1. Observation on 06/01/26 from 9:33 A.M. to 9:50 A.M. revealed in the refrigerator a tub of applesauce and a tub of fruit was undated, shredded cheese was open and undated and four orange juice containers had no dates. In the freezer biscuits were uncovered and open to air. In the dry storage area were two dented cans of mandarin oranges and pears with significant dents at the seals, four bags of cheese sauce mix with no dates, a bag of penne noodles and two bags of rice were opened and undated, a cornbread mix and bread mix were opened and undated, a package of spaghetti noodles were opened, undated, and had significant debris from an opened food package above the spaghetti noodles, and a container of flour with a use by date of 10/08/25. Interview on 06/01/26 at 9:50 A.M. with Kitchen Manager #137 verified the food should be stored in a closed container and should be labeled and dated. She verified the above food items being stored in an unsanitary manner. Review of the policy titled Dating for Food Storage undated revealed items in the refrigerator should be labeled and dated. All items should be in air tight containers and not exposed.2. Observation on 06/03/26 at 12:10 P.M. revealed [NAME] #205 took food temperatures while wearing gloves. She took temperatures of the mashed potatoes and got mashed potato on her gloves. Without changing her gloves she took the temperature of the mechanical soft sweet potatoes and got sweet potato reside also on the gloves. Observation and interview on 06/03/26 at 12:40 P.M. revealed [NAME] #205 had sweet potato debris on her hands and made up an additional 10 plates of food. She verified her gloves were soiled and completed hand hygiene after surveyor intervention. Observation and interview on 06/03/26 at 1:05 P.M. Dietary Aide #163 had gloves on her hands when she touched the trash can lid that had food debris on it. Then with the same gloves on touched the food items of pudding and ice cream containers. Dietary Aide #163 verified she had not changed her gloves and preform hand hygiene after touching the soiled trashcan. Review of the policy titled Hand Hygiene, dated 10/01/22 revealed hands should be washed anytime they were visibly soiled and gloves should be changed and hands washed when gloves were soiled.

Based on observation, interview, record review, resident council review, personnel file review, and Quality Assurance and Performance Improvement (QAPI) review, the facility failed to effectively administer the facility by failing to ensure the activities program was directed by qualified personnel and failing to ensure residents received an activity program that addressed their assessed interests, preferences, and psychosocial well-being. In addition, the facility failed to implement effective corrective actions to achieve compliance after the facility's QAPI program identified concerns related to activity programming and staffing. This had the potential to affect all 74 residents residing in the facility. The facility census was 74.Findings Included:Review of the personnel file for Activity Director #192 failed to reveal documentation demonstrating the individual met the qualifications required to direct the facility's activities program. Further review revealed the facility had been without a Certified Activity Assistant since 04/07/26.Observations conducted throughout the survey revealed residents on multiple units were frequently observed sitting in common areas with limited to no staff-facilitated engagement, individualized activities, one-to-one programming, or organized activity programming occurring despite scheduled activities listed on the facility activity calendar. Interview with the Administrator on 06/01/26 at 3:40 P.M. revealed his expectation was for Certified Nursing Assistant (CNA)s to assist residents to and from activities and follow the activity calendar. When informed of surveyor observations of residents sitting in common areas with limited engagement, the Administrator stated staff should know better. When asked how the facility verified scheduled activities were occurring during evenings and weekends, the Administrator acknowledged, That is a good point. We don't have anything. Interview with Activities Director #192 on 06/02/26 at 2:18 P.M. revealed one-to-one activity visits were not being consistently documented, weekend activities were not being tracked, and resident-specific programs were not being completed consistently.A follow-up interview with the Administrator on 06/08/26 at 2:23 P.M. revealed the facility's QAPI committee routinely reviewed activity programming, staffing concerns, resident concerns, employee retention, and resident outcomes. The Administrator identified activity programming as an area currently being monitored through QAPI and stated the facility was aware of concerns involving the activity department. The Administrator further stated the facility was working with certified activity personnel and seeking additional support for the activity department to improve services provided to residents.This deficiency represents non-compliance investigated under Complaint Numbers 2699816 and 2614048.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to perform hand hygiene prior to exiting a residents room and touching a hallway door. This had the potential to affect all residents residing on the second hall (rooms 201 to 214). In addition, the facility failed to follow enhanced barrier precautions (EBP) during tube feeding care. This affected one (Resident #09) out of three residents reviewed for EBP. The facility census was 74. Findings Included: 1. Observation on 06/02/26 at 6:35 A.M. revealed the Certified Nursing Assistant (CNA) #223 exiting room [ROOM NUMBER] carrying soiled linens while wearing gloves. CNA #223 proceeded directly to the soiled linen room located on the 200 Hall. Prior to removing gloves or performing hand hygiene, CNA #223 was observed using the same gloved hand that had been handling the soiled linens to enter the keypad code and operate the door handle to the soiled linen room. Interview with CNA #223 on 06/02/26 at 6:37 A.M., verified the gloves worn while handling the soiled linens from room [ROOM NUMBER] were also used to enter the keypad code and touch the soiled linen room door handle. CNA #223 acknowledged no glove change or hand hygiene was performed prior to touching the environmental surfaces. 2. Review of the medical record revealed Resident #9 was admitted on [DATE]. Diagnoses included duodenal ulcer, dysphagia following cerebral infarction, and Type 2 Diabetes Mellitus. Review of the Resident #9's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was rarely/never understood and had a feeding tube. Observation of feeding tube change was completed between 8:13 A.M. and 8:36 A.M. on 06/04/26. Resident #9 was laying in bed in the resident's room. Registered Nurse (RN) #162 performed the changing of the feeding tube. Upon entering the residence room, RN #162 washed hands, but had not donned a gown prior to performing care. Interview with RN #162 about 8:36 A.M. on 06/04/26 verified a gown was not worn during tube feeding change. Review of the facility policy titled Enhanced Barrier Precautions (Revised 07/13/22) states that enhanced barrier precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. The policy defines device care of a feeding tube as a high-contact resident care activity.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure a dignified dining experience for all residents except those who eat in the dining room. Facility identified 27 Residents (#1, #4, #5, #6, #7, #8, #12, #27, #34, #37, #43, #44, #50, #54, #56, #58, #60, #61, #62, #64, #65, #66, #67, #71, #73, and #74) who eat in the dining room. Facility census was 74. Findings include: Observations on 06/01/26 at approximately 9:00 A.M. revealed residents who did not eat in the dining room were served their meal in the sitting nook on bedside tables that were pulled out from the rooms and/or stored in the corner of the sitting nook. Residents were not provided a stable table to sit at. Resident's food was left on the serving tray and the food covers were not removed for the resident's.Observations on 06/01/26 at approximately 12:45 P.M. revealed residents who did not eat in the dining room were served their meal in the sitting nook on bedside tables. Residents were not provided a stable table to sit at, and were eating their food off bedside tables. Resident food was also served on the serving tray and the food covers were not removed. Observations and interview on 06/03/26 at approximately 1:25 P.M. with Kitchen Manager #137 revealed residents who did not eat in the dining room were served their meal in the sitting nook on bedside tables. She confirmed this was not a dignified home like dining environment and revealed she was not sure why residents were not set up to eat at the tables on the unit or in the dining room. Kitchen Manager #137 also verified resident food was also served and left on the trays without having trays and food covers removed. Kitchen Manager #137 confirmed in the dining room resident have food uncovered and plates are placed on the table along with drinks and silverware. She reported she was unsure why staff did not removed the lids and trays but reported its probably a faster clean up for the staff.Review of facility policy titled Customer Service undated, revealed every resident deserves to be treated with respect and dignity at all times. This deficiency represents non-compliance investigated under Complaint Number 2699816

