Every finding on record at Gardens of Belden Village

Based on observation and interview, the facility failed to dispose of expired foods in a timely manner which resulted in expired food being served to residents. This had the potential to affect all 80 residents that received food from the kitchen. The facility census was 80.Findings include: On 04/01/26 at 11:00 A.M., an observation of the kitchen revealed one unopened case of Thick and Easy apple juice that expired on 02/17/26, one unopened case of Thick and Easy cranberry juice that expired on 02/19/26, and one opened case of Thick and Easy orange juice that expired on 03/14/26. An interview at the time of observation with Dietary Manager #887 verified the expired thickened beverages. Dietary Manager #887 also confirmed that expired food had been served to residents in January 2026 when there was a winter storm and the dietary staff utilized food items from the emergency food supply, which included a case of individual cups of peaches that had been expired for several months. Dietary Manager #887 stated staff were unaware that expired food had been served to residents until someone complained about it. This deficiency represents noncompliance investigated under Complaint Numbers 2741464, 2725826, 2593694, 2592864 and 2579173.

Based on observation and interview, the facility failed to ensure the laundry cart used to transport clean clothing/linens from the washing machines to the dryers did not have water dripping into them from a leak in the ceiling. This had the potential to affect all 80 residents residing in the facility. Findings include:An observation on 04/01/26 at 9:04 A.M. revealed there was water dripping from the ceiling above the washing machines. The ceiling tiles had brownish color, and the metal crossbars were rusted. Some of the water dripping was pooling in a cart used to transport clean laundry from the washers to the dryers. Several damp looking bath towels were lying on the floor. Housekeeper/Laundry Supervisor #847 verified water was dripping from the ceiling and pooling in the cart used to transport clean laundry. Housekeeper/Laundry Supervisor #847 stated the ceiling leaked when it rained. As surveyor walked from the laundry area to the dryer area, and water dripped on the surveyor's head. An interview on 04/01/26 at 11:41 A.M. Maintenance Director #854 verified the ceiling above the washers was leaking. Maintenance Director #854 stated it only leaked when it rained. Maintenance Director #854 verified the crossbars were rusted and the ceiling tiles were discolored. He also verified that the laundry room was located on the first floor, and there was a second floor over the laundry area. Maintenance Director #854 stated that the rainwater could follow the duct work and come out of the ceiling in various areas. Maintenance Director #854 stated he had tried to patch the roof, and there had been discussions about getting a new roof. This deficiency represents non-compliance investigated under Master Complaint Number 2804797 and Complaint Numbers 2741464, 2721789, 2593694, 2579366, 2579173 and 1282446 (OH00166150).

Based on medical record review, observation, hospital record review, review of guidance from the American Diabetes Association (ADA), review of guidance from the Centers for Disease Control and Prevention (CDC), review of guidance from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), review of guidance from the National Institutes of Health (NIH) and National Library of Medicine's MedlinePlus information, facility policy review and interviews, the facility failed to adequately monitor Resident #42's diabetes; failed to ensure medications were available for Resident #99's use; failed to ensure adequate indication for blood sugar testing (finger sticks) for Resident #33; failed to ensure skin assessments and treatments were in place for Residents #27, #35 and #62; failed to ensure testing instructions were followed for Resident #7; and failed to ensure urinalysis lab testing was completed as ordered for Resident #6. This affected eight (Residents #42, #99, #33, #27, #35, #62, #7, and #6) of 36 residents reviewed for quality of care. The facility census was 80.Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 01/09/26 with diagnoses including type two diabetes mellitus, acute kidney failure, chronic kidney disease (CKD) Stage III, vascular dementia, and cognitive communication deficit. Review of the hospital records dated 12/29/25 through 01/09/26 (prior to admission) revealed Resident #42 had blood sugar levels ranging from 100 to 294 milligrams per deciliter (mg/dL), had a urine glucose reading of 3+, received insulin glargine (long-acting insulin)10 units daily at bedtime, insulin lispro (rapid-acting insulin) 0 to 5 units sliding scale with meals, and blood sugar Accu-Chek (finger stick blood sugar monitoring) four times daily before meals and at bedtime. The hospital nurse practitioner's note dated 12/31/25 at 5:29 P.M. indicated Resident #42's Jardiance (oral medication to manage blood sugars) and Glipizide (oral medication to manage blood sugars) were on hold and were to be resumed upon discharge. Review of the hospital Discharge summary dated [DATE] indicated Resident #42's home medications were resumed upon discharge to skilled nursing facility. There was no Hemoglobin A1C (laboratory test that measures average blood sugar levels over the past two to three months, indicating the percentage of hemoglobin coated with sugar) in the hospital records. Review of the care plan created 01/12/26 revealed Resident #42 was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included providing diabetes medications as ordered and monitoring for side effects and effectiveness implemented 01/12/26, educating the resident and family on the correct protocol for glucose monitoring and insulin injections effective 01/12/26, collect fasting serum blood sugars as ordered effective 01/12/26, identify areas of non-compliance or other difficulties in resident diabetic management effective 01/12/26, monitor and document the resident and family's ability to manage the treatment program effective 01/12/26, monitor and document any signs or symptoms of hyperglycemia or hypoglycemia effective 01/12/26, and monitor and document compliance with diet and document any problems effective 01/12/26. Review of the physician's note dated 01/19/26 indicated Resident #42 was doing okay, diabetic with good control, medications included Glyburide (oral medication to manage blood sugars) 5 milligrams (mg) and Metformin (oral medication to manage blood sugars) 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included hypertension, acute kidney failure, and anxiety disorder with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. A modification of the quarterly MDS assessment captured Resident #42's diagnosis of diabetes mellitus. Review of the physician's note dated 02/14/26 indicated Resident #42 was seen for a monthly follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, hypertension, and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the physician's note dated 03/04/26 indicated Resident #42 was seen for a follow-up, doing okay, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, anxiety disorder, and hypertension with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the physician's note dated 03/10/26 indicated Resident #42 was seen for a follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, hypertension, and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the physician's note dated 03/16/26 indicated Resident #42 was seen for a follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, anxiety disorder, and hypertension with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the physician's note dated 03/23/26 indicated Resident #42 was seen for a cough and shortness of breath, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included cough with plan for chest x-ray and Mucinex (expectorant) for five days, and hypertension and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring. Review of the physician's orders for Resident #42 revealed there were no orders for blood sugar checks or anti-diabetic medications (including insulin, Glyburide, Metformin, Jardiance, and Glipizide) from 01/09/26 through 03/23/26. Further review of the physician's orders revealed blood sugar checks twice daily was ordered 03/24/26, insulin glargine 20 units injected daily at bedtime was ordered 03/26/26, and Farxiga (oral medication to manage blood sugars) 10 mg once daily by mouth was ordered 03/26/26. Review of the vital signs for Resident #42 revealed there were no blood glucose readings obtained from 01/09/26 through 03/23/26. On 03/24/26, Resident #42's blood glucose was 582 mg/dL. Review of the laboratory results for Resident #42 revealed the sample collected on 03/23/26 and resulted on 03/24/26 indicated a blood glucose of 425 mg/dL, which the report indicated was high compared to the normal range of 65 to 99 mg/dL for fasting results and 65 to 125 mg/dL for non-fasting results; a hemoglobin A1C of 16.7%, which the report indicated was high compared to the normal range of 4.1% to 6.1%; and the mean blood glucose was 433 mg/dL, which was flagged as high compared to the normal range of 70 to 120 mg/dL. The report indicated the hemoglobin A1C result was verified by repeat analysis. Further review of the laboratory results for Resident #42 revealed the sample collected on 03/25/26 and resulted on 03/26/26 indicated a blood glucose of 447 mg/dL, which the report indicated was high compared to the normal range of 65 to 99 mg/dL for fasting results and 65 to 125 mg/dL for non-fasting results; a hemoglobin A1C of 17.0%, which the report indicated was high compared to the normal range of 4.1% to 6.1%; and the mean blood glucose was 441 mg/dL, which was flagged as high compared to the normal range of 70 to 120 mg/dL. The report indicated the hemoglobin A1C result was verified by repeat analysis. Review of the progress note dated 03/26/26 at 7:44 P.M. revealed Resident #42's A1C was 17% and Physician #950 was notified. New orders were provided for insulin glargine 20 units once daily at bedtime and Farxiga 10 mg once daily. On 03/31/26 at 9:19 A.M., an interview with Assistant Director of Nursing (ADON) #893 stated it was standard protocol for diabetics to get finger stick blood sugars. On 03/31/26 at 4:15 P.M., an interview with Regional Director of Operations (RDO) #916 and Regional Clinical Director (RCD) #952 stated the hospital had discontinued all of Resident #42's diabetes medications and insulin prior to sending the resident to the facility, and there were no hospital discharge orders for blood sugar checks. On 04/01/26 at 8:52 A.M., an interview with Physician #950 stated it was his protocol that anyone who admitted with a diagnosis of diabetes got blood sugar checks upon admission, and that should have been established for Resident #42. Physician #950 further stated Resident #42 should have been getting blood sugars since admission to establish a baseline. On 04/01/26 at 9:30 A.M., an interview with ADON #893 verified Resident #42 did not have any blood sugar checks prior to 03/24/26. ADON #893 claimed she misspoke previously because it was not the protocol to do blood sugar checks on all diabetics. On 04/01/26 at 1:46 P.M., an interview with RDO #916 verified Physician #950's notes (01/19/26 through 03/23/26) all indicated Resident #42 had good control of diabetes, indicated Resident #42 had medications including Glyburide and Metformin, and there was no evidence that diabetes monitoring occurred until Resident #42's A1C was obtained and resulted at 17%. On 04/01/26 at 1:48 P.M., an interview with RCD #952 stated Physician #950 did not have any standing orders at the facility and ADON #893 had reported that Physician #950 verbally instructed her of standing orders. RCD #952 also stated because of the concern identified with Resident #42's diabetes management, a full audit was conducted on all residents with diabetes to assess for any concerns with blood sugar control. RCD #952 confirmed Physician #950's notes for Resident #42 had discrepancies including listing Glyburide and Metformin under the medications, listing the most recent weight as 149 pounds obtained in 2014 and not addressing the change of condition that occurred with Resident #42. RCD #952 said the facility was in the process of looking for a new house physician because of Physician #950's discrepancies and lack of documentation. Review of the urinalysis results dated 04/02/26 revealed Resident #42 had a urine glucose reading of 4+, which had increased from the 3+ obtained in the hospital prior to admission to the facility. On 04/07/26 at 10:07 A.M., an interview with RCD #952 stated Resident #42's daughter informed the facility that Resident #42 had an endocrinologist that the facility could follow up with if there were concerns with Resident #42's diabetes. RCD #952 stated prior to that, the facility had no idea Resident #42 had an endocrinologist. On 04/07/26 at 10:40 A.M., an interview with the Administrator, RDO #916, and RCD #952 claimed that no harm occurred to Resident #42 because the facility nursing staff followed the physician's orders since admission and they responded appropriately when the elevated blood sugar was identified. On 04/07/26 at 12:02 P.M., an interview with Physician #950 stated there were no A1C results available for Resident #42 upon admission. Physician #950 recanted his previous statement, now claiming there was no protocol for checking blood sugars on admission for residents with diabetes unless the hospital sends them with orders to check the blood sugar. Physician #950 stated if residents with diabetes were admitted from the hospital with no orders for insulin or blood sugar checks, it was assumed their diabetes was well controlled. When asked how he knew Resident #42's diabetes was well controlled as indicated on his notes for the three months Resident #42 had been in the facility since they were not doing blood sugar checks, Physician #950 again stated if they were sent from the hospital with no orders for insulin or blood sugar checks then it was assumed they were well controlled. Physician #950 also stated he did not review the hospital documentation for Resident #42 upon admission; he only reviewed the discharge summary and discharge orders. On 04/07/26 at 12:25 P.M., an interview with Resident #42's daughter stated Resident #42 had been diabetic for many decades and was taking Jardiance and Glipizide at home to manage diabetes. Resident #42's daughter said when the resident admitted to the facility, she asked about the diabetic medications and the facility informed her Resident #42 was not ordered any diabetic medications. Resident #42's daughter stated she informed the facility which diabetic medications the resident was supposed to be on, and the facility did not implement those orders, instead claiming the facility said they were managing through diet. Resident #42's daughter stated she had been begging the facility to obtain a hemoglobin A1C since admission, and when they finally obtained it, it was off the charts. Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, dated December 2015, indicated the purpose of the policy was to help residents control diabetes, prevent recurrent hyperglycemia or hypoglycemia, and recognize and manage the treatment of complications commonly associated with diabetes. Hyperglycemia was defined as a blood sugar above target levels with symptoms including lethargy and loss of appetite. Prolonged poorly controlled diabetes could lead to other complications such as cardiovascular disease, cerebrovascular disease, kidney disease, glaucoma, cataracts, retinopathy, blindness, nerve damage, foot complications, skin problems, and gastroparesis. The management of individuals with diabetes should follow relevant protocols and guidelines for glucose monitoring, the physician should order the frequency of glucose monitoring, residents whose blood sugar was poorly controlled or those taking insulin may require more frequent monitoring, finger sticks measure the current blood glucose levels with normal ranges defined as 80 to 130 mg/dL before meals and less than 180 mg/dL after meals, hyperglycemia would be anything above the target reference range, and A1C measures the average blood glucose over two to three months and was a better estimate of treatment efficacy with healthy diabetic adults having an A1C value of less than 6.5%. Review of the American Diabetes Association's (ADA's) publication titled Understanding Your A1C Test, not dated, revealed the A1C blood test indicated what the average blood sugar levels had been for the past two to three months. Review of the ADA's information on A1C and estimated average glucose (eAG), retrieved from https://diabetes.org/A1C-eag-conversion-calculator on 04/06/26, revealed an A1C level of 17% converted to an estimated average glucose of 441 mg/dL. The ADA's website indicated the A1C test gave a picture of the average blood glucose control for the previous two to three months, providing a good idea of how well diabetes was controlled. Review of the ADA's information on hyperglycemia (high blood glucose), retrieved from https://diabetes.org/living-with-diabetes/treatment-care/hyperglycemia on 04/06/26, revealed hyperglycemia could be a serious problem if left untreated. The ADA's website indicated part of managing diabetes was checking blood glucose often and treating high blood glucose early to help avoid problems associated with hyperglycemia. Review of the ADA's information on diabetes complications, retrieved from https://diabetes.org/about-diabetes/complications on 04/06/26, revealed diabetes could lead to severe and sometimes life-threatening complications, including heart, kidney, and eye disease as well as nerve damage. Review of the ADA's information on important health checks for people with diabetes, retrieved from https://diabetes.org/living-with-diabetes/newly-diagnosed/health-checks-people-with-diabetes on 04/06/26, revealed an A1C test was important for people with diabetes because it measured the average blood glucose level over the past two to three months and a high A1C was indicative of frequent high blood glucose, which increased risk for complications such as nerve damage, kidney disease, and vision impairment. The target range for A1C was less than 7% for many adults and a target of less than 8% may be appropriate for older adults who may have other health complications that require extra caution. Review of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) information on diabetes complications, retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/all-content on 04/06/26, revealed high blood glucose from diabetes could damage the blood vessels and nerves that control the heart, cause diabetic neuropathy (nerve damage), increase risk of developing diabetic kidney disease, cause foot problems due to nerve damage, increase risk of developing diabetic eye diseases, increase risk of developing oral (mouth) diseases, and increase risk of developing urinary tract infections. Review of the Center for Disease Control and Prevention's (CDC's) information on diabetes, retrieved from https://www.cdc.gov/diabetes/about/about-type-2-diabetes.html on 04/06/26, revealed keeping blood sugar levels close to target will help prevent or delay diabetes complications. Review of the CDC's information on monitoring blood sugars with diabetes, retrieved from https://www.cdc.gov/diabetes/diabetes-testing/monitoring-blood-sugar.html on 04/06/26, revealed monitoring blood sugars was the most important thing to manage diabetes. The CDC's website indicated target ranges for blood sugars were 80 to 130 mg/dL before meals and below 180 mg/dL after meals. In addition to regular blood sugar monitoring, an A1C should be tested at least twice per year. Review of the National Institutes of Health (NIH) and National Library of Medicine's MedlinePlus information on glucose in urine testing, retrieved from https://medlineplus.gov/lab-tests/glucose-in-urine-test/ on 04/06/26, revealed urine normally contained very little or no glucose and having more glucose than normal in the urine could indicate too much glucose in the blood. A glucose in urine test is one way to monitor diabetes, and too much glucose in the urine may mean diabetes is not well controlled. 2. Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses that included encephalopathy, psychoactive substance abuse, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and schizoaffective disorder. Resident #99 was discharged home on [DATE]. Review of the medication administration record (MAR) revealed Resident #99 was ordered nifedipine (calcium-channel block to treat high blood pressure and/or chest pain) 30 milligrams (mg) upon rising and to hold if systolic pressure was less than 90. The MAR had documentation of nifedipine being administered upon rising on 08/06/25 and 08/07/25. No blood pressures were recorded on the MAR. Review of the blood pressure summary revealed on 08/06/25 Resident #99's blood pressure was taken at 11:30 P.M. On 08/07/25, Resident #99's blood pressure was checked at 5:19 P.M. An interview on 04/06/26 at 12:48 P.M. RCD #952 verified blood pressures were not checked before Resident #99 was administered nifedipine on 08/06/25 and 08/07/25. 3. Review of the medical record revealed Resident #33 was admitted [DATE] with diagnoses that included acute embolism and thrombosis deep vein of right lower leg, type II diabetes mellitus, and hemiplegia and hemiparesis. The hospital discharge information revealed Resident #33 had orders for an insulin sliding scale. The hospital assessment/plan revealed the resident had type II diabetes mellitus. The 5-day admission MDS 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact. The MDS revealed Resident #33 did not receive insulin or hypoglycemic medications. The MDS was marked no for the resident having diabetes mellitus. The plan of care dated 03/13/26 revealed Resident #33 was at risk for hypo/hyperglycemia. Interventions included diabetes medication as ordered and fasting serum blood sugar as ordered. A physician order dated 03/27/26 revealed Resident #33 was to have blood sugar checks three times a day for one week and results reported to the doctor. Review of the MAR revealed Resident #33's blood sugar was checked on 03/27/26 in the evening and at bedtime, and on 03/28/26 at rising but no results were recorded. An interview on 03/30/26 at 10:43 A.M. Resident #33 stated his fingers were sore. The resident stated he was not a diabetic and wondered why his blood glucose was being checked three times a day. An interview on 03/31/26 at 8:47 A.M. ADON #893 verified there was nothing in Resident #33's progress notes why blood glucose checks were ordered three times a day for seven days. ADON #893 stated it was protocol to check blood glucose levels for anyone that was diabetic. ADON #893 then recanted that it was protocol to check blood glucose levels for residents that were diabetic. An additional interview on 03/31/26 at 9:19 A.M. ADON #893 verified Resident #33's blood glucose levels were checked but not recorded twice on 03/27/26 and once on 03/28/26. An interview on 03/31/26 at 12:47 P.M. Physician #950 stated he could not recall why blood glucose levels were ordered 25 days after Resident #33 was admitted . An interview on 04/01/26 at 11:27 A.M. MDS Nurse #831 verified the hospital records stated Resident #33 was a diabetic, but there was nothing to support Resident #33 being a diabetic. The MDS was coded as the resident not being a diabetic since there were no anti-glycemic medications ordered. An interview on 04/01/26 at 1:47 P.M. RCD #952 stated audits were being completed after it was discovered Resident #42 did not have blood glucose monitoring done. RCD #952 verified Resident #33 had a diagnosis of diabetes upon admission, and no blood glucose checks were ordered. RCD #952 also verified Resident #33's blood glucose levels were not recorded twice on 03/27/26 and once on 03/28/26. Review of the obtaining a fingerstick glucose level policy revised October 2011 revealed the person performing this procedure should record the following information in the resident's medical record: the blood sugar results. 4. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of right leg, type II diabetes, nondisplaced fracture of the head of the radius, and methicillin resistant staphylococcus aureus (MRSA) infection. The admission care plan dated 03/16/26 revealed Resident #62 had right ankle bruising/blister, left toes calloused, bruising to left knee and right antecubital, and a surgical wound to the left inner arm. Wound care documentation from an outside company dated 03/19/26 revealed Resident #62 was being seen for initial consultation for wound care to left foot, right foot, and right hand. Resident #62 had a diabetic ulcer to the fourth digit of the left foot that was scabbed/crusted and measured 0.5 centimeters (cm) long and 0.5 cm wide. The diabetic ulcer was to be cleansed with normal saline, painted with betadine (antiseptic), and left open to air every day and as needed. The resident had a diabetic ulcer to the right plantar foot that measured 1.0 cm long and 0.5 cm wide. The diabetic ulcer was to be cleansed with normal saline, painted with betadine, and left open to air every day and as needed. The resident also had a diabetic ulcer to the third digit of the right foot that measured 0.3 cm long and 0.3 cm wide. The diabetic ulcer was to be cleansed with normal saline, painted with betadine, and left open to air every day and as needed. Resident #62 had an arterial ulcer to the first digit of the right hand that measured 0.5 cm long and 0.5 cm wide. The wound was to be cleansed with normal saline, Skin-prep (sterile, alcohol-free wipes that create a protective barrier on skin, preventing irritation from adhesives and reducing friction) (per the resident's request) to the wound and left open to air on Monday, Wednesday, Friday, and as needed. The resident had an arterial ulcer to the second digit of the right hand that measured 0.3 cm long and 0.3 cm wide. The wound was to be cleansed with normal saline, Skin-prep (per the resident's request) to the wound and left open to air on Monday, Wednesday, Friday, and as needed. The admission MDS 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 had two venous and arterial ulcers, a diabetic ulcer, and a surgical wound. Wound care documentation from an outside company dated 03/25/26 revealed Resident #62 had a diabetic ulcer to the fourth digit of the left foot that was scabbed/crusted and measured 0.8 cm long, 0.7 cm wide, and 0.3 cm deep. The diabetic ulcer was debrided with post debridement measurements of 0.5 cm long, 0.5 cm wide, and 0.3 cm deep. A new order for the ulcer to be cleansed with normal saline, petrolatum gauze (sterile, non-adherent dressing impregnated with petroleum jelly) applied, and covered with bordered gauze dressing every Monday, Wednesday, Friday, and as needed. The resident had a diabetic ulcer to the right plantar foot that measured 1.0 cm long and 0.4 cm wide. The treatment was to continue as ordered. The resident diabetic ulcer to the third digit of the right foot was healed. Resident #62 had an arterial ulcer to the first digit of the right hand that measured 0.3 cm long and 0.3 cm wide. The treatment was to continue as ordered. The arterial ulcer to the second digit of the right hand was healed. A new diabetic ulcer to left planter foot was evaluated for the first time. The wound measured 2.5 cm long, 2.7 cm wide, and 0.2 cm deep. There was a scant amount of drainage. The ulcer was to be cleansed with normal saline, petrolatum gauze applied and covered with bordered gauze every Monday, Wednesday, Friday, and as needed. The plan of care dated 03/27/26 revealed Resident #62 was at risk for skin breakdown. Interventions included encouraging and assisting the resident to turn and reposition as tolerated and as needed and encouraging the resident to float his heels as tolerated. Resident #62 had a diabetic ulcer to fourth digit of left foot, right plantar, and right foot third digit. Interventions included monitoring/documenting the wound size, depth, margins, peri wound, skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, and gangrene, The progress of the wound healing was to be documented on an ongoing basis. Wound care documentation from an outside company dated 04/01/26 revealed Resident #62 had a diabetic ulcer to the fourth digit of the left foot that measured 0.4 cm long, 0.4 cm wide, and 0.2 cm deep. The treatment was to continue as ordered. The resident had a diabetic ulcer to the right plantar foot that was healed. Resident #62 had an arterial ulcer to the first digit of the right hand that was healed. A diabetic ulcer to left planter foot measured 1.2 cm long, 1.1 cm wide, and 0.2 cm deep. There was a light amount of drainage. The wound was debrided and the treatment was to continue as ordered. An interview on 04/01/26 at 12:20 P.M. Licensed Practical Nurse (LPN) #884 verified there were no measurements or treatments put in place for the diabetic, arterial, and venous ulcers Resident #62 had upon admission until the outside wound nurse visited on 03/19/26. LPN #884 stated it was a crazy week, and the outside wound nurse did not come on 03/18/26 as scheduled. Resident #62 was evaluated by the outside wound nurse on 03/19/26, and measurements and treatments were put into place at that time. LPN #884 stated the hospital did not put in exact orders for Resident #64's wound care, and the hospitals were awful about giving orders when they discharged residents. LPN #884 verified the nurses could have measured the areas and contacted the physician to obtain orders for the wounds. LPN #884 verified there were no treatment orders for Resident #62 until 03/20/26. An interview on 04/02/26 at 11:31 A.M. RCD #952 verified the outside wound company found the new wound to Resident #62's left foot on 03/25/26. RCD #952 could not answer why the nurses did not find the area to the planter area of the residents left foot. RCD #952 stated education had been started. 5. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, muscle weakness and generalized anxiety. Resident #27 resides on the secured memory care unit (SMCU). Review of Resident #27's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #27's skin breakdown care plan revealed an intervention dated 03/05/26 to observe skin for signs and symptoms of breakdown; document and notify the physician. Review of Resident #27's physician orders revealed an order dated 03/26/26 to cleanse the right breast with normal saline, apply triple antibiotic ointment and cover with a bordered foam dressing one time a day at 6:00 A.M. Observation 03/31/26 at 7:41 A.M. with Registered Nurse (RN) #867 revealed the resident's right breast had an undated clear Opsite (transparent film) type of dressing applied. Interview on 03/31/26 at 7:45 A.M. with RN #867 confirmed the resident was supposed to have a bordered foam dressing covering the wound and not a clear Opsite dressing on the wound. 6. Review of Resident #35's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia and diabetes. Review of Resident #35's physician orders revealed an order dated 10/14/25 for weekly skin checks one time a day every Tuesday for skin prevention and monitoring. Complete weekly skin assessment in the electronic health record and document any new abnormal skin findings to the nurse practitioner/medical director. Review of Resident #35's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #35's MAR and treatment administration records (TAR) from 03/01/26 to 03/31/26 revealed no documented evidence weekly skin checks were completed on 03/03/26, 03/10/26, and 03/17/26. Observation on 03/30/26 at 9:06 A.M. with Certified Nursing Services (CNA) #912 revealed Resident #35 had a scabbed dime-sized open area on the right inner wrist. Interview on 03/31/26 at 7:32 A.M. with RN #867 confirmed the wound nurse was doing skin ch