Based on observations, interview and facility policy review, the facility failed to maintain a home like environment by ensuring residents had maintained personal property/personal items This affected one resident (#26) of five reviewed for environment, the facility also failed to ensure the linen provided did not have holes in it this affected one resident (#50) of five reviewed for environment. Facility census was 74. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 01/05/24. Diagnoses included dementia without behaviors, psychotic disturbance, vascular dementia, dysphagia and pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition. Review of the plan of care dated 01/06/25 revealed resident needed encouragement to participate in activities of interest and preferred self-directed activities such as listening to music in his room. The care plan dated 05/01/25 revealed resident had behaviors of hoarding food in drawers. Review of the medical record found no mention of behaviors of removing pictures from his wall or information stating resident was not allowed to have access to his personal items. Observation and interview on 06/01/26 at 11:28 A.M. with Resident #26 revealed he had nothing on his walls but had several pictures on the floors. He stated he was not allowed to hang pictures due to it putting holes in the walls. He had a dresser that had two drawer face boards that were broken off and sitting on top of the dresser. No personal items were observed in the resident's room besides the pictures on the floor. Observation and interview on 06/01/26 at 11:30 A.M. with Certified Nursing Assistant (CNA) #213 confirmed Resident #26 had pictures on the floor as the resident pulled them down. She also reported resident broke the dresser drawer face boards. CNA #213 confirmed it was not easy to open the drawers with the face board broken off and stated maintenance would fix the dresser when able. Interview on 06/01/26 at 2:49 P.M. with Resident #26's representative revealed the resident's room was bare with no personal items put up. He confirmed the resident had a few pictures and also confirmed the resident had a radio but stated it was broken or missing. Interview on 06/03/26 at 8:20 A.M. with the Administrator confirmed the Resident would put his radio in his dresser drawer and he was asked to return the radio to the family. The Administrator showed the radio to the survey team and confirmed it had been in his office for several months. He confirmed the family visits frequently and confirmed he had not returned the radio during any of these visits and had no explanation why he kept the radio in his office and why he had not returned Resident #26's personal belongings to the family. He confirmed staff do not have full access to his office to get the radio if resident had requested it. Review of facility policy titled Resident Rights dated 06/01/24 revealed the facility shall inform the resident of their rights and ensure direct care and indirect care staff were educated on resident rights. Review of facility policy titled Safe and Homelike Environment dated 06/01/24 revealed facility shall provide a safe clean and homelike environment allowing resident to use personal belongings to the extent possible. The facility shall create and maintain a homelike environment that deemphasizes the institutional setting including allowing residents to use their personal belongings. 2.Review of medical record for Resident #50 revealed an admission date of 04/24/26 with diagnoses including unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Type II Diabetes Mellitus. Observation on 06/02/26 at 8:46 A.M. and 3:01 P.M. revealed Resident #50's bed spread with several holes covering her bed. Interview on 06/01/26 at 3:01 P.M. with Certified Nursing Assistant (CNA) #193 verified the several holes in the blanket and it was not appropriate. Interview on 06/04/26 at 2:35 P.M. with Director of Maintenance #152 revealed if the laundry staff have linens with holes in them, they put them in a pile, and he uses them as rags, but the facility had purchased blankets recently. Review of purchasing invoices dated 03/31/26, 04/02/26, and 04/14/26 provided by the facility revealed no blankets had been ordered and verified by the Director of Maintenance #152. Review of facility policy titled Resident Environmental Quality revised 11/29/22, revealed it is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. This violation represents non-compliance investigated under Complaint 2574479, 2584875, and 2739488.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests, preferences, and psychosocial needs of residents. This affected four residents (#5, #28, #35, and #54) of four residents reviewed for activities. The facility census was 74. 1. Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, weakness, difficulty walking, unsteadiness on feet, and right hip fracture. Review of the quarterly Care Conference Summary dated 01/22/26 revealed Resident #35 enjoyed socializing within the unit, watching television, and attending movie and popcorn activities. The review further documented the resident generally refused daily group activities but tolerated one-to-one activities. Review of the Activities Quarterly/Annual Participation Review dated 02/25/26 revealed Resident #35 preferred one-to-one visits or in-unit activities with occasional group activities. The assessment documented the resident preferred low-stimulation activities due to decreased energy levels, enjoyed visual entertainment, movie events with popcorn, and select social gatherings when able. Review of activity documentation revealed extremely limited evidence that one-to-one visits, individualized activities, or in-unit programming were provided to Resident #35 consistent with the resident's assessed preferences. Observation of the 100 Hall on 06/01/26 at 9:00 A.M., 10:45 A.M., 12:15 P.M., 1:50 P.M., and 3:35 P.M. revealed residents, including Resident #35, were either seated in the common area or remained in their rooms. During each observation, residents were observed listening to music or sitting quietly. No organized activities, individualized programming, one-to-one visits, or staff-facilitated engagement were observed. Observation of the facility on 06/01/26 from 3:12 P.M. until 3:30 P.M. revealed residents on the 100 Hall were seated in the common area with a television on. No organized activity, staff-facilitated engagement, or individualized activity programming was observed. Residents appeared to be sitting quietly with minimal interaction noted. Review of the facility activity calendar revealed Oldies Music with Karaoke was scheduled during the observation period. At approximately 3:25 P.M., CNA #163 stated, I'm not in activities and I'm the only one on the floor right now. Interview with Activities Director #192 on 06/02/26 at 2:18 P.M. revealed one-to-one activities had not been documented as required. Activities Director #196 stated, To be honest, those 1:1 documents haven't been documented like they should be. We have the residents identified, but the paperwork isn't there. Activities Director #196 further stated activities were not being tracked on weekends and acknowledged resident-specific programs were not being completed consistently. Interview with the Administrator on 06/01/26 at 3:40 P.M. revealed his expectation was for CNAs to assist residents to and from scheduled activities. When informed of surveyor observations of residents sitting in common areas with limited to no staff-facilitated engagement or structured activity programming occurring throughout the survey, the Administrator stated staff should know better. When asked how the facility verified scheduled activities were occurring during evenings and weekends, the Administrator acknowledged, That is a good point. We don't have anything. 2. Review of Resident #54's medical record revealed an admission date of 03/15/24 with diagnoses including senile degeneration of the brain, schizoaffective disorder bipolar type, dysphagia, congestive heart failure, chronic kidney disease, Type 2 diabetes mellitus with hyperglycemia, and hypertension. Review of the Activities Quarterly/Annual Participation Review dated 04/27/26 revealed Resident #54 attended activities of choice in the activity room or on the unit. The assessment further documented Resident #54 enjoyed socializing with other residents, live music, and painting. The assessment indicated activity-related goals were being met and interventions were effective. Observation of the 100 Hall on 06/01/26 at 9:00 A.M., 10:45 A.M., 12:15 P.M., 1:50 P.M., and 3:35 P.M. revealed residents were either seated in the common area or remained in their rooms. Residents were observed listening to music or sitting quietly. No organized activities, painting activities, social activities, individualized programming, or staff-facilitated engagement were observed. Observation of the facility on 06/01/26 from 3:12 P.M. until 3:30 P.M. revealed residents on the 100 Hall were seated in the common area with a television on. No organized activity, staff-facilitated engagement, or individualized activity programming was observed. Residents appeared to be sitting quietly with minimal interaction noted. Interview with Activities Director #192 on 06/02/26 at 2:18 P.M. revealed one-to-one activities had not been documented as required and activities were not being tracked on weekends. Activities Director #192 further acknowledged resident-specific activity programs were not consistently occurring. Interview with the Administrator on 06/01/26 at 3:40 P.M. revealed his expectation was for residents to be assisted to activities and for scheduled activities to occur. When informed of surveyor observations showing limited resident engagement and no structured activity programming, the Administrator stated staff should know better. The Administrator further acknowledged the facility did not have a method to verify scheduled activities were occurring during evenings and weekends. 3.Review of Resident #28's medical record revealed an admission date of 04/26/24 with diagnosis including fracture of fourth thoracic vertebra, dementia, adjustment disorder with mixed disturbance of emotions and conduct, insomnia, and Alzheimer's disease. Review of the activities assessment dated [DATE] revealed Resident #28 prefers to do activities on the unit, resident enjoys watching tv on the unit. Review of the activities assessment dated [DATE] revealed Resident #28 enjoys in unit socialization with an occasional group led activity, enjoys watching classic movies with his peers on unit. He also enjoys when we have live music and social events. Resident #28 also enjoys walking outside when weather permitted. Review of most recent Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #28 with severe cognitive impairment. Review of the significant change MDS dated [DATE] revealed Resident #28 likes to be around animals, likes to do favorite activities, enjoys going outside to get fresh air when the weather is good, listens to music, and to do favorite activities. Observations made on 06/01/26 at 11:30 A.M. and 3:00 P.M.; and 06/02/26 at 10:00 A.M. and 2:00 P.M. revealed Resident #28 laying in his bed and no independent preferred or group activities provided. Interview on 06/02/26 at 2:18 P.M. with the Activities Director #192 revealed 1-on-1 activities for residents with high-acuity needs or cognitive impairments she performs 1-on-1 visits but acknowledged these are not documented, noting she was unaware of the requirement to document these interactions until recently. Reviewed activity documentation for Resident #28 from January 2026 through June 2026 revealed 1-on-1 activities ranging from walking on unit, listening to music, folding laundry, coloring, playing ball toss and reading. 1-on1 activities being provided eight times a month. Interview on 06/03/26 at 3:38 P.M. with Certified Nursing Assistant (CNA) #136 revealed she does not do activities with residents. The activity department does the activities. She knows what activities they are having by the calendar on the wall. Interview on 06/03/26 at 3:41 P.M. with CNA # 213 revealed she does assist with the activities in the evenings. The residents watch tv and play music. Interview on 06/03/26 at 3:43 P.M. with Licensed Practical Nurse (LPN) #182 revealed she does a lot of activities with the residents. She plays music and dances with them. Interview on 06/04/26 at 10:03 A.M. with Activities Director #192 stated she provided the documentation she had for activities. No other documentation to indicate Resident #28 was provided activities per preference. 