Based on record review, review of the American Diabetes Association's (ADA's) information on A1C and estimated average glucose (eAG), review of the facility policy and interview, the facility failed to ensure the physician provided comprehensive care for Resident #42. This affected one (Resident #42) out of three residents reviewed for physician's services. The facility census was 80.Findings include:Review of the medical record for Resident #42 revealed an admission date of 01/09/26 with diagnoses including type two diabetes mellitus, acute kidney failure, chronic kidney disease (CKD) Stage III, vascular dementia, and cognitive communication deficit.Review of the hospital records dated 12/29/25 through 01/09/26 (prior to admission) revealed Resident #42 had blood sugar levels ranging from 100 to 294 milligrams per deciliter (mg/dL), had a urine glucose reading of 3+, received insulin glargine (long-acting insulin)10 units daily at bedtime, insulin lispro (rapid-acting insulin) 0 to 5 units sliding scale with meals, and blood sugar Accu-Chek (finger stick blood sugar monitoring) four times daily before meals and at bedtime. The hospital nurse practitioner's note dated 12/31/25 at 5:29 P.M. indicated Resident #42's Jardiance (oral medication to manage blood sugars) and Glipizide (oral medication to manage blood sugars) were on hold and were to be resumed upon discharge. Review of the hospital Discharge summary dated [DATE] indicated Resident #42's home medications were resumed upon discharge to skilled nursing facility. There was no Hemoglobin A1C (laboratory test that measures average blood sugar levels over the past two to three months, indicating the percentage of hemoglobin coated with sugar) in the hospital records.Review of the care plan created 01/12/26 revealed Resident #42 was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included providing diabetes medications as ordered and monitoring for side effects and effectiveness implemented 01/12/26, educating the resident and family on the correct protocol for glucose monitoring and insulin injections effective 01/12/26, collect fasting serum blood sugars as ordered effective 01/12/26, identify areas of non-compliance or other difficulties in resident diabetic management effective 01/12/26, monitor and document the resident and family's ability to manage the treatment program effective 01/12/26, monitor and document any signs or symptoms of hyperglycemia or hypoglycemia effective 01/12/26, and monitor and document compliance with diet and document any problems effective 01/12/26.Review of the physician's note dated 01/19/26 indicated Resident #42 was doing okay, diabetic with good control, medications included Glyburide (oral medication to manage blood sugars) 5 milligrams (mg) and Metformin (oral medication to manage blood sugars) 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included hypertension, acute kidney failure, and anxiety disorder with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's note dated 02/14/26 indicated Resident #42 was seen for a monthly follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, hypertension, and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's note dated 03/04/26 indicated Resident #42 was seen for a follow-up, doing okay, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, anxiety disorder, and hypertension with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's note dated 03/10/26 indicated Resident #42 was seen for a follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, hypertension, and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's note dated 03/16/26 indicated Resident #42 was seen for a follow-up, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included vascular dementia, anxiety disorder, and hypertension with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's note dated 03/23/26 indicated Resident #42 was seen for a cough and shortness of breath, diabetic with good control, medications included Glyburide 5 mg and Metformin 500 mg, and the weight listed on the physician's note was 149 pounds obtained 08/22/14. The physician's assessments included cough with plan for chest x-ray and Mucinex (expectorant) for five days, and hypertension and hypothyroidism with the plan to continue with present care. There was no assessment or plan listed for diabetes monitoring.Review of the physician's orders for Resident #42 revealed there were no orders for blood sugar checks or anti-diabetic medications (including insulin, Glyburide, Metformin, Jardiance, and Glipizide) from 01/09/26 through 03/23/26. Further review of the physician's orders revealed blood sugar checks twice daily was ordered 03/24/26, insulin glargine 20 units injected daily at bedtime was ordered 03/26/26, and Farxiga (oral medication to manage blood sugars) 10 mg once daily by mouth was ordered 03/26/26.Review of the laboratory results for Resident #42 revealed the sample collected on 03/23/26 and resulted on 03/24/26 indicated a blood glucose of 425 mg/dL, which the report indicated was high compared to the normal range of 65 to 99 mg/dL for fasting results and 65 to 125 mg/dL for non-fasting results; a hemoglobin A1C of 16.7%, which the report indicated was high compared to the normal range of 4.1% to 6.1%; and the mean blood glucose was 433 mg/dL, which was flagged as high compared to the normal range of 70 to 120 mg/dL. The report indicated the hemoglobin A1C result was verified by repeat analysis.Further review of the laboratory results for Resident #42 revealed the sample collected on 03/25/26 and resulted on 03/26/26 indicated a blood glucose of 447 mg/dL, which the report indicated was high compared to the normal range of 65 to 99 mg/dL for fasting results and 65 to 125 mg/dL for non-fasting results; a hemoglobin A1C of 17.0%, which the report indicated was high compared to the normal range of 4.1% to 6.1%; and the mean blood glucose was 441 mg/dL, which was flagged as high compared to the normal range of 70 to 120 mg/dL. The report indicated the hemoglobin A1C result was verified by repeat analysis.Review of the progress note dated 03/26/26 at 7:44 P.M. revealed Resident #42's A1C was 17% and Physician #950 was notified. New orders were provided for insulin glargine 20 units once daily at bedtime and Farxiga 10 mg once daily.On 04/01/26 at 8:52 A.M., an interview with Physician #950 stated it was his protocol that anyone who admitted with a diagnosis of diabetes got blood sugar checks upon admission, and that should have been established for Resident #42. Physician #950 further stated Resident #42 should have been getting blood sugars since admission to establish a baseline.On 04/01/26 at 1:46 P.M., an interview with Regional Director of Operations (RDO) #916 verified Physician #950's notes (01/19/26 through 03/23/26) all indicated Resident #42 had good control of diabetes, indicated Resident #42 had medications including Glyburide and Metformin, and there was no evidence that diabetes monitoring occurred until Resident #42's A1C was obtained and resulted at 17%.On 04/01/26 at 1:48 P.M., an interview with Regional Clinical Director (RCD) #952 stated Physician #950 did not have any standing orders at the facility and ADON #893 had reported that Physician #950 verbally instructed her of standing orders. RCD #952 also stated because of the concern identified with Resident #42's diabetes management, a full audit was conducted on all residents with diabetes to assess for any concerns with blood sugar control. RCD #952 confirmed Physician #950's notes for Resident #42 had discrepancies including listing Glyburide and Metformin under the medications, listing the most recent weight as 149 pounds obtained in 2014 and not addressing the change of condition that occurred with Resident #42. RCD #952 said the facility was in the process of looking for a new house physician because of Physician #950's discrepancies and lack of documentation.Review of the urinalysis results dated 04/02/26 revealed Resident #42 had a urine glucose reading of 4+, which had increased from the 3+ obtained in the hospital prior to admission to the facility.On 04/07/26 at 12:02 P.M., an interview with Physician #950 stated there were no A1C results available for Resident #42 upon admission. Physician #950 recanted his previous statement, now claiming there was no protocol for checking blood sugars on admission for residents with diabetes unless the hospital sends them with orders to check the blood sugar. Physician #950 stated if residents with diabetes were admitted from the hospital with no orders for insulin or blood sugar checks, it was assumed their diabetes was well controlled. When asked how he knew Resident #42's diabetes was well controlled as indicated on his notes for the three months Resident #42 had been in the facility since they were not doing blood sugar checks, Physician #950 again stated if they were sent from the hospital with no orders for insulin or blood sugar checks then it was assumed they were well controlled. Physician #950 also stated he did not review the hospital documentation for Resident #42 upon admission; he only reviewed the discharge summary and discharge orders.Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, dated December 2015, indicated the purpose of the policy was to help residents control diabetes, prevent recurrent hyperglycemia or hypoglycemia, and recognize and manage the treatment of complications commonly associated with diabetes. Hyperglycemia was defined as a blood sugar above target levels with symptoms including lethargy and loss of appetite. Prolonged poorly controlled diabetes could lead to other complications such as cardiovascular disease, cerebrovascular disease, kidney disease, glaucoma, cataracts, retinopathy, blindness, nerve damage, foot complications, skin problems, and gastroparesis. The management of individuals with diabetes should follow relevant protocols and guidelines for glucose monitoring, the physician should order the frequency of glucose monitoring, residents whose blood sugar was poorly controlled or those taking insulin may require more frequent monitoring, finger sticks measure the current blood glucose levels with normal ranges defined as 80 to 130 mg/dL before meals and less than 180 mg/dL after meals, hyperglycemia would be anything above the target reference range, and A1C measures the average blood glucose over two to three months and was a better estimate of treatment efficacy with healthy diabetic adults having an A1C value of less than 6.5%.Review of the ADA's information on A1C and eAG, retrieved from https://diabetes.org/A1C-eag-conversion-calculator on 04/06/26, revealed an A1C level of 17% converted to an estimated average glucose of 441 mg/dL. The ADA's website indicated the A1C test gave a picture of the average blood glucose control for the previous two to three months, providing a good idea of how well diabetes was controlled.Review of the ADA's information on hyperglycemia (high blood glucose), retrieved from https://diabetes.org/living-with-diabetes/treatment-care/hyperglycemia on 04/06/26, revealed hyperglycemia could be a serious problem if left untreated. The ADA's website indicated part of managing diabetes was checking blood glucose often and treating high blood glucose early to help avoid problems associated with hyperglycemia. Review of the ADA's information on important health checks for people with diabetes, retrieved from https://diabetes.org/living-with-diabetes/newly-diagnosed/health-checks-people-with-diabetes on 04/06/26, revealed an A1C test was important for people with diabetes because it measured the average blood glucose level over the past two to three months and a high A1C was indicative of frequent high blood glucose, which increased risk for complications such as nerve damage, kidney disease, and vision impairment. The target range for A1C was less than 7% for many adults and a target of less than 8% may be appropriate for older adults who may have other health complications that require extra caution.