4. Review of Resident #5's medical record revealed an admission date of 08/10/22 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, unspecified mood (affective) disorder, pre-excitation syndrome, difficulty in walking ad muscle weakness. Review of activities care plan last revised 11/23/25 revealed Resident #5 needs encouragement to participate in activities of interest, is dependent on staff for activities, cognitive stimulation, social interaction due to cognitive impairment. He enjoys physical activities such as bowling, ball toss, basketball, parties and social events, morning coffee socials and walking on the unit and socializing with his peers. Interventions included arrange for activity aide to visit and encourage resident to observe or designate activity, assist/escort to activities of choice that reflect prior interests and desired activity level, encourage resident to participate in group activities and engage resident in group activities. Review of activities progress notes from March 2026 through June 2026 revealed five documented group activities Resident #5 participated in. Review of one-on-one activity documentation from January 2026 through June 2026 revealed eight one-on-one sessions a month provided by activities. Review of the most recent activities quarterly assessment dated [DATE] revealed Resident #5 prefers group activities and social events, physical sports, coffee socials and other party settings. Interview on 06/02/26 at 2:18 P.M. with the Activities Director #192 revealed 1-on-1 activities for residents with high-acuity needs or cognitive impairments she performs 1-on-1 visits but acknowledged these are not documented, noting she was unaware of the requirement to document these interactions until recently. Interview on 06/03/26 at 3:38 P.M. with Certified Nursing Assistant (CNA) #136 revealed she does not do activities with residents. The activity department does the activities. She knows what activities they are having by the calendar on the wall. Interview on 06/03/26 at 3:41 P.M. with CNA # 213 revealed she does assist with the activities in the evenings. The residents watch tv and play music. Interview on 06/03/26 at 3:43 P.M. with Licensed Practical Nurse (LPN) #182 revealed she does a lot of activities with the residents. She plays music and dances with them. Interview on 06/04/26 at 10:03 A.M. with Activities Director #192 stated she provided the documentation she had for activities. No other documentation to indicate Resident #5 was provided activities per preference. Review of the facility policy titled Activities, revised 06/01/24 revealed it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. This deficiency represents non-compliance investigated under Complaint Number 2739488.

Based on observations, staff interviews and policy review, facility failed to ensure furniture was maintained in a safe manner. This affected 25 Residents (#4, #7, #9, #12, #16, #18, #19, #23, #26, #30, #31, #36, #42, #45, #47, #49, #61, #62, #64, #66, #68, #69, #70, #72, and #75) living in the third hall. Facility census was 74. Findings include: Observation and interview on 06/01/26 at 10:20 A.M. and 11:28 A.M. revealed the third hall nook had a variety of chairs and couches sitting against the wall. A chair had damage on the arm with the wood framing exposed that was rough. A couch was also damaged with torn/peeling fabric. Interview and observation on 06/03/26 at 1:50 P.M. confirmed the chair in the third hall nook was damaged with exposed wood and a couch in the third hall nook had torn fabric. The Registered Nurse (RN) #199 confirmed residents pick at the furniture and caused the ripped material. She confirmed residents were sitting in the damaged chair and couch and could not remember for how long they had been damaged. Review of facility policy titled Resident Environmental Quality dated 11/29/22 revealed facility shall constructed and maintained to provide a safe functional and sanitary environment for residents. All personnel were responsible for reporting broken equipment. 2.Review of the medical record for Resident #55 revealed an admission date of 10/30/12 with diagnoses including neurocognitive disorder with Lewy Bodies, aphasia, contracture, unspecified joint, adult failure to thrive, muscle wasting and atrophy, unspecified site, and unspecified psychosis not due to a substance or known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) could not be conducted. Interview on 06/01/26 at 3:01 P.M. with Certified Nursing Assistant (CNA) #193 verified the missing baseboard to wall behind the bed was not intact and hanging hallway off. Review of purchasing invoices dated 03/31/26, 04/02/26, and 04/14/26 provided by the facility revealed no blankets have been ordered and verified by the Director of Maintenance #152. Review of facility policy titled Resident Environmental Quality revised 11/29/22, revealed it is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. This deficiency represents non-compliance investigated under Complaint Numbers 2748921, 2739488, and 2584875.

Based on medical record review and interview, the facility failed to ensure assessments were accurately completed. This affected one (Resident #55) of one resident reviewed for range of motion. The facility census was 74.Findings include:Review of the medical record for Resident #55 revealed an admission date of 10/30/12. Diagnoses included neurocognitive disorder with Lewy Bodies, aphasia, contracture, unspecified joint, adult failure to thrive, muscle wasting and atrophy, unspecified site, and unspecified psychosis not due to a substance or known physiological condition.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) could not be conducted, the resident was dependent for all care, and Section GG indicated Resident #55 had no impairments to upper or lower extremities.Review of Resident #55's physicians orders dated 09/22/25 revealed an order to place two rolled washcloths in bilateral hands at all times while at rest.Review of the Activities of Daily Living (ADL) care plan last revised 10/30/20 revealed Resident #55 had self-care deficits, requires total assistance with ADL's and is non-ambulatory. Interventions included rolled washcloths to both hands as ordered.Interview on 06/04/26 at 12:59 P.M., with the MDS Coordinator #229 verified the quarterly MDS dated [DATE] was coded incorrectly for upper and lower extremities impairments.

Based on record review, staff interview and policy review, the facility failed to complete a thorough investigation of injuries of unknown origin. This affected two residents (#20 and #83) of two reviewed for abuse investigations. Facility census was 74. Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 04/10/26. Diagnoses included displaced fracture of lateral left fibula, right femur fracture, wedge compression fracture, dementia without behaviors, kidney disease, muscle weakness, and osteoporosis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of six indicating impaired cognition and required partial moderate assistance with activities of daily living.Review progress notes dated 04/14/26 revealed during morning rounds resident was observed to be lying in bed holding her right leg and yelling in pain. The resident was unable to state if she had fallen and a stat X-ray was ordered. The X-ray later resulted and identified a fracture of the neck of the right femur and the resident was sent to the hospital for further treatment. Review of the Self-Reported Incident (SRI) investigation number 273302 revealed staff became aware of the incident on 04/14/26 and informed the Administrator on 04/14/26 around 2:00 P.M. The resident had pain in the right leg that was found to be a femur fracture without a known cause. The investigation reviewed the injury of unknown origin and revealed the resident had recently sustained a fracture of the humorous at the previous facility and a fractured finger while at the hospital. The investigation stated facility shall do a look back of staff from the past 72 hours. The schedule revealed within the past 72 hours, Registered Nurses (RN) #127 and #199, Licensed Practical Nurses (LPN) #117, #133, #143, and Certified Nursing Aides (CNA) #106, #138, #142, #154, #169, #173, #213, #217, #223, and #225 had worked on Resident #20's hall. Review of staff interviews revealed LPN #133 and #143 and CNA #138 and #169 were interviewed by management but no statements were provided. LPN #117 and CNA #154 and #225 were contacted with no return calls made and no statements provided. RN #127 and #199, and CNA #106, #142, #173, #213, #217, and #223 were not interviewed or attempted to be interviewed and no statements were provided. The investigation also did not include staff education and did not include review or interviews with like residents. Interview on 06/03/26 at 8:35 A.M. with the Administrator confirmed several staff members were contacted but did not return their call to provide a statement and several staff were not interviewed. He also confirmed the file had no evidence of staff education and no mention of like residents having interviews or skin checks.2. Review of the medical record for Resident #83 revealed an admission date of 08/30/24 and discharge date on 03/30/26. Diagnoses included Alzheimer's disease, vascular dementia, and mood disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition Resident #83 required substantial maximum assistance with activities of daily living.Review progress notes dated 03/23/26 revealed staff found a discoloration to the right buttocks with outer edges yellow and center was purple. Resident was guarding his hip. An X-ray was completed and found no fracture or dislocation. Review of the Self-Reported Incident (SRI) investigation number 272461 revealed staff became aware of the incident on 03/23/26 around 2:00 P.M. The resident had a large bruise of unknown source. The investigation revealed the injury of unknown origin investigation did not state which staff reported the incident and what hall the resident resided on. The statements obtained came from staff working various halls according to review of the staff schedules. Interviews and statements were conducted with LPN #171 and CNA #190 and #214. Additional staff working from 03/22/26 to 03/23/26 included RN #116 and #162, LPN #105, #115, #133, #198, and #300, and CNA's #126, #131, #142, #154, #159, #163, #193, #204, #208, #213, #225, #305, #310. The investigation found no evidence of staff training of abuse and no evidence of an assessment being completed for Resident #83.Interview with the Administrator on 06/03/26 at 8:35 A.M. confirmed the injury of unknown origin was reported to him about 24 hours after it was found and then he reported it and began the investigation. Review of facility policy titled Abuse, Neglect and Exploitation dated 01/01/24 revealed facility shall investigate suspicion of abuse or neglect including interviewing all persons including the alleged victim, perpetrator any possible witnesses. Facility shall also complete thorough documentation of the investigation. This deficiency represents non-compliance investigated under Complaint Number 2994932 and Complaint Number 2739488.

Based on medical record review, review of hospital records, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman regarding a hospitalization and transfer for one resident (Resident #35) and failed to assist one resident (Resident #8) with discharge planning services. This affected two residents (#35 and #8) of three residents reviewed for discharge planning. The facility census was 74. Findings Include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, and right hip fracture. Review of hospital records revealed Resident #35 was transferred to the hospital on [DATE] following a fall on 05/12/26 which resulted in right hip pain. Continued review revealed Resident #35 was diagnosed with a right femur fracture and underwent a right hip hemiarthroplasty on 05/14/26. The resident returned to the facility on [DATE] following hospitalization and surgical repair. Review of the facility documentation dated 05/21/26 revealed Resident #35 returned to the facility with post-operative care needs including pain management, wound care, physical therapy, occupational therapy services, and fall precautions. Documentation further revealed the resident required substantial to maximal assistance with activities of daily living following the hospitalization. Interview with the Director of Nursing (DON) on 06/04/26 revealed the requested documentation related to care conferences and transfer documentation for Resident #35 was not available. The DON verified no documentation was available demonstrating the Office of the State Long-Term Care Ombudsman had been notified regarding Resident #35's hospitalization and transfer. Interview with Social Services Director #181 on 06/05/26 at 10:36 A.M. Social Services Director #181 stated the Ombudsman was not notified of Resident #35's hospitalization because she was unaware such notification was required. Social Services Director #181 further stated the facility had discussed the issue and was creating a tracking log to ensure future Ombudsman notifications were completed. Social Services Director #181 was unable to provide documentation demonstrating the Ombudsman had been notified regarding Resident #35's hospitalization and transfer. No documentation was provided prior to survey exit to support notification occurred. 2. Review of Resident # 08's medical record revealed an admission date of 10/28/21. Diagnoses included Alzheimer's disease, dementia, mood affective disorder and multiple sclerosis. Review of Resident # 08's Minimum Data Set 3.0 (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required total assistance from staff with incontinence care, transfers and mobility. Interview on 06/04/26 with Resident #08's power of attorney (POA) revealed in November 2025 she requested the facility initiate transfer to a different facility. She stated the facility had not followed up with getting needed information or regarding status of the transfer from the requested facility. Interview on 06/04/26 at 9:25 A.M. with the Social Services Director #181 revealed the process for transferring a resident to another facility is once the request was received from family, the facility sends all the required information, logs it in the transfers log and notifies the Ombudsman's office. She stated the facility follows up with the transfer request for any additional information they may need and the status of the transfer. Interview on 06/04/26 at 9:28 A.M. with the Administrator verified there was a request for transfer in November 2025, and he stated he sent the requested information; however, he had not followed up on the status and had no documentation of sending requested documents or communication with the transfer facility. The Administrator verified the facility was responsible for coordinating the transfer and following up with the transfer request and he had no evidence it was completed for Resident #08. This deficiency represents non-compliance investigated under Complaint Number 2667090.

Based on record review and interview, the facility failed to establish and implement an admission policy. This affected one resident (# 81) of one resident investigated for admission policy. This had the potential to affect all facility residents. The facility census was 74. Findings include: Resident #81 was admitted [DATE] and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disorder (COPD), and chronic kidney disease. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #81 had severe cognitive impairment. Review of the medical record for Resident #81 found a statement that the Resident did not have an attending physician due to refusal to consent for treatment. Interview was conducted with the Administrator between 2:32 P.M. and 3:00 P.M. on 06/02/26. The Administrator confirmed that Resident #81 did not have a completed admission agreement or consent to treat for the entire stay at the facility. Interview was conducted with the Administrator at 10:54 A.M. on 06/03/26. The Administrator was requested to provide the facility's admission policy. Interview with the Director of Nursing (DON) was conducted between 1:40 P.M. and 1:48 P.M. on 06/04/26. DON confirmed Resident #81's medical record documented the Resident did not have an attending physician due to refusal to consent for treatment. Interview was conducted with the Administrator at 9:32 A.M. on 06/04/26 and confirmed an admission policy could not be found. A document titled Referral admission Checklist was provided and the Administrator indicated this was the process followed for admission.

Based on record review, interview, and facility policy review, the facility failed to ensure choice was offered for hospice services provider. This affected one resident, (#2) of one residents reviewed for hospice. The facility census was 74.Findings include: Review of the medical record for Resident #2 revealed an admission date of 07/20/18 with diagnoses including dementia with other behavioral disturbance, Diabetes Mellitus due to underlying condition with diabetic autonomic neuropathy, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, severe with psychotic symptoms and chronic kidney disease stage V. Review of physician orders for Resident #2 revealed an order dated 04/02/26 to admit to Hospice #333 for end stage renal disease. Review of the care plan dated 04/02/26 revealed resident/family has elected hospice care. Admit to Hospice #333 for diagnosis of end stage renal stage. Interventions included all resident/family wishes will be maintained in the clinical record and reviewed on a quarterly and as needed basis to ensure that all wishes are still relevant, encourage activities of choice and coordinate plan of care with resident, family and hospice staff. Review of the Hospice #333 consent form revealed it was signed by Resident #2's Guardian on 03/31/26. An Interview with the Guardian of Resident #2 on 06/01/26 at 4:00 P.M. via telephone revealed they were not offered a choice of hospice providers when hospice services were initiated for Resident #2. The Guardian reported they were simply informed that Resident #2 was being placed on hospice services through a specific hospice agency and were not provided with information regarding alternative hospice providers or given the opportunity to select a hospice agency of their choosing. Subsequent record review for Resident #2 revealed a hospital Discharge summary dated [DATE], which stated the family was initially interested involving hospice but at time of discharge informed hospital they were not ready to transition to hospice at discharge and will consider it at a later time. Interview on 06/03/26 at 4:45 P.M. with the Director of Nursing (DON) verified the facility had no evidence of documentation of any hospice provider choice being offered or conversations regarding which hospice provider the the guardina would like Resident #2 to be referred to. Interview on 06/04/26 at 10:00 A.M. with Director of Social Services #181 revealed she discussed hospice services with Resident #2's family through a care conference. The care conference sign-in sheet provided was dated 04/23/26 after Resident #2 was admitted to hospice. Director of Social Services #181 verified she had no further evidence that a hospice provider of choice was offered for Resident #2. Review of the facility policy titled, Hospice Services Facility Agreement, revised October 2022, revealed it is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility.