Based on record review, review of the McGreer Criteria and interview, the facility failed to ensure Resident #33 did not receive unnecessary antibiotics. This affected one (Resident #33) out of six residents reviewed for unnecessary medications. The facility census was 80.Findings include:Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included acute embolism and thrombosis deep vein of right lower leg, type II diabetes mellitus, and hemiplegia and hemiparesis. A physician order dated 03/03/26 revealed Resident #33 was ordered nitrofurantoin/Macrobid (antibiotic) 100 milligram (mg) every morning and at bedtime for urinary tract infection (UTI) prophylactic for prevention. The infection control log revealed Resident #33 had an onset date of a UTI on 03/03/26. There was an unknown pathogen and nitrofurantoin/Macrobid was ordered. The revised McGeer Criteria for infection surveillance checklist revealed the date of infection was 03/03/36 and the date of review was 03/17/26. The criteria were met for skin and soft tissue infections. Table 2 revealed a UTI without indwelling catheter met criteria with acute costovertebral angle pain or tenderness. A Consultant Pharmacist Recommendations to Nursing dated 03/03/26 revealed Resident #33 had an order for nitrofurantoin/Macrobid 100 mg twice a day for UTI prophylaxis; however, Macrobid is dosed twice a day for UTI treatment and nitrofurantoin was dosed every day for prophylaxis. Please clarify this order with prescriber and update the medication administration record (MAR) accordingly. A progress note dated 03/03/26 at 3:35 P.M. authored by the former Director of Nursing (DON) revealed per pharmacy recommendations, Resident #33's nitrofurantoin 100 mg was to be discontinued and generic Macrobid 100 mg would be ordered. The DON updated the order. The MAR revealed Resident #33 received nitrofurantoin 100 mg on 03/03/26 upon rising. A new order was entered and Resident #33 received Macrobid 100 mg at bedtime on 03/03/26 and twice a day through 03/11/26. The 5-day admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact. The MDS also revealed the resident was frequently incontinent of bowel and bladder. On 03/12/26 Resident #33 did not receive Macrobid. On 03/13/26, Resident #33 started receiving Macrobid 100 mg once daily. An interview on 04/01/26 at 9:25 A.M. Assistant Director of Nursing (ADON) #893 verified Resident #33 did not meet the McGreer criteria for Macrobid to be administered, and she had completed the revised McGeer Criteria for infection surveillance checklist incorrectly. She verified the pharmacy had made the recommendation for Macrobid to be decreased to once a day on 03/03/26 and it was not decreased until 03/13/26. ADON #893 stated Resident #33 was listed on the infection control log again on 03/13/26 since there was a new order.

Based on record review, observation, facility policy review and interview, the facility failed to ensure Residents #64 and #66 were provided with dignity during meals. This finding affected two (Residents #64 and #66) of five residents reviewed for dignity and respect during meals. The facility census was 80.Findings include:1. Review of Resident #66's medical record revealed the resident was admitted on [DATE] with diagnoses including osteomyelitis of vertebra, dysphagia, generalized anxiety disorder, dementia, heart failure, unspecified psychosis, anemia, history of stroke, and history of venous thrombosis/embolism. Review of Resident #66's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #66's physician orders revealed an order dated 03/20/26 and again on 04/04/26 for a regular diet, mechanical soft texture with nectar thickened liquids consistency. Observation on 03/30/26 at 9:44 A.M. revealed Certified Nursing Assistant (CNA) #890 was standing beside Resident #66's bed feeding the resident eggs, hashbrowns and oatmeal. Interview on 03/30/26 at 9:45 A.M. with Licensed Practical Nurse (LPN) #882 confirmed there was a chair in the resident's room to sit down and assist the resident with the breakfast meal. 2. Review of Resident #64's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, major depressive disorder and vascular dementia. Review of Resident #64's physician orders revealed an order dated 08/14/25 for a regular diet, regular texture with thin liquids consistency. Review of Resident #64's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Observation on 03/31/26 at 7:56 A.M. revealed CNA #912 was standing beside Resident #64's bed feeding the resident eggs, hashbrowns and oatmeal. Interview on 03/31/26 at 8:00 A.M. with CNA #912 confirmed there was no chair in the resident's room to sit down and assist the resident with the breakfast meal. Review of the Assistance with Meals policy revised 07/2017 revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. This deficiency represents noncompliance investigated under Complaint Numbers 2725826 and 2579366.

Based on record review and interview, the facility failed to implement a comprehensive care plan with relevant interventions for Resident #77. This affected one (Resident #77) out of one resident reviewed for elopement. The facility census was 80.Findings include: Review of the medical record for Resident #77 revealed an admission date of 03/04/26 with diagnoses including psychoactive substance abuse, depression, anxiety, and post-traumatic stress disorder.Review of the elopement risk assessment dated [DATE] revealed Resident #77 was at low risk for elopement with a score of 9.0. There were no additional elopement risk assessments available for review.Review of the progress note dated 03/21/26 at 8:01 P.M. revealed Resident #77 demanded to leave the facility and went outside the building. Facility staff called Resident #77's guardian who spoke to Resident #77 and informed her she was not allowed to leave the facility per the local probate court. Resident #77 was returned to the facility, and a Wanderguard was placed along with 15-minute checks for safety.Review of the physician's orders for Resident #77 identified orders for a Wanderguard (a bracelet that alerts staff if someone who should not leave tries to go out the door) to the left arm for safety with placement checks every day and night shift effective 03/21/26.Review of the elopement risk care plan dated 03/23/26 revealed Resident #77 was an elopement risk or wanderer related to disoriented to place, history of attempts to leave the facility unattended, and impaired safety. There were no interventions listed on the care plan.On 03/31/26 at 11:20 A.M., an interview with Minimum Data Set (MDS) Nurse #831 confirmed Resident #77's care plan for elopement did not have any interventions listed and verified the elopement risk was identified on 03/21/26.

Based on record review and interview, the facility failed to revise the care plan to accurately reflect the status of Resident #26. This affected one (Resident #26) out of three residents reviewed for catheter use. The facility census was 80.Findings include: Review of the medical record for Resident #26 revealed an admission date of 10/09/25 with diagnoses including cellulitis of abdominal wall, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, morbid obesity, depression, heart failure, chronic kidney disease (CKD) Stage III, gastro-esophageal reflux disease (GERD), hypothyroidism, restless legs syndrome, post-traumatic stress disorder (PTSD), generalized anxiety disorder, and bipolar disorder.Review of the catheter care plan dated 01/28/26 revealed Resident #26 had an indwelling catheter related to urinary retention. Interventions included 16 French 10 milliliter catheter with bag and tubing positioned below the level of the bladder and away from the entrance room door implemented 01/28/26, check tubing for kinks each shift implemented 01/28/26, maintain dignity cover over indwelling urinary catheter bag implemented 01/28/26, monitor and document intake and output per facility policy implemented 01/28/26, monitor for signs and symptoms of discomfort implemented 01/28/26, monitor and document for pain due to catheter implemented 01/28/26, and monitor and record signs and symptoms of urinary tract infections (UTI) and report to the physician implemented 01/28/26.Review of the progress note dated 02/26/26 at 1:04 P.M. revealed Resident #26's catheter balloon was out of the urethra. Resident #26 stated she was sore from having catheters placed so many times and she wanted a break.Review of the physician's orders for Resident #26 revealed the orders for urinary catheter maintenance and output monitoring were discontinued on 03/01/26, and no new catheter orders were implemented.On 04/01/26 at 2:56 P.M., an interview with Resident #26 stated she no longer had a catheter.On 04/02/26 at 9:52 A.M., an interview with Minimum Data Set (MDS) Nurse #831 verified Resident #26 had an active care plan for catheter use, and the care plan should have been discontinued because Resident #26 no longer had a catheter.This deficiency represents noncompliance investigated under Complaint Number 2725826.