Based on interview and record review, the facility failed to provide spend down notices when resident's personal funds account reached $200 less than the Social Security Insurance resource limit. This affected two residents, (Resident #26 and Resident #47) of five residents reviewed for personal funds. The facility census was 74. Findings include: 1.Resident #26 was admitted [DATE] and had diagnoses that included dementia, psychotic disturbance, and major depressive disorder. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was unable to complete an interview to assess mental status. Review of the facility's quarterly statement of resident funds for Resident #26 indicated an ending balance of $4234.16 on 03/31/26. Review of the spend down notice for Resident #26 dated 04/23/26 revealed the Resident Fund balance was within $200 or was exceeding what is allowable under Medical Assistance. Interview with Business Office Manager (BOM) #216 on 06/02/26 at approximately 1:58 P.M. confirmed the spend down limit for Medicaid residents in Ohio was $2000. Interview with BOM # 216 on 06/03/26 at approximately 3:16 P.M. confirmed that last documented spend down notice provided by the facility to Resident #26 was in April 2026. 2.Resident #47 was admitted [DATE] and had diagnoses that included dementia, psychotic disturbance, and chronic kidney disease. Review of Resident #47's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was unable to complete an interview to assess mental status. Review of the facility's quarterly statement of resident funds for Resident #47 indicated an ending balance of $5162.44 on 03/31/26. Review of the spend down notice for Resident #47 dated 04/23/26 revealed the Resident Fund balance was within $200 or was exceeding what is allowable under Medical Assistance. Facility record review documented that both Resident #26 and Resident #47 had Ohio Medicaid as their primary payer of healthcare service. Review of the trial balance of funds handled by the facility for residents revealed Resident # 26 and Resident #47 had balances in excess of $4,500. Interview with Business Office Manager (BOM) #216 on 06/02/26 at approximately 1:58 P.M. confirmed the spend down limit for Medicaid residents in Ohio was $2000. Interview with BOM # 216 on 06/03/26 at approximately 3:16 P.M. confirmed that last documented spend down notice provided by the facility to Resident #47 was in April 2026. This violation represents non-compliance investigated under Complaint 2579178.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure the Physician and family were notified of a change in condition. This affected oneresident, (#36) of one reviewed for change in condition. The facility census was 74. Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating resident was rarely if ever understood. The MDS stated Resident was dependent with most activities of daily living and required moderate to maximum assistance for mobility. Review of the plan of care dated 04/04/26 revealed resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included to communicate with staff, family, physician and the resident regarding the resident's needs and obtain input from family and friends.Review of physician orders dated 04/24/26 for Amlodipine Besylate (used to treat high blood pressure) oral tablet 10mg to give once daily, Aspirin (analgesic) oral tablet 81 mg delayed release give once daily, Cholecalciferol (vitamin) oral capsule 25 micrograms (mcg) give once daily, Cyanocobalamin (vitamin) oral tablet 500 mcg daily, Memantine (used for dementia) oral tablet 10mg give once daily, Quetiapine (antipsychotic) 25mg give 0.5mg tablet once daily, Divaproex Sodium (anticonvulsant) oral capsule 125 mg delayed release sprinkle give four capsules twice daily all of the prior listed medication were scheduled to be given at 7:00A.M. Resident # 36 also had physician orders dated 04/23/26 for Fluticasone-Salmeterol 250-50mcg aerosol powder give one puff twice daily, Pantoprazole Sodium (proton pump inhibitor) 40 mg oral tablet delayed release give one twice daily, both scheduled at 7:00A.M. and Sucralfate (antiulcer medication) 1 gram (GM) give four times daily an scheduled at 9:00 A.M. and 1:00P.M. Review of physician orders dated 05/29/26 for nicotine transdermal patch 24 hour 14MG/24hr transdermal patch once daily and scheduled for 7:00 A.M.Review of the medical record revealed Resident #36 had not been administered morning medications on 06/04/26. Review of progress notes as of 06/04/26 at 1:29 P.M. revealed no mention of any change in condition, notification to residents family or the physician or Director of Nursing and no indication or documentation that resident was not given any morning medications or had nausea or vomiting. Progress notes did not indicate any mention of care conferences or planning for the care conferences. Interview on 06/04/26 at 12:50 P.M. with Registered Nurse (RN) #162 confirmed Resident #36 had not received any of his morning medications. RN reported he had been ill earlier in the morning and had vomited on the floor. He reported he did not give resident any of his morning medications due to his illness. The RN confirmed he had not informed the family or the Physician of Resident #36's condition and reported he was waiting for the Physician to come onsite to inform them and see what the plan should be. He reported resident had vomited around 8:30 A.M. to 9:00 A.M. and acknowledged it was almost 1:00:P.M. in the afternoon and the resident had afternoon medications coming due. The RN also confirmed he did not complete any assessment (including vital signs) on Resident #36 as he was resting and acknowledged he had not documented anything related to the resident's condition or a reasoning of why Resident #36 missed his morning medication. Interview on 06/04/26 at 1:20 P.M. with the Director of Nursing confirmed her expectation would be with any condition change the Physician or Nurse Practitioner and family to be notified immediately. She confirmed this would include if resident had nausea and vomiting and missed all morning medications. At 2:40 P.M. the DON confirmed after surveyor intervention, she spoke with the medical team and they had been notified and resident had been assessed. Review of facility policy titled Notification of Changes dated 01/01/25 revealed the facility shall promptly inform the physician and residents family for any changes in condition. This deficiency represents non-compliance investigated under Complaint Number 2739488.

Based on record review and staff interview, the facility failed to provide accurate Notices of Medicare Non-Coverage (NOMNC) for two residents, (#20 and #36) of four reviewed for Medicare beneficiary notices. The facility census was 74.Findings include:1.Review of the medical record for Resident #20 revealed an admission date of 04/10/26. Diagnoses included displaced fracture of lateral left fibula, right femur fracture, wedge compression fracture, dementia without behaviors, kidney disease, muscle weakness, and osteoporosis. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 6 indicating impaired cognition and required partial moderate assistance with activities of daily living.Review of Resident #20's Notice of Medicare Non-Coverage (NOMNC) revealed the notice failed to identify the specific services being discontinued, the potential financial liability should the resident appeal the determination, and the method by which the notice was communicated to the resident representative.Interview with the Social Services Director #181 on 06/08/26 at 1:46 P.M. revealed that when a NOMNC is issued, facility staff review the notice with the resident representative either in person or by telephone. The Social Services Director confirmed the facility does not complete sections of the notice identifying the specific services being discontinued, the potential financial liability should the resident appeal the determination, or the method used to communicate the notice to the resident representative.2.Review of the medical record for Resident #36 revealed an admission date of 04/22/26. Diagnoses included metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive and edema. Review of Resident #36's the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating resident was rarely if ever understood. The MDS stated Resident was dependent with most activities of daily living and required moderate to maximum assistance for mobility. Review of Resident #36's Notice of Medicare Non-Coverage (NOMNC) revealed the notice failed to identify the specific services being discontinued, the potential financial liability should the resident appeal the determination, and the method by which the notice was communicated to the resident representative.Interview with the Social Services Director #181 on 06/08/26 at 1:46 P.M. revealed that when a NOMNC is issued, facility staff review the notice with the resident representative either in person or by telephone. The Social Services Director confirmed the facility does not complete sections of the notice identifying the specific services being discontinued, the potential financial liability should the resident appeal the determination, or the method used to communicate the notice to the resident representative.