Based on record review, observation, facility policy review and interview, the facility failed to ensure Resident #64's eyes were free of debris and Resident #26 received showers as scheduled. This finding affected two (Residents #26 and #64) of four residents reviewed for activities of daily living (ADL). The facility census was 80.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 10/09/25 with diagnoses including cellulitis of abdominal wall, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, morbid obesity, depression, heart failure, chronic kidney disease (CKD) Stage III, gastro-esophageal reflux disease (GERD), hypothyroidism, restless legs syndrome, post-traumatic stress disorder (PTSD), generalized anxiety disorder, and bipolar disorder. Review of the care plan dated 10/20/25 revealed Resident #26 had a self-care deficit related to decreased functional mobility. Interventions included grooming and hygiene assistance of one staff implemented 10/20/25, set up bath items and put out clothes as needed implemented 10/20/25, and provide transfer assistance of one to two staff as required implemented 10/20/25. Review of the care plan dated 10/20/25 revealed Resident #26 had an ADL self-care performance deficit related to decreased functional mobility. Interventions included bathing or showering and avoiding scrubbing dry sensitive skin implemented 10/20/25, provide sponge bath when a full bath or shower could not be tolerated implemented 10/20/25, and washing hair once weekly per resident preference implemented 03/25/26. Review of the paper shower sheets for Resident #26 revealed preferred bathing days were Tuesdays and Fridays and bathing was performed on 01/02/26, 01/06/26, 01/17/26, 01/30/26, 02/01/26, 02/06/26, 02/10/26, 02/22/26, 03/04/26, 03/10/26, 03/11/26, 03/13/26, 03/18/26, 03/24/26, 03/28/26, and 03/30/26. Review of the shower documentation under the nurse aide tasks in the electronic medical record (EMR) revealed showering or bathing was marked as not applicable on 03/08/26, 03/12/26, 03/16/26, 03/22/26, 04/04/26, and 04/05/26, and there were no documented showers, tub baths, bed baths, or refusals documented in previous 30 days. There was no evidence of bathing performed on or around 01/09/26, 01/13/26, 01/20/26, 01/23/26, 01/27/26, 02/13/26, 02/17/26, 02/27/26, 03/06/26, and 03/20/26. The showering and bathing documentation provided by the facility indicated bathing was performed for Resident #26 on 16 days out of 26 scheduled opportunities between 01/01/26 and 03/31/26. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had no cognitive impairment and was dependent on staff for showering and bathing. Review of the progress notes from 01/01/2026 through 03/30/2026 revealed no evidence of Resident #26 refusing showers. On 04/01/26 at 2:47 P.M., an interview with Resident #26 stated she had concerns with receiving bathing and hygiene assistance. On 04/06/26 at 9:22 A.M., an interview with Assistant Director of Nursing (ADON) #893 verified the showering and bathing documentation for Resident #26. ADON #893 claimed Resident #26 got a bed bath every day and staff must not have documented it. On 04/06/26 at 10:57 A.M., an interview with the Director of Nursing (DON) confirmed the paper documentation provided for Resident #26 included a paper shower sheets with multiple bathing days documented that spanned from the beginning of January 2026 through the end of February 2026 and a second paper shower sheet with multiple bathing days documented that spanned from the beginning of March 2026 through the end of March 2026. The DON claimed there must be missing documentation. On 04/06/26 at 11:08 A.M., an interview with Regional Clinical Director (RCD) #952 verified the bathing documentation provided for Resident #26. RCD #952 also stated Resident #26 received a bed bath as part of the daily ADL care and staff were not documenting it every day, they were only documenting it on scheduled shower days. RCD #952 also confirmed there were no documented refusals of bathing for Resident #26. Review of the facility's policy titled Giving a Bed bath, dated October 2010, revealed the purpose of the procedure was to promote cleanliness and provide comfort to the resident. In preparation, staff were to review the resident's care plan to assess for any special needs including information about the type of bath to be provided, amount of assistance needed, limitation in positions or activity, skin care products to use, and any other special considerations. The date and time the bed bath was performed, the name and title of the staff performing the bed bath, assessment data obtained during the bed bath, the resident's tolerance of the bed bath, refusals of bed baths as applicable, and the signature and title of the person recording the bed bath should all be documented in the resident's ADL record and the medical record. 2. Review of Resident #64's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, essential hypertension and major depressive disorder. The resident resided on the secured memory care unit (SMCU). Review of Resident #64's physician orders revealed an order dated 03/01/25 for refresh eye ointment at bedtime for both eyes for dry eyes; and an order dated 02/23/26 to instill baby shampoo infant care products in both eyes every morning and at bedtime for dry eyes. Apply to eyelids, dilute and use to clean eyes. Review of Resident #64's Annual MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. She was dependent on staff for personal hygiene and bathing. Observation on 03/30/26 at 8:28 A.M. revealed Resident #64 was sitting in the television area in a wheelchair. The resident's bilateral eyes appeared matted with debris. Interview at the time of the observation with Regional Director of Operations (RDO) #916 confirmed the observation. Observation on 03/31/26 at 8:43 A.M. revealed Certified Nursing Assistant (CNA) #825 was transporting the resident into the common lounge area in a wheelchair. The resident's bilateral eyes appeared matted. Interview on 03/31/26 at 8:44 A.M. with CNA #825 revealed she would clean the resident's eyes later because the nurse was putting ointments on the resident's eyes. Interview on 03/31/26 at 8:45 A.M. with Registered Nurse (RN) #867 confirmed Resident #64's bilateral eyes were to be cleaned with baby shampoo which the CNAs could perform. Resident #64 confirmed the resident had matted eyes and it was a chronic condition. Observation on 04/01/26 at 8:13 a.m. revealed Resident #64 was seated in a wheelchair in the television area of the SMCU. Both eyes appeared crusted. The resident did not exhibit behaviors. Review of the Giving a Bed bath policy revised 10/2010 revealed to place a towel over the resident's chest, make a mitten out of the washcloth, wash the resident's eyes from the nose to the outside of the face using water only, after washing one eye, fold the wash cloth and wash the other eye, wash the resident's face. This deficiency represents non-compliance investigated under Complaint Numbers 2725826, 2721789 and 1282446 (OH00166150).

Based on observation, record review, and interview, the facility failed to ensure Resident #1's oxygen tubing was stored in the proper manner when not in use. This affected one (Resident #1) out of one reviewed for respiratory care. The facility census was 80. Findings include:Review of the medical revealed Resident #1 was admitted on [DATE] with diagnoses that included acute kidney failure, congestive heart failure, transient cerebral ischemic attack, and chronic obstructive pulmonary disease. A plan of care dated 04/12/24 revealed Resident #1 received oxygen therapy. Interventions included to change oxygen tubing and oxygen settings via nasal cannula as ordered. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severely impaired cognitive skills. The MDS also revealed Resident #1 received oxygen therapy. A physician order dated 01/08/26 revealed Resident #1's oxygen saturation was to be monitored every day and night shift. A physician order dated 02/11/26 revealed Resident #1 was ordered oxygen at two liters per minute via nasal canula every day and night shift and as needed for oxygen saturation below 90%. An observation on 03/30/26 at 7:54 A.M. revealed Resident #1 was lying in bed with a blanket over her. Resident #1's oxygen tubing was observed to be under the blanket at the bottom of the bed. An observation on 03/30/2026 at 10:50 A.M. revealed Resident #1's oxygen tubing was still observed to be under the blanket at the bottom of the bed. Certified Nursing Assistant (CNA) #832 verified Resident #1 should be wearing oxygen and the oxygen tubing should not be placed on the bed. CNA #832 verified Resident #1 was not able to remove oxygen tubing and place it under the blanket at the bottom of the bed. An interview on 03/31/26 at 12:42 P.M. Regional Director of Operations (RDO) #916 revealed the facility did not have a policy for the storage of oxygen tubing. RDO verified the nasal cannula should be in the resident's nares or stored appropriately if not in use.

Based on record review, interview and policy review, the facility failed to ensure Resident #100 had pain medication available. This affected one (Resident #100) out of six residents reviewed for pain management. The facility census was 80. Findings include:Review of the medical record revealed Resident #100 was admitted on [DATE] with diagnoses that included cellulitis, type II diabetes, morbid obesity, ventral hernia with obstruction, and venous thrombosis and embolism. Resident #100 was discharged to the hospital on [DATE]. Review of the discharge record from the hospital revealed a paper copy of the prescription for oxycodone (opioid for severe pain) five milligram (mg) every six hours as needed for up to three days. A general progress note dated 07/19/25 at 8:54 A.M. revealed Resident #100 arrived at the facility via a stretcher on 07/18/25 at 8:30 P.M. from the hospital. The resident complained of pain and discomfort due to an abdominal incision. The nursing admit/readmit care plan dated 07/19/25 revealed Resident #100 rated pain a three on a scale of zero to ten with ten being the worst pain. Resident #100's pain goal was zero. Resident #100's pain began after surgery and lasted on and off for a few days. The quality of pain was described as sharp with medication and rest alleviating the pain. The pain affected sleep, mood, socialization, activity of daily living, and the physical activity and mobility. An interim care plan dated 07/19/25 revealed Resident #100 was not cognitively impaired. Medications and treatments included pain medications. The pain assessment dated [DATE] revealed Resident #100 had occasional pain that made it hard to sleep at night and limited day-to-day activities during the last five days. The resident rated pain a three on a scale of zero to ten. The resident's pain goal was zero. The Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had modified independence with cognitive skills and did not receive scheduled or as needed pain medication. A general progress note dated 07/20/25 at 8:45 A.M. revealed Resident #100 became agitated and stated night shift was not friendly or helpful. Resident #100 was reassured that staff would help the resident get out of bed and get a shower. A general progress note dated 07/20/25 at 11:56 A.M. revealed the pharmacy was called about pulling Resident #100's pain medication. The pharmacy stated the paper prescription had not been received. The nurse faxed the paper prescription to the pharmacy. A general progress note dated 07/20/25 at 12:38 P.M. revealed the pharmacy stated they did not receive the paper prescription. The nurse resent the prescription to the pharmacy. A general progress note dated 07/20/25 at 1:40 P.M. revealed the pharmacy stated they still did not have a paper prescription. The nurse resent the paper prescription for the third time. A general progress note dated 07/20/25 at 3:00 P.M. revealed Resident #100 stated she could not breathe. The resident's oxygen saturation was 100% on room air. The resident's family was at bedside and called 911 while the nurse was assessing the resident. Review of the medication administration record (MAR) revealed Resident #100 received no as needed pain medication. The treatment administration record (TAR) revealed Resident #100 was to have pain assessed and monitored every shift. The TAR had a checkmark the evening of 07/19/25 and the morning of 07/20/25. The TAR did not reveal what Resident #100 reported as her pain level. An interview on 04/06/26 at 3:38 P.M. Regional Clinical Director (RCD) #952 verified Resident #100 did not receive any as needed pain medication and did not have appropriate pain monitoring. RCD #952 verified the hospital had sent a paper prescription for Resident #100's oxycodone. RCD #952 verified the pharmacy could give authorization for the oxycodone to be pulled from the emergency supply with a paper prescription from the facility. This deficiency represents noncompliance investigated under Complaint Numbers 2579173 and 2579366.

Based on record review and interviews, the facility failed to monitor and maintain adequate communication with the outside dialysis center to include vital signs and weights before and after dialysis and failed to ensure the facility had a dialysis policy. This affected one (Resident #7) of one resident reviewed for dialysis. The facility identified Resident #7 as the only resident receiving dialysis in the facility. The facility census was 80.Findings include:Review of the medical record for Resident #7 revealed an admission date of 11/28/25. Diagnoses included end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia and cognitive communication deficit.Review of the physician orders for March 2026 revealed an order for hemodialysis every Tuesday, Thursday, and Saturday morning with transport pick up at 9:40 A.M. and chair time of 10:45 A.M. to an outside dialysis facility. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15.Review of the dialysis communication binder for March 2026 for Resident #7 revealed on 03/03/26, 03/19/26, 03/24/26, 03/26/26, and 03/28/26 there was no communication form with the pre weight and vital signs or the post dialysis form to and from the outside dialysis facility.Interview on 03/30/26 at 2:49 P.M. with Licensed Practical Nurse (LPN) #882 confirmed the dialysis forms were not consistently sent, missing documentation from facility, and missing documentation from the outside dialysis facility. LPN #882 confirmed there were no forms for 03/03/26, 03/19/26, 03/24/26, 03/26/26, and 03/28/26. Interview on 03/30/26 at 2:54 P.M. with LPN #862 confirmed the dialysis forms were not consistently sent, missing documentation from facility, and missing documentation from the outside dialysis facility. LPN #862 confirmed there were no forms for 03/03/26, 03/19/26, 03/24/26, 03/26/26, and 03/28/26. Interview on 03/31/26 at 6:32 A.M. with Assistant Director of Nursing (ADON) #893 confirmed the dialysis forms are not consistently sent, missing documentation from facility, and missing documentation from the outside dialysis facility. ADON #893 confirmed there were no forms for 03/03/26, 03/19/26, 03/24/26, 03/26/26, and 03/28/26. Interview on 04/01/26 at 3:41 P.M. with Dialysis Registered Nurse (RN) #955 confirmed they do not receive any documentation from the facility. Dialysis RN #955 reported it was important to know his condition prior to dialysis so if there were any changes during or after dialysis. RN #955 reported they fax over the post dialysis to the facility daily.Review of the physician's orders for April 2025 revealed orders for hemodialysis in the morning every Tuesday, Thursday, and Saturday at an outside dialysis facility and to send communication the form. Interview on 04/06/26 at 2:59 P.M. with Regional Director of Operations #916 confirmed the facility had no policy for dialysis.This deficiency represents noncompliance investigated under Complaint Number 2721789.