Based on staff interview and medical record review the facility failed to ensure indications for use were appropriate for psychotropic medications for two residents, (#49 and #75) and the facility failed to ensure two residents (#2 and #49) were monitored for psychotropic medication side effects. This affected three out of five residents sampled for unnecessary medications. The facility census was 74.Findings include: 1. Review of Resident # 49's medical record revealed an admission date of 06/21/23 with diagnoses that included but were not limited to dementia, anxiety disorder, mood affect disorder, pseudobulbar affect, psychosis, and frontotemporal neurocognitive disorder. Review of Resident # 49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required total assistance from staff with toileting, transfers and hygiene. Further review revealed she received antipsychotics, antianxiety and antidepressant medications with indications for use noted. Review of Resident # 49's active clinical physicians orders for June 2026 revealed the following orders: Order dated 04/24/26 for Seroquel (antipsychotic) Oral Tablet 25 milligrams (mg); give one tablet by mouth every eight hours for agitation.Order dated 05/22/26 for Seroquel Oral Tablet 25 mg; give 25 mg by mouth at bedtime for mood.Order dated 06/05/26 for Depakote (anticonvulsant) Oral Tablet Delayed Release 125 milligram (mg); give three tablets by mouth at bedtime for depression with psychotic features.Order dated 06/05/26 for Depakote Oral Tablet Delayed Release 125 mg; give one tablet by mouth in the afternoon for depression with psychotic features. Review of Resident #49's Medication Administration Records (MARs) dated May 2026, and June 2026 revealed no documentation for monitoring adverse effects of psychotropic medications. Interview on 06/03/26 at 1:50 P.M. with the Director of Nursing (DON) confirmed indications for use for psychotropic medications were not appropriate and there were no orders for monitoring adverse effects or documentation for monitoring adverse effects for Resident # 49's psychotropic medications. 2. Review of the medical record for Resident #2 revealed an admission date of 07/20/18 with diagnoses including dementia with other behavioral disturbance, diabetes mellitus due to underlying condition with diabetic autonomic neuropathy, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, severe with psychotic symptoms and chronic kidney disease stage V. Review of the most recent significant change Minimum Data Set (MDS) 3.0 assessment for Resident #2 dated 04/08/26 revealed the resident had moderate impaired cognition and indicated Resident #2 had a diagnosis of psychotic disorder, depression and was taking an antipsychotic medication on a routine basis. Review of the physician's order for Resident #2 revealed an order dated 03/28/26 for Quetiapine Fumarate (an antipsychotic medication) 50 milligrams (mg) by mouth two times a day for agitation and mood disorder; and an order dated 05/09/26 for Quetiapine Fumarate (an antipsychotic medication) 25 mg two times a day for agitation and mood disorder. Review of the medical record for Resident #2 revealed it did not include monitoring of side effects related to the administration of Quetiapine Fumarate. Further review of the medical record for Resident #2 revealed Abnormal Involuntary Movement Scale (AIMS) evaluations were completed on 08/15/25 and 05/13/26. Review of the care plan last revised on 05/12/26, revealed Resident #2 has the potential for adverse side effects of psychotropic drug use related to dementia, depression, psychosis, behaviors, agitation. Interventions included AIMS per policy and as needed and document side effects of medication. Interview on 06/03/26 at 11:44 A.M. with the Director of Nursing (DON) verified AIMS test were not completed per policy and no side effect monitoring was completed for Resident #2. Review of facility policy titled Use of Psychotropic Medication last revised 10/01/22, revealed the indications for use of any psychotropic drug will be documented in the medical record. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. The effects of the psychotropic medication on a resident's physical, mental, and psychosocial well-being will be evaluated on an on-going basis. The resident's response to the medication, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 3.Review of Resident # 75's medical record revealed an admission date of 10/29/25 with diagnoses that included but were not limited to Alzheimer's disease, dementia with agitation, anxiety and insomnia. Review of Resident # 75's Minimum Data Set 3.0 (MDS) dated [DATE] revealed he had severe cognitive impairment and required assistance from staff with transfers, toileting hygiene and dressing. Further review revealed he received antipsychotic and antidepressant medications with indications for use noted. Review of Resident # 75's clinical physicians orders for June 2026 revealed the following orders: Order dated 05/11/26 for Olanzapine (antipsychotic) Oral Tablet 5 milligrams (mg); give 0.5 tablet by mouth at bedtime for psych. Order dated 05/11/26 for Risperidone (antipsychotic) Tablet 0.25 mg; give one tablet by mouth two times a day related to Dementia with severe agitation. Interview on 06/03/26 at 1:52 P.M. with the DON confirmed indications for use for psychotropic medications were not appropriate for Resident # 75's psychotropic medications. This deficiency represents non-compliance investigated under Complaint Number 2739488.

Based on record review, staff interview, and facility policy review, the facility failed to ensure an injury of unknown origin was reported timely to the state agency. This affected one resident (#83) of two reviewed for abuse investigations. The facility census was 74. Findings include:Review of the medical record for Resident #83 revealed an admission date of 08/30/24 and discharge date on 03/30/26. Diagnoses included Alzheimer's disease, vascular dementia, and mood disorder. Review of the Minimum Data Set (MDS)3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition, Resident #83 was coded to require substantial maximum assistance with activities of daily living.Review progress notes dated 03/23/26 revealed staff found a discoloration to the right buttocks with outer edges yellow and center was purple. Resident was guarding his hip. An X-ray was completed and found no fracture or dislocation. Review of the Self-Reported Incident (SRI) investigation number 272461 revealed staff became aware of the incident on 03/23/26 around 2:00 P.M. and informed the Administrator on 03/24/26 around 3:00 P.M. The incident was reported to the Health department on 03/24/26. Interview on 06/03/26 at 8:35 A.M. with the Administrator confirmed a delay in reporting the allegation of abuse to the state agency. He confirmed the injury of unknown origin was reported to him about 24 hours after it was found and then he reported it and began the investigation. Review of facility policy titled Abuse, Neglect and Exploitation dated 01/01/24 revealed facility shall report all alleged violations within specified timeframes.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, review of CMS Memo QSO 20-38 revised 09/10/21, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility COVID-19 positive timeline, review of the county community COVID-19 transmission rate, review of staff time sheets, review of census, review of staff screening forms, review of resident and staff rapid point of care (POC) test results, review of resident's vaccination logs, staff interviews, review of the facility COVID-19 procedure policy, and observations, the facility failed to implement effective and recommended infection control practices including contact tracing and prevention of the transmission of COVID-19 in the facility. The facility failed to ensure staff reported respiratory symptoms timely, had access to and utilized appropriate PPE and disinfectant, and residents were social distancing during a COVID-19 outbreak to help reduce the potential spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 09/09/21 when Licensed Practical Nurse (LPN) #100 who developed respiratory symptoms ([MEDICATION(S)] symptoms) 09/09/21 and did not timely notify the facility after he had provided direct care to 25 residents on the facility 2nd Street unit. LPN #100 had left the faciity on [DATE] at 8:15 A.M. after completing his 12 hour shift and started exhibiting respiratory symptoms (congestion) and by 9:00 A.M., a headache. LPN #100 had returned to the facility at 2:30 P.M., for his routine outbreak testing. LPN #100 did not report his respiratory symptoms to the staff during testing. LPN #100 left after the COVID-19 sample was collected and the facility had determined at 2:45 P.M., the LPN had tested positive for COVID-19 via rapid testing. The facility failed to perform an investigation/contact tracing to determine those residents or staff the positive staff member had contact with for exposure to COVID-19, quarantine exposed residents, ensure staff reported respiratory symptoms timely, followed infection control protocols for isolation/quarantine, and ensure adequate supplies of personal protective equipment (PPE) and disinfectant were available and properly used by all staff. On 10/13/21 at 11:35 A.M. the Administrator was notified Immediate Jeopardy began on 09/09/21 when LPN #100 started to exhibit respiratory symptoms and failed to report symptoms timely after he had provided direct care to 25 residents on 2nd Street on the morning of 09/09/21. The facility failed to conduct proper contact tracing and implement quarantine procedures. Continued observations during the onsite investigation revealed the facility was not following infection control practices to prevent the spread of COVID-19. The risk for hospitalization , serious harm and/or death are likely related to a COVID-19 outbreak in the nursing home resident population. This had the potential to affect all 68 residents residing in the facility. The Immediate Jeopardy was removed on 10/13/21 when the facility implemented the following correction actions: · On 10/12/21 at 4:20 P.M., the interdisciplinary team (IDT) meeting was held with the Medical Director (MD) #105 and IDT team (Administrator, DON, Maintenance Director #108, Assistant Director of Nursing (ADON) #109, Human Resource (HR) #110, Therapy Director (TM) #111, Social Service Director (SSD) #112, Minimum Data Set (MDS) #113, Business Office Manager (BOM) #114, Housekeeping Director (HD) #115, and Activity Director (AD) #116. The IJ template provided by ODH was reviewed. A plan of correction was developed to address the affected residents, for potentially affected residents, what education was needed, and how toaudit the implementation of plan. · On 10/12/21 from 5:15 P.M. to 6:00 P.M., 31 of 31 residents that have not previously tested positive residing on the affected units (2nd and 3rd Street) were tested for COVID-19 by Director of Nursing/designee. One new resident (Resident #56) tested positive for COVID-19 and was moved to the COVID-19 unit on 10/12/21. · On 10/12/21 at 6:00 P.M., a dedicated COVID-19 unit was constructed on 3rd Street. By 9:40 P.M. the six positive residents (Resident #13, #23, #32, #39, #52, and #56) were moved to the COVID-19 unit. · On 10/12/21 at 6:00 P.M., 66 (19 of 28 STNA's, 7 of 9 RN's, 7 of 9 LPN's, 2 of 2 receptionists, 1 of 1 Admissions, 1 of 1 administrator, 3 of 3 adult day care, 10 of 10 dietary, 1 of 1 HR, 1 of 1 Business office, 6 of 6 housekeeping/laundry, 1 of 1 maintenance, 3 of 3 activity staff, 1 of 1 social service, and 3 of 3 therapy) of 79 staff from all departments including contract staff were educated in person and via phone on the following policies: contact tracing policy, screening policy, PPE contingency planning policy, staff mask and eyewear policy, triage quarantining and isolation unit protocol by Director of Nursing/designee. In addition, staff were educated to report any new onset of symptoms to their immediate supervisor. 