Based on record review and interview, the facility failed to ensure individual patient-controlled substance administration records and medication administration records were accurate for Resident #99. This affected one (Resident #99) out of six residents reviewed for unnecessary medications. The facility census was 80. Findings include: Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses including encephalopathy, psychoactive substance abuse, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and schizoaffective disorder. Resident #99 was discharged home on [DATE]. The facility physician orders dated 08/03/25 revealed Resident #99 was ordered oxycodone (opioid for moderate to severe pain) 5 milligrams (mg) every eight hours as needed. The individual patient-controlled substance administration record date 08/03/25 revealed Resident #99 was ordered 1/2 tab (2.5 mg) every eight hours as needed; two half tablets (5 mg) every eight hours as needed. The medication administration record (MAR) revealed Resident #99 received oxycodone five milligrams (mg) on 08/03/25 at 9:17 A.M. and 5:19 P.M. The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 2.5 mg on 08/03/25 at 8:00 A.M. and 2.5 mg five mg at 5:00 P.M. The MAR revealed Resident #99 received oxycodone 5 mg on 08/03/25 at 9:17 A.M. and 5:19 P.M. The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 2.5 mg on 08/04/25 at 8:00 P.M. (signed out prior to the 9:16 A.M. dose), 5 mg at 9:16 A.M. and 5 mg at 9:01 P.M. The MAR revealed Resident #99 received oxycodone 5 mg on 08/04/25 at 9:16 A.M. and 9:01 P.M.The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 5 mg on 08/05/25 at 2:00 P.M. and 7:35 P.M.The MAR revealed Resident #99 received oxycodone 5 mg on 08/05/25 at 7:33 P.M.The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 5 mg on 08/06/25 at 2:00 P.M. and 2.5 mg on 10:00 P.M.The MAR revealed Resident #99 did not receive any oxycodone on 08/06/25.The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 2.5 mg on 08/07/25 at 6:06 A.M.The MAR revealed Resident #99 received oxycodone 5 mg on 08/07/25 at 6:06 A.M.The individual patient-controlled substance administration record revealed Resident #99 received oxycodone 5 mg on 08/08/25 at 2:00 P.M. The MAR revealed oxycodone was discontinued on 08/07/25 at 11:59 P.M. A discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #99 was cognitively intact and received opioid medication. The MDS also revealed Resident #99 received scheduled and as needed pain medication for occasional pain. An interview on 04/06/26 at 12:48 P.M. Regional Clinical Director (RCD) #952 verified that the order was entered incorrectly on the MAR for oxycodone 5 mg only and did not match the order on the oxycodone sent from pharmacy. RCD #952 verified oxycodone was sent in half tabs of 2.5 mg and sometimes the nurses gave 2.5 mg and sometimes they gave two half tablets to equal 5 mg. RCD #952 verified the individual patient-controlled substance administration record and MAR did not match when oxycodone was administered. This deficiency represents noncompliance investigated under Complaint Number 2721789.

Based on record review, observation, facility policy review and interview, the facility failed to implement personal protective equipment (PPE) as required during care of Residents #45 and #62 who were in contact isolation precautions. The facility also failed to put the correct infection control precautions in place when Resident #62 was admitted . This finding affected two (Residents #45 and #62) of three residents reviewed for contact isolation precautions. The facility census was 80.Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of right leg, type II diabetes, nondisplaced fracture of the head of the radius, and methicillin resistant staphylococcus aureus (MRSA) infection. Review of the hospital discharge records dated 03/16/26 revealed Resident #62 had several blood cultures and wound cultures positive for MRSA. A physician order dated 03/17/26 for Resident #62 to have enhanced barrier precautions (EBP) in place. A plan of care dated 03/17/26 revealed Resident #62 was on EBP. Interventions included EBP signage on the door and gloves and gowns to be worn for high contact. Review of the treatment administration record (TAR) revealed Resident #62 had EBP in place from 03/17/26 to 03/26/26. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact. A physician order dated 03/26/26 revealed contact isolation precautions were ordered for Resident #62 The TAR revealed on 03/26/26 Resident #62 had contact isolation precautions put into place. An interview on 04/01/26 at 12:15 P.M. Assistant Director of Nursing (ADON) #893 verified Resident #62 was admitted with MRSA but was not put in contact isolation until 03/26/26. ADON #893 verified that EBP were not adequate precautions since Resident #62 had positive blood and wound culture results for MRSA. Isolation-Categories of Transmission-Base Precautions policy, revised January 2012, revealed contact precautions should be implemented for residents known or suspected microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Gloves and a disposable gown should be worn when entering the contact precaution room. 2. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of right leg, type II diabetes, nondisplaced fracture of head of radius, and MRSA infection. A physician order dated 03/26/26 revealed contact isolation precautions were ordered for Resident #62. The TAR revealed on 03/26/26 Resident #62 had contact isolation precautions put in place. An observation on 03/30/26 at 12:45 P.M. revealed a contact isolation sign outside Resident #62's room. Surveyor donned gown and gloves and went into the resident's room. At 12:55 P.M. Certified Nursing Assistant (CNA) #832 entered Resident #62's room to turn off the resident's call light. CNA #832 did not don gloves or a gown. CNA #832 turned off the call light, asked Resident #62 what he needed and left the room. At 12:57 P.M. CNA #832 entered Resident #62's room again without gloves or a gown. CNA #832 verified Resident #62 was in contact isolation and gowns and gloves were to be worn in the resident's room. CNA #832 verified she did not put a gown or gloves on either time she entered Resident #62's room while the surveyor was present. CNA #832 picked up Resident #62's lunch tray and carried it out of the room. Isolation-Categories of Transmission-Base Precautions policy, revised January 2012, revealed contact precautions should be implemented for residents known or suspected microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Gloves and a disposable gown should be worn when entering the contact precaution room. 3. Review of Resident #45's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, cutaneous abscess of the chest wall and anxiety disorder. The resident resided on the secured memory care unit (SMCU). Review of Resident #45's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #45's After Visit Summary note dated 03/25/26 at 1:00 P.M. revealed the resident had MRSA infection and pseudomonas aeruginosa infection. Review of Resident #45's physician orders revealed an order dated 03/25/26 to place the resident in contact isolation precautions for Vancomycin-resistant Enterococci (VRE) of the left breast wound. Observation on 03/31/26 at 7:09 A.M revealed Certified Occupational Therapy Aide (COTA) #868 was in Resident #45's room. She was observed moving the resident's right leg up and down. COTA #868 did not have an isolation gown in place at the time of the observation. She did have gloves in place during the observation. Interview on 03/31/26 at 7:10 A.M. with COTA #868 confirmed Resident #45 was in isolation precautions, and she should have had an isolation gown to protect against cross contamination for other residents. Observation on 03/31/26 at 7:36 A.M. revealed Human Resources (HR) #802 was observed moving items around in Resident #45's room without gloves or an isolation gown in place. Signage on the door revealed the resident was in contact precautions. Interview on 03/31/26 at 7:39 A.M. with HR #802 confirmed the above findings. Review of Isolation- Categories of Transmission-Based Precautions, revised 01/2012, revealed in addition to wearing gloves as outlined under standard precautions, wear gloves when entering a room, remove gloves and wash hands when leaving the room and wear a disposable gown upon entering the Contact Precautions room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental services.

Based on record review, facility policy review and interview, the facility failed to ensure Resident #7's medical record was accurate and complete. This finding affected one (Resident #7) of three residents reviewed for accuracy of medical records. The facility census was 80.Findings include:1. Review of Resident #7's medical record revealed the resident was admitted on [DATE] with diagnoses including end state renal disease with dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and diabetes. The medical record revealed the resident's daughter was the legal guardian and power-of-attorney (POA) for health care and financial.Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #7's physician orders revealed an order dated 01/01/26 (discontinued 01/05/26) for hospice services.Review of Resident #7's Hospice Patient Medication Cover Sheet form dated 01/01/26 revealed the resident was ordered acetaminophen (analgesic), hydralazine (vasodilator to treat high blood pressure), labetalol (medication to treat high blood pressure), omeprazole (reduces stomach acid), sertraline (antidepressant), bisacodyl (laxative), polyethylene glycol (laxative), promethazine (antihistamine), hydroxyzine pamoate (antihistamine) and tramadol (narcotic pain medication). The form was signed by the legal guardian.Review of Resident #7's physician orders revealed an order dated 01/01/26 for tramadol 50 milligrams (mg) give one tablet by mouth every six hours as needed for severe pain. The order was discontinued on 01/13/26.Review of Resident #7's progress note dated 01/01/26 at 7:18 P.M. (late entry created on 01/22/26 at 11:19 A.M.) revealed a new order to discontinue the tramadol due to non-utilization per the physician.Review of Resident #7's medication administration records (MAR) from 01/01/26 to 01/13/26 revealed on 01/06/26 at 12:38 A.M., the resident received a tramadol for a pain level of seven on a pain scale of zero to ten, ten being the worst.Review of Resident #7's progress note dated 01/02/26 at 12:11 P.M. revealed the resident's daughter admitted the resident to hospice on 01/01/26 and called on this date to revoke hospice services.Review of Resident #7's Care Conference note dated 01/07/26 revealed hospice was discussed and a copy of the summary was provided to the resident's guardian (daughter). The medications were reviewed. The resident's guardian expressed concerns regarding the tramadol narcotic administration. The facility would obtain an order to discontinue the tramadol if the guardian requested.Review of Resident #7's Care Conference note dated 01/22/26 revealed Ombudsman #915 asked the resident's guardian if she had restrictions regarding medications. She stated medication decisions were at the physician discretion, provided the nephrologist agreed.Interview on 04/01/26 at 9:24 A.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #893 revealed that the late entry progress note created on 01/22/26 for 01/01/26 stated to discontinue the tramadol on 01/01/26 and the orders stated to discontinue the tramadol on 01/13/26. The resident received a dose of tramadol on 01/07/26.Interview on 04/01/26 at 12:28 P.M. with RN Regional Clinical Director (RCD) #952 revealed Resident #7's guardian had reported some concerns about pain medications on 01/07/26. RN RCD #952 revealed the guardian was aware the resident was ordered tramadol on 01/01/26 during initiation of hospice services, and she thought when she revoked hospice services on 01/02/26, the orders would automatically revert to pre-hospice orders. RN RCD #952 indicated when the family voiced concerns about the tramadol and the possibility of addiction during the care conference on 01/07/26, the tramadol should have been discontinued, but the tramadol was not discontinued until 01/13/26. RN RCD #952 confirmed Resident #7 had only received one dose of the tramadol and that was prior to the family concern during the care conference. RN RCD #952 also confirmed she was unsure why Former Director of Nursing (DON) #951 put in a late entry to discontinue the tramadol on 01/01/26 when the order was not discontinued.Review of the Administering Medications policy, revised 02/2012, revealed medications shall be administered in a safe and timely manner, and as prescribed.2. Review of Resident #7's medical record revealed the resident was admitted on [DATE] with diagnoses including end state renal disease with dependence on renal dialysis, COPD, and diabetes. The medical record revealed the resident's daughter was the legal guardian and POA for health care and financial.Review of Resident #7's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #7's physician orders for March 2026 revealed an order for Total Daily fluid Restriction 2000 milliliter (ml), Dietary 1200 ml and Nursing 800 ml two times a day for fluid restriction.Review of the MAR and treatment administration records (TAR) for March 2026 revealed 03/01/26 and 03/06/26 the morning box for the Total Daily Fluid Restriction for the morning was blank for the Dietary and Nursing intake. There were no intake amounts or initials of completion.Interview on 04/02/26 at 2:49 P.M. Unit Manager Licensed Practical Nurse (LPN) #884 confirmed on 03/01/26 and 03/06/26 the MAR/TAR was not completed and left blank. Unit Manager LPN #884 reported it was to be completed and initialed. Interview on 04/07/26 at 7:00 A.M. via phone, with LPN #900 confirmed on 03/01/26 and 03/06/26, she worked and did the fluid restriction. LPN #900 reported sometimes the computer has a glitch and doesn't record it correctly. LPN #900 confirmed the boxes should have had her initials and intake amount.Review of the facility policy, Charting and Documentation, revised July 2017, revealed all services provided to the resident shall be documented in the resident's medical record. Further states the following information is to be documented in the resident medical record to include medications and treatments administered/performed. Documentation of procedures and treatments will include care-specific details, including the date and time the procedure treatment was provided.Review of the facility policy, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner as prescribed to include the individual administering the medication will record in the resident's medical record the date and time the medication was administered.This deficiency represents noncompliance investigated under Complaint Number 2721789.

Based on record review, interviews, review of photos and facility policy review, the facility failed to ensure medications were not left at bedside of Resident #7. This affected one (Resident #7) of one resident reviewed for unsecured medications. The facility census was 80.Findings include:Review of the medical record for Resident #7 revealed an admission date of 11/28/25. Diagnoses included end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia and cognitive communication deficit.Review of the physician orders for December 2025 revealed an order for Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (antiseptic) to give 15 milliliters (ml) by mouth (PO) every morning and at bedtime for teeth extractions to swish and spit. Review of the photos provided by Resident #7's guardian, dated 12/20/25 at 7:32 A.M. revealed a medicine cup on Resident #7's over the bed tray with one capsule in it and a plastic drinking cup with yellow/pale fluid in it. Interview on 03/30/36 at 2:49 P.M. and at 2:54 P.M. with Licensed Practical Nurse (LPN) #882 and LPN #862 confirmed medications were not to be left at the bedside. Telephone interview on 04/01/26 at 10:24 A.M. with Resident #7's guardian revealed the photo dated 12/30/25 at 7:33 A.M. had a medicine cup with one capsule in it and a plastic drinking cup with yellow/pale fluid which was his oral rinse. Resident #7's guardian reported the staff were to stay until the medications were taken and his rinse was completed per physician orders.Interview on 04/02/26 at 8:49 A.M. with Regional Nurse #952 confirmed the photo had a medicine cup with one capsule in it and a plastic cup with yellow/pale fluid in it. Regional Nurse #952 confirmed medications were not to be left at the bedside.Review of the facility policy, Administering Medications, revised December 2012, revealed medications were to be administered in a safe and timely manner, and as prescribed.This deficiency represents noncompliance investigated under Complaint Number 2721789.

Based on record review, observation and interview, the facility failed to ensure Resident #1's oxygen tubing was stored in the proper manner when not in use. This affected one (Resident #1) out of one reviewed for respiratory care. The facility census 80. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included acute kidney failure, congestive heart failure (CHF), transient cerebral ischemic attack, and chronic obstructive pulmonary disease (COPD). A plan of care dated 04/12/24 revealed Resident #1 received oxygen therapy. Interventions included changing oxygen tubing and oxygen settings via nasal cannula as ordered. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severely impaired cognitive skills. Resident #1 received oxygen therapy. A physician order dated 01/08/26 revealed Resident #1's oxygen saturation was to be monitored every day and night shift. A physician order dated 02/11/26 revealed Resident #1 was ordered oxygen at two liters per minute via nasal canula every day and night shift and as needed for oxygen saturation below 90%. An observation on 03/30/26 at 7:54 A.M. revealed Resident #1 was lying in bed with a blanket over her. Resident #1's oxygen tubing was observed to be under the blanket at the bottom of the bed. An observation on 03/30/2026 at 10:50 A.M. revealed Resident #1's oxygen tubing was still observed to be under the blanket at the bottom of the bed. Certified Nursing Assistant (CNA) #832 verified Resident #1 should be wearing oxygen and the oxygen tubing should not be placed on the bed. CNA #832 verified Resident #1 was not able to remove oxygen tubing and place it under the blanket at the bottom of the bed. An interview on 03/31/26 at 12:42 P.M. Regional Director of Operations (RDO) #916 revealed the facility did not have a policy for the storage of oxygen tubing. RDO verified the nasal cannula should be in the resident's nares or stored appropriately if not in use.

Based on record review, interview, facility self-reported incident (SRI) review, police report review, and facility policy review, the facility failed to ensure Resident #77 was free from sexual abuse. This affected one resident (Resident #77) of three residents reviewed for abuse.Findings include:Review of the medical record for Resident #77 revealed an admission date of 01/09/26 with diagnoses including but not limited to dementia with psychotic disturbance, cognitive communication deficit and type 2 diabetes mellitus. Review of the care plan dated 01/09/26 revealed Resident #77 has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included administer medications as ordered, communicate with resident/family, identify self at each interaction, cue, reorient, supervise, keep resident routine consistent, monitor and document and report any changes.Review of Resident #77s 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment Review of Resident #77's progress notes revealed no notes regarding physical or sexual abuse by Resident #43 on 02/08/26. Review of the medical record Resident #43 revealed an admission date of 12/27/25 with diagnoses including but not limited to cerebral Infarction, schizophrenia and psychoactive substance abuse.Review of the care plan dated 12/29/25 revealed Resident #43 had no care plans related to sexual history or sexual behaviors.Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #43 had intact cognition and was ambulatory.Review of the facility SRI tracking number 270705 dated 02/08/26 revealed on the evening of 02/08/26 Certified Nursing Assistant (CNA) #221 witnessed Resident #43 lift up Resident #77's shirt and touch her left breast. CNA #221 immediately separated Resident #77 from Resident #43. CNA #221 reported Resident #43 denied doing it and when she asked why, he responded she should wear a bra. CNA #221 reported the incident to Licensed Practical Nurse (LPN) #211 who reported it via phone to Director of Nursing (DON). An investigation was started to include monitoring Resident #77 and Resident #43. An SRI was submitted at that time. The facility investigation concluded no abuse had occurred. Review of the police report #2026-00012974, report date 02/19/26 at 3:50 P.M. revealed Police Officer #300 was notified of a sex offense that occurred on 02/08/26 between Resident #43 and Resident #77. Statements were received by Administrator, LPN #211, CNA #221, and Resident #77's husband. Interview on 02/18/26 at 7:49 A.M. and a second interview on 02/23/26 at 9:07 A.M. with Resident #77's husband revealed he was notified of the alleged sexual abuse but it was downplayed by the Administrator. Resident #77's husband denied any knowledge of her breast being touched inappropriately. He also reported the Administrator told him the police would be notified. Resident #77's husband reported Resident #77 has impaired cognition with confusion and is not able to make her needs known. Resident #77's husband reported the administrator made a motion with his hand circling stomach, to indicated that is where Resident #43 touched his wife. Resident #77's husband reported he never told the Administrator his wife lifted up or pulled off her clothes. Resident #77's husband reported he told the Administrator she would pull at her clothes sometimes. Resident #77's husband then reported on 02/20/26, unable to recall time, he received a call from the police and was told they wanted to interview him and they are starting an investigation.An attempt to interview Resident #77 on 02/18/26 at 9:29 A.M. was unsuccessful as Resident #77 was only able to state her name but unable to answer any questions. Interview on 02/18/26 at 10:30 A.M. with DON revealed she was notified by LPN #211 that Resident #77 who was touched inappropriately by Resident #43 and the facility immediately separated the residents and Resident #43 was put on 1:1 observation. DON reported she notified the Administrator, Regional Director of Operations (RDO) #289 and Regional Nurse #288 by phone of the alleged sexual abuse. Investigation was started. Interview on 02/18/26 at 2:21 P.M. with CNA #221, via phone, revealed on 02/08/26 at approximately 10:30 P.M. she witnessed Resident #43 lift up Resident #77's shirt and rubbing her left boob at the nurses station. CNA #221 reported she immediately went to him, and asked what he was doing and he threw her shirt back down and ran to his room. CNA #221 reported the allegation to LPN #211 and LPN #267 who approached the aide because they heard the aide questioning Resident #43. Interview on 02/18/26 at 2:50 P.M. with Administrator reported he was initially notified on 02/08/26 by the DON who informed him the alleged victim was Resident #24 but it was discovered during the investigation, the alleged victim was Resident #77. Administrator revealed the information provided by the DON initially of the resident involved was incorrect. Administrator revealed he was notified on 02/08/26 regarding alleged sexual abuse with Resident #77. Administrator revealed the facility found the allegation of sexual abuse to be unsubstantiated because it was reported the resident lifted her shirt up and there was no witnesses. In review of CNA #221's witness statement that Resident #43 touched Resident #77's breast with Administrator, the Administrator revealed he was unaware of this. Interview on 02/23/26 at 3:47 P.M. with Police Officer (PO) #300, via phone, revealed she received a call on 02/19/26 at 3:50 P.M. approximately from the Administrator regarding a sexual abuse allegation. PO #300 reported she spoke with Resident #77's husband who felt the facility downplayed what really happened. PO #300 reported she went to the facility on [DATE] that evening and interviewed LPN #211 and CNA #221 working on 02/08/26. PO #300 reported Resident #77 was asleep, and she didn't interview based on her interview with the LPN #211 and CNA #221 who reported Resident #77 had dementia, was confused, and unable to make her needs know. PO #300 reported Resident #77's husband wanted to think about it over the weekend and let them know if he wanted to press charges. On 02/24/26 at 6:32 P.M. a voice message from PO #300 revealed Resident #77's husband was pressing charges and PO #300 would no longer be her case. PO #300 reported Detective #301's will follow the case since it was a sexual offense. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 11/01/2019, revealed the policy is to investigate all alleged violations of abuse and the person investigating the incident should take the following actions to include interviewing all witnesses to cover all employees on the unit. This deficiency represents non-compliance investigated under Master Complaint Number 2787731 and Complaint Number 2743289.