13 staff members were not able to be reached and will be educated prior to next working shift. · On 10/12/21 at 8:00 P.M., the Administrator and DON were educated on the following policies: contact tracing, screening, PPE contingency planning, staff mask and eyewear policy, triage quarantining and isolation unit protocol by Regional Quality Assurance Nurse (RQAN) #117. · On 10/12/21 by 9:40 P.M., a new quarantine unit was constructed on 3rd Street by the IDT team and the six quarantine residents (Resident #3, #5, #20, #31, #48, and #65) were moved to the quarantine unit. · On 10/12/21 AD #116 filled the PPE carts with surgical masks, disposable gowns, gloves, hand sanitizer, disinfectant wipes, and face shield. Staff will change out face shields when exiting an isolation room on the quarantine unit. The face shields will be disposed in a box for proper sanitation for reuse later. Extra PPE can be found in the central supply room, which is accessible to the nursing staff. · Observation audits will be conducted daily beginning on 10/13/21 on proper screening of visitors and staff for 2 weeks then 3 times per week for 2 weeks by Director of Nursing/designee. · Observation audits will be conducted daily beginning on 10/13/21 on contact tracing if applicable for 2 weeks then 3 times per week by Director of Nursing/designee. · Observation audits will be conducted daily beginning on 10/13/21 on PPE use and cleaning for 2 weeks then 3 times per week by Director of Nursing/designee. · Observation audits will be conducted daily beginning on 10/13/21 on proper isolation of exposed residents and those that are positive for 2 weeks then 3 times per week by Director of Nursing/designee. Although the Immediate Jeopardy was removed on 10/13/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions including staff education and monitoring to ensure on-going compliance. Finding include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). 1. On 10/07/21 at 10:41 A.M., interview with the Director of Nursing (DON) revealed the facility currently had a COVID-19 outbreak. The DON revealed on 09/02/21 a housekeeper had tested positive for COVID-19 outside of the facility. The facility started outbreak testing on 09/03/21. On 09/08/21 a nurse (LPN #100) had come to work on night shift with [MEDICATION(S)] symptoms. He did not report any respiratory symptoms to administration nor did he report respiratory symptoms on the COVID-19 screening questionnaire completed on 09/08/21 at 7:00 P.M. The LPN had worked a twelve hour shift and provided direct care to residents on 2nd Street unit. LPN #100 finished his 12 hour night shift assignment on 09/09/21 and went home. He returned later that day (09/09/21) for the routine outbreak testing. LPN #100's sample was collected and he returned home. Once the facility completed the POC test, it was determined that LPN #100 was positive for COVID-19. The DON reported she had called the LPN to notify him of the positive results and to have him come back in for an additional POC testing. When the LPN answered the phone, she could tell by the LPN sound of his voice he was sick. LPN #100 reported to the DON he was having sinuses trouble. The DON instructed LPN #100 to return to the facility for a second POC test, which was positive for COVID-19 as well. LPN #100 reported to the DON he didn't think it was COVID because he had been vaccinated. The facility determined the resident's COVID-19 outbreak stemmed from resident exposure to LPN #100 due to the residents not leaving the building and not having visitors. The outbreak of resident's started on 2nd Street unit on 09/20/21. The DON reported the facility did not have a dedicated COVID-19 unit. The positive resident was placed on 2nd Street; however, 2nd Street consisted of mixture of residents including isolation, quarantine and regular (non-isolated/quarantine) rooms. The DON reported the facility does not have dedicated staff for the COVID-19 isolation/quarantine rooms. The 3rd Street unit staff must pass through 2nd Street to get to the unit. The facility currently had two quarantine rooms on 3rd Street as well. The residents on the 2nd Street were noted to be both vaccinated and unvaccinated. On 10/07/21 at 1:35 A.M. and 10/12/21 at 1:00 P.M., interview with the Administrator and DON revealed the facility did not quarantine the unvaccinated residents (Resident #12, #17, #22, #36, and #67) on 2nd Street that had exposure to LPN #100 on 09/08/21 and 09/09/21 due to LPN #100 wearing a N95 correctly and they did not feel he had any length of exposure (15 minutes at one time) with the residents. The facility reported they were not aware of the new guidelines under the CMS 20-38 memo regarding close contact to include the cumulative total of 15 minutes or more over a 24-hour period. LPN #100 was identified to have been in direct contact with Residents (#1, #6, #12, #15, #17, #18, #20, #22, #24, #25, #29, #33, #36, #37, #38, #41, #47, #49, #51, #56, #59, #61, #64, #67, and #69) who resided on 2nd Street on 09/08/21 and 09/09/21. The facility did not initiate investigation/contact tracing on residents or staff when LPN #100 had tested positive. The Administrator and DON confirmed on 09/20/21 four Residents' (#22, #29, #59, and #64) on 2nd Street had tested positive for COVID-19. On 09/23/21 two Resident's (Resident #33 and #49) on 2nd Street tested positive for COVID-19. On 09/27/21 Resident #36 on 2nd Street and Resident #68 on 3rd Street had tested positive on COVID-19. On 09/30/21 three residents (#16, #27, and #58) tested positive for COVID-19 and 10/04/21 Resident #32 tested positive. The facility had determined the residents had been exposed to LPN #100, which had caused the outbreak due to the residents had not left the building or had visitors since 09/03/21. The DON reported it was determined that residents on 3rd Street unit had possibly been exposed to LPN #100 as well due to there were two rooms (216 and 218) that were on 3rd Street that the LPN had provided direct care to. On 10/13/21 at 10:40 P.M., interview with LPN #100 via phone confirmed his symptoms had not started until the morning of 09/09/21. He started with nasal congestion and then his headache started around 9:00 A.M. He did not report his new symptoms to the facility until his test results had come back for positive for COVID-19, because he thought he was just having [MEDICATION(S)] trouble. The LPN confirmed he had worn an N95 and eye protection when he had worked on 09/05/21, 09/06/21, 09/07/21, and 09/08/21. On 10/13/21 at 11:26 A.M., interview with the Administrator and DON via phone confirmed LPN #100 had returned to the facility around 2:30 P.M. on 09/09/21, for testing, however he did not report he was having any respiratory symptoms. At 2:45 P.M., the DON called LPN #100 to notify him of his positive COVID-19 results and the DON noticed he sounded congested. LPN #100 then reported he was having [MEDICATION(S)] trouble. The DON had LPN #100 return to the facility for second test and instructed the LPN to stay in the car. LPN #100 returned immediately. Review of LPN #100's timecard dated 09/05/21 to 09/15/21 revealed the LPN worked 09/05/21 7:00 P.M. to 7:45 A.M., 09/06/21 from 7:00 P.M. to 7:45 A.M., 09/07/21 from 7:00 P.M. to 8:00 A.M., and 09/08/21 from 7:00 P.M. to 8:15 A.M. Review of LPN #100's COVID-19 screening logs dated 09/06/21, 09/07/21, and 09/08/21 revealed the LPN marked he had no symptoms (fever, cough, shortness of breath, chills, fatigue, muscle or body aches, headache, loss of taste/smell, sore throat, congestion, runny nose, nausea, vomiting, or diarrhea). Review of email from the Administrator dated 10/13/21 at 10:38 A.M., revealed LPN #100 had worked 2nd street unit on 09/05/21, 09/06/21, 09/07/21, and 09/08/21. Review of LPN #100's POC test results dated 09/09/21 revealed the LPN had tested positive twice for COVID-19 on 09/09/21. The results didn't include a time the sample was collected or time the test was performed. Review of the facilities COVID-19 staff testing log dated 09/09/21 revealed LPN #100 had tested positive for COVID-19. Review of the facilities census sheet dated 09/08/21 revealed Resident's (#1, #6, #12, #15, #17, #18, #20, #22, #24, #25, #29, #33, #36, #37, #38, #41, #47, #49, #51, #56, #59, #61, #64, #67, and #69) resided on 2nd Street on 09/08/21 into the morning of 09/09/21. Review of the facility's resident vaccination log undated revealed Resident's #12, #17, #22, #36, and #67 were not vaccinated, who resided on 2nd Street on 09/08/21. Review of the facilities COVID-19 resident testing log dated 09/03/21 to 10/04/21 revealed on 09/20/21 Resident's #22, #29, #59, and #64 were positive for COVID-19. Resident #33 and #49 tested positive on 09/23/21, Resident #36 and #68 on 09/27/21, Resident #16, and #27 on 09/30/21, and Resident #32 on 10/04/21. The log did not include Resident #58's positive results dated 09/30/21. Interview on 10/12/21 at 1:00 P.M., via phone with the DON confirmed the log was inaccurate and Resident #58's had tested positive for COVID-19 on 09/30/21. The DON also confirmed only positive test results and testing are documented in the medical record. The only place the negative results are documented were on the log. Review of the facilities COVID-19 positive timeline for residents undated revealed on 09/20/21 four residents (#22, #29, #59, and #64) on 2nd Street had tested positive for COVID-19. On 09/23/21 two (Resident #33 and #49) on 2nd Street tested positive for COVID-19. On 09/27/21 Resident #36 on 2nd Street and Resident #68 on 3rd Street had tested positive on COVID-19. On 09/30/21 three residents (#16, #27, and #58) tested positive for COVID-19 and 10/04/21 Resident #32 tested positive. The timeline only included resident names and the date they tested positive. The facility provided an updated COVID-19 positive timeline on 10/12/21 that revealed three additional residents (Resident #13, #23, and #30) tested positive on 10/08/21 and two additional residents (Resident #39, and #52) on 10/11/21. Review of the county community transmission level per the CMS website, dated 09/07/21 revealed the county level was yellow (greater than 5% positivity rate), 09/14/21 to 09/21/21 was red (greater than 10%), and 09/28/21 the level was yellow. 2. On 10/07/21 from 10:21 A.M. to 10:41 A.M. an initial tour and observation of the facility with the Director of Nursing (DON) revealed the facility was a secured dementia facility consisting of three locked units. Staff and visitors enter a secured locked front door. The front office personnel obtained the staff/visitors temperatures; however, the staff/visitor completed a COVID-19 screening form and a logbook. Upon entering a resident care unit there was a locked secured door that led into 2nd Street. To the left was another secured locked door for 1st Street, and straight back through 2nd Street was another secured locked door that leads to 3rd Street. The DON reported staff were required to wear N95 and eye protection in the building. Staff were to receive a new N95 at the beginning of each shift. The staff were not fit tested for the N95 the facility was currently using. The DON reported staff were to replace the N95 if they removed and re-placed the N95 more than five times. In the isolation/quarantine rooms staff were required to wear a gown, gloves, eye protection, and a surgical mask over the N95. When exiting the isolation/quarantine all personal protective equipment (PPE) would be removed and discarded except for the eye protection. The DON did not indicate any procedure for cleaning the eye protection after exiting. The DON reported staff were not educated or instructed on cleaning the eye protection after leaving the isolation/quarantine unit and she had never thought about it. The DON confirmed 2nd Street had a mixture of residents. Some were in isolation, quarantine, and a few regular non isolation/quarantine unit and vaccinated and non-vaccinated. Observation of 1st Street revealed resident were not social distancing. Three residents were sitting at a three by three foot table with no masks. Two other residents were sitting at three by three table with no masks. Then there were two residents sitting next to each. One was in a recliner and the other one was sitting in a wheelchair. Neither resident had a mask on. The DON confirmed findings and instructed staff to separate residents by following the red X on the wall for six foot placement. Observation of 2nd Street revealed Resident #56 (room [ROOM NUMBER]) was in a quarantine room for an exposure to a positive resident. There was no evidence of surgical mask in the PPE cart of disinfectant/cleaner for eye protection. Resident #16 and #27 were in room [ROOM NUMBER], which the DON reported was an isolation room due to the residents were both positive for COVID-19. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. Resident #58 was in room [ROOM NUMBER], which was a private room for isolation. The resident had tested positive for COVID-19 per the DON. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. Resident's #68 and #36 were in room [ROOM NUMBER]. The DON reported both residents had tested positive for COVID-19 on the same day. Resident #19 was in a quarantine room (room [ROOM NUMBER]) due to exposure to another resident. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. Resident #32 was in an isolation room (room [ROOM NUMBER]) because she had tested positive for COVID-10 on 10/04/21. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. Resident's #30 and #48 were in a quarantine room (room [ROOM NUMBER]) due to exposure to a positive resident. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. Rooms 202 A and B, 204 A and B, 205 A and B, 206 A and B, 206 A and B, 210 A and B, 212 A and B were occupied by non-isolated/quarantined residents. Rooms 216 A and B and 218 A and B were part of 2nd Street; however, they were located on the other side of the secured doors in 3rd Street unit. The DON reported she was having staff fill the PPE bins with surgical mask and disinfectant/cleaner for staff to use to clean eye protection when leaving and isolation/quarantine unit. Observation of 3rd Street revealed rooms [ROOM NUMBERS] had two quarantine rooms. There was no evidence of surgical mask or disinfectant/cleaner for the eye protection in or on the PPE cart. There were nine residents observed in the common area not social distancing or wearing masks. This finding confirmed with the DON during observation and the DON instructed a staff member who was sitting near the residents to separate the resident to ensure they were six feet apart. Interviews on 10/07/21 from 10:44 A.M. to 10:51 A.M., with State tested Nurse's Aide (STNA) #102, STNA #103, and Registered Nurse (RN) #104 revealed the staff members reported they would have to leave the isolation/quarantine room and locate the nurse to get disinfectant cleaner to clean their eye protection. 3. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident immunization revealed he was not eligible for COVID-19 vaccine. There was no documented evidence of the resident had received the COVID-19 vaccine. Review of Resident #27's Medication Administration Records (MAR) dated 09/2021 revealed on 09/29/21 the resident was marked he had a cough on the daily COVID-19 screening. Review of Resident #27's nursing progress notes dated 09/28/21 to 09/30/21 revealed no documented evidence regarding the residents cough or physician notification. Further review revealed on 09/30/21 during routine outbreak testing Resident #27 had tested positive for COVID-19. Review of the facility's resident vaccine log undated revealed Resident #27 was vaccinated. Interview on 10/12/21 at 1:00 P.M., with the DON via phone confirmed Resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the resident was not tested until 09/30/21, which was the resident scheduled outbreak testing. The resident was in quarantine due to exposure to a positive roommate. The DON reported on admission the resident's family member that lives out of state reported the residents had been vaccinated. The DON reported the facility should have followed up with the family to get documented evidence of vaccine. Review of CMS QSO-20-38-NH requirement, revised 09/10/21, revealed close contact referred to someone who had been within six feet of a COVID-19 positive person for cumulative total of 15 minutes or more over 24-hour period. Staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of COVID-19 testing. Documentation of testing for symptomatic staff include the date and times identification of signs and symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. Resident testing results must be documented in the resident medical record. Review of the CDC recommendation titled, Interim Prevention and Control recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 09/10/21, revealed: the facility should identify space in the facility that could be dedicated to monitor and care of residents with confirmed [CONDITION(S)]-CoV-2 infections by: - Determine the location of the COVID-19 care unit and create a staffing plan. - The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. - Identify health care personnel (HCP) who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum this should include the primary nursing assistants (NA's) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID-19 care unit and other units during the same shift. - To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. - Ideally, environmental services (EVS) staff should be dedicated to this unit, but to the extent possible, EVS staff should avoid working on both the COVID-19 care unit and other units during the same shift. - To the extent possible, HCP dedicated to the COVID-19 care unit (e.g., NA's and nurses) will also be performing cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant into the room and wipe down high-touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room. Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection - Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). - Fully vaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section. Fully vaccinated residents and residents with [CONDITION(S)]-CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP or Resident - HCP and residents with symptoms of COVID-19: - Symptomatic HCP, regardless of vaccination status, should be restricted from work pending evaluation for [CONDITION(S)]-CoV-2 infection. - Symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by HCP using a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for [CONDITION(S)]-CoV-2 infection. - Perform contact tracing to identify any HCP who have had a higher-risk exposure or residents who may have had close contact with the individual with [CONDITION(S)]-CoV-2 infection: - All HCP who has had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested immediately as described in the testing section. - Unvaccinated residents who are close contacts and HCP with higher-risk exposures: - Unvaccinated residents who are close contacts should be managed as described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. - Fully vaccinated residents who are close contacts and HCP with higher-risk exposures: - Fully vaccinated residents who are close contacts should be managed as described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. - If testing of close contacts reveals additional HCP or residents with [CONDITION(S)]-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with [CONDITION(S)]-CoV-2 infection. - A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - If the outbreak investigation is broadened to either a facility-wide or unit-based approach, follow recommendations below for alternative approaches to individual contact tracing. - Alternative, broad-based approach: - If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility). - Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. - Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than 2 days after the exposure, if known) and, if negative, again 5-7 days later. - Unvaccinated residents and HCP: - Unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. - Close contacts, if known, should be managed as described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. - In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for fully vaccinated residents and work restriction of fully vaccinated HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. - If additional cases are identified, testing should continue affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE use for care of unvaccinated residents, until there are no new cases for 14 days. Review of the CDC recommendation titled Strategies for Optimizing the Supply of Eye Protection updated 09/13/21 revealed: When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider: 1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. 2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA approved hospital disinfectant solution. 3. Wipe the outside of face shield or goggles with clean wat