Based on record review, interview, facility self-reported incident (SRI) review, police report, and facility policy review, the facility failed to thoroughly investigate a sexual abuse allegation for Resident #77. This affected one resident (Resident #77) out of three residents reviewed for abuse. The facility census was 92.Findings include:Review of the medical record for Resident #77 revealed an admission date of 01/09/26 with diagnoses including but not limited to dementia with psychotic disturbance, cognitive communication deficit and type 2 diabetes mellitus. Review of the care plan dated 01/09/26 revealed Resident #77 has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included administer medications as ordered, communicate with resident/family, identify self at each interaction, cue, reorient, supervise, keep resident routine consistent, monitor and document and report any changes.Review of Resident #77s 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment Review of Resident #77's progress notes revealed no notes regarding physical or sexual abuse by Resident #43 on 02/08/26. Review of the medical record Resident #43 revealed an admission date of 12/27/25 with diagnoses including but not limited to cerebral Infarction, schizophrenia and psychoactive substance abuse.Review of the care plan dated 12/29/25 revealed Resident #43 had no care plans related to sexual history or sexual behaviors.Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #43 had intact cognition and was ambulatory.Review of the facility SRI tracking number 270705 dated 02/08/26 revealed on the evening of 02/08/26 Certified Nursing Assistant (CNA) #221 witnessed Resident #43 lift up Resident #77's shirt and touch her left breast. CNA #221 immediately separated Resident #77 from Resident #43. CNA #221 reported Resident #43 denied doing it and when she asked why, he responded she should wear a bra. CNA #221 reported the incident to Licensed Practical Nurse (LPN) #211 who reported it via phone to Director of Nursing (DON). An investigation was started to include monitoring Resident #77 and Resident #43. An SRI was submitted at that time. The facility investigation concluded no abuse had occurred. Further in the investigation LPN #267 was never interviewed and she was working the evening CNA #221 reported it to LPN #211. LPN #267 was oriented with LPN #211. Review of the police report #2026-00012974, report date 02/19/26 at 3:50 P.M. revealed Police Officer #300 was notified of a sex offense that occurred on 02/08/26 between Resident #43 and Resident #77. Statements were received by Administrator, LPN #211, CNA #221, and Resident #77's husband. Interview on 02/18/26 at 7:49 A.M. and a second interview on 02/23/26 at 9:07 A.M. with Resident #77's husband revealed he was notified of the alleged sexual abuse but it was downplayed by the Administrator. Resident #77's husband denied any knowledge of her breast being touched inappropriately. He also reported the Administrator told him the police would be notified. Resident #77's husband reported Resident #77 has impaired cognition with confusion and is not able to make her needs known. Resident #77's husband reported the administrator made a motion with his hand circling stomach, to indicated that is where Resident #43 touched his wife. Resident #77's husband reported he never told the Administrator his wife lifted up or pulled off her clothes. Resident #77's husband reported he told the Administrator she would pull at her clothes sometimes. Resident #77's husband then reported on 02/20/26, unable to recall time, he received a call from the police and was told they wanted to interview him and they are starting an investigation.An attempt to interview Resident #77 on 02/18/26 at 9:29 A.M. was unsuccessful as Resident #77 was only able to state her name but unable to answer any questions. Interview on 02/18/26 at 10:30 A.M. with Director of Nursing (DON) revealed she was notified on 02/08/26 by Licensed Practical Nurse (LPN) #267 on 02/08/26 Resident #43 went into Resident #24's room and was touching Resident #24 inappropriately. Interview on 02/18/26 at 2:21 P.M. with CNA #221, via phone, revealed on 02/08/26 at approximately 10:30 P.M. she witnessed Resident #43 lift up Resident #77's shirt and rubbing her left boob at the nurses station. CNA #221 reported she immediately went to him, and asked what he was doing and he threw her shirt back down and ran to his room. CNA #221 reported the allegation to LPN #211 and LPN #267 who approached the aide because they heard the aide questioning Resident #43. Interview on 02/18/26 at 2:50 P.M. with Administrator reported he was initially notified on 02/08/26, late evening, by the DON who informed him of alleged sexual abuse and the alleged victim was Resident #24 but it was discovered during the investigation, the alleged victim was Resident #77. Administrator reported he started an investigation and initiated a SRI immediately and confirmed he did not interview LPN #267 during the investigation. Administrator revealed the facility found the allegation of sexual abuse to be unsubstantiated because it was reported the resident lifted her shirt up and there was no witnesses. In review of CNA #221's witness statement that Resident #43 touched Resident #77's breast with Administrator, the Administrator revealed he was unaware of this. Interview on 02/18/26 at 3:54 P.M. with LPN #267 revealed she worked on 02/08/26 with LPN #211 when the incident occurred with Resident #43 touching Resident #77 inappropriately. LPN #267 reported she was orienting with LPN #211 when they came out of a resident's room and walking down the hall when CNA #221 reported the sexual abuse to LPN #211. LPN #267 reported CNA #221 reported Resident #43 went into Resident #77's shirt and started rubbing her breast. LPN #267 reported she was never interviewed or asked to write a statement regarding sexual abuse. Interview on 02/23/26 at 3:47 P.M. with Police Officer (PO) #300, via phone, revealed she received a call on 02/19/26 at 3:50 P.M. approximately from the Administrator regarding a sexual abuse allegation. PO #300 reported she spoke with Resident #77's husband who felt the facility downplayed what really happened. PO #300 reported she went to the facility on [DATE] that evening and interviewed LPN #211 and CNA #221 working on 02/08/26. PO #300 reported Resident #77 was asleep, and she didn't interview based on her interview with the LPN #211 and CNA #221 who reported Resident #77 had dementia, was confused, and unable to make her needs know. PO #300 reported Resident #77's husband wanted to think about it over the weekend and let them know if he wanted to press charges. On 02/24/26 at 6:32 P.M. a voice message from PO #300 revealed Resident #77's husband was pressing charges and PO #300 would no longer be her case. PO #300 reported Detective #301's will follow the case since it was a sexual offense. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 11/01/2019, revealed the policy is to investigate all alleged violations of abuse and the person investigating the incident should take the following actions to include interviewing all witnesses to cover all employees on the unit. This deficiency represents non-compliance investigated under Master Complaint Number 2787731 and Complaint Number 2743289.

Based on record review, interviews, and facility policy review, the facility failed to ensure am individualized comprehensive nutrition plan was in place for Resident #5 and Resident #95 to properly monitor weights, nutritional status, and treat weight loss properly. This affected two residents (Resident #5 and #95) out of three residents reviewed for weights. Facility census was 92.Findings include:1.Review of the medical record for Resident #95 revealed an admission date of 12/19/25 and a discharge date of 02/16/26 to the hospital. Diagnoses included but not limited to Alzheimer's Disease, intermittent explosive disorder, and dementia.Review of the physician order for 12/19/25 revealed an order for regular diet, regular texture, thin liquids and for Med pass supplement 6 ounces (oz) with meals to give one container serving and record amount consumed. The order was discontinued on 02/13/26.Review of the care plan dated 12/19/25, revised on 12/27/25 revealed Resident #95 was at increased risk for malnutrition due to diagnoses of Alzheimer's Disease, dementia, depression, depression medications and order for supplement. Interventions included administer medications as ordered, monitor, document, and report refusing to eat, monitor/record/report to physician as needed signs and symptoms of malnutrition to include significant weight loss. The care plan wasn't revised or individualized to include the weight loss.Review of the weights for Resident #95 revealed admission weight on 12/19/25 of 121.2 pounds (#), next weight taken on 01/05/26 of 117.8 #, next weight on 01/16/26 of 112.6 #, and last weight on 02/04/26 of 110 #. Weekly weights were not taken weekly the first four weeks of admission.Review of the admission minimum data set (MDS), dated [DATE] revealed Resident #95 had severely impaired cognition with a Brief Interview Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe impaired cognition.Review of the Registered Dietician (RD) #293 note dated 01/19/26 a significant weight change of 8% in one month. RD #293 ordered to discontinue current supplement, Med Pass 6 oz with meals with new order for Med Pass 4 oz six (6) times a day and to monitor weights per physician order. Physician and Resident family representee were notified.Review of the physician orders for 01/19/26 revealed the Med Pass Supplement of 6 oz with meals was not discontinued until 01/30/26. The new order for Med Pass supplement 4 oz, 6 times a day and to monitor weights per physician order was ordered on 01/30/26, 11 days after RD #293 changed the med pass supplement orders. Review of the Medication Administration Records (MARS) for January 2026 revealed the order for Med Pass 4 oz, 6 times a day was put in on 01/30/26.Interview on 02/25/26 at 12:28 P.M. with Registered Dietician (RD) #293 confirmed weights were not taken as ordered to be on admission, weekly for four weeks and then when a significant change was identified should have been take weekly until stable. RD #293 unable to state why this didn't occur. RD #293 confirmed the order for the supplement change on 01/19/26 should have been changed to Med Pass 4 oz, six time a day but was unable to state why it occurred. RD #293 revealed she develops and revises nutrition care plans and confirmed Resident #95's care plan was not individualized or updated to reflect the weight loss. Interview on 02/26/26 at 8:44 A.M. with (RD) #293 and Regional Director of Operations (RDO) #289 confirmed weights are to be taken on admission and then weekly for four weeks. RD #293 and RDO #289 confirmed Resident #95's weights were not taken correctly, and the care plan was not updated to reflect the weight loss. RD #293 and RDO #289 confirmed the order to change the supplement on 01/19/26 was not ordered in the computer until 01/30/26. RD #293 and RDO #289 unable to provide a reason as to why this wasn't done. Interview on 03/02/26 at 10:15 A.M. with DON confirmed for Resident #95's order for Med Pass 4 oz, 6 times a day was not ordered on 01/19/26. DON unable to give a reason as to why. DON stated when she was checking orders she saw Resident #45's med pass wasn't ordered so she entered it on 01/30/26. DON confirmed weights are to be done on admission, then weekly for four weeks, and continue weekly for a significant weight change. DON confirmed Resident #95's weight wasn't monitored weekly and her care plan was not updated/revised with weight changes.Review of the facility policy, Weight Assessment and Intervention - Garden and Northwood Healthcare, revised 01/10/23, revealed nursing staff will measure resident weights on admission and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since last weight assessment will be retaken the next day for confirmation. The threshold for significant unplanned and undesired weight loss will be based on the following criteria, 1 month of 5% weight loss is significant. Care planning for weight loss or impaired nutrition will be multidisciplinary effort and individualized care plans shall address the identified causes of weight loss, goals for improvement and time frames and parameters for monitoring and reassessment. 2. Review of the medical record Resident #43, revealed an admission date of 12/27/25. Diagnoses included but not limited to cerebral Infarction, schizophrenia and psychoactive substance abuse.Review of the care plan dated 12/29/25 for Resident #43 revealed there was no care plan for the weight loss.Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #43 had intact cognition. Review of the weights for Resident #43 revealed admission weight on 12/30/25 164 #, on 01/05/26 166 #, on 01/06/26 156 #, and on 02/04/26 154 #. Resident #42's weight was not taken at admission or weekly for four weeks upon admission.Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #5 had intact cognition.Review of the RD #293 note dated 02/12/26 at 10:57 A.M. revealed Resident #43 had a significant weight change of 7% in one month. Intervention was to discontinue current rate and flush bolus 250 ml Jevity 1.5 with 185 ml six (6) times per day. Nutrition monitoring to continue and monitor weights per physician order and notifications to physician and resident done.Interview on 02/26/26 at 8:44 A.M. with RD #293 and RDO #289 confirmed weights were not taken as ordered to be on admission, weekly times for four weeks and then when a significant change was identified should have been take weekly until stable. RD #293 reported weights should have been taken on 12/27/25, admission weight, 01/03/26, 01/10/26 and 01/17/26. RD #293 was unable to state why this didn't occur. RD #293 confirmed a significant weight loss occurred. RD #293 reported weights should have been taken weekly with the weight loss. RD #293 confirmed there was no care plan to address the weight loss and was unable to give a reason why there was no care plan.Review of the facility policy, Weight Assessment and Intervention - Garden and Northwood Healthcare, revised 01/10/23, revealed nursing staff will measure resident weights on admission and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since last weight assessment will be retaken the next day for confirmation. The threshold for significant unplanned and undesired weight loss will be based on the following criteria, 1 month of 5% weight loss is significant. Care planning for weight loss or impaired nutrition will be multidisciplinary effort and individualized care plans shall address the identified causes of weight loss, goals for improvement and time frames and parameters for monitoring and reassessment.

Based on observation, record review, facility policy review and interview, the facility failed to ensure effective measures/systems were in place to prevent resident falls with injury. The facility failed to ensure Resident #38 was transferred appropriately using a gait belt and failed to ensure Resident #48's bed U-bar side rail was maintained in good repair. This affected two residents (#38 and #48) of four residents reviewed for accidents and hazards. Actual harm occurred on 09/25/24 at 9:40 A.M. to Resident #38, when Certified Nursing Assistant (CNA) #831 attempted to transfer Resident #38 from a bedside commode to the wheelchair without using a gait belt as care planned. Resident #38 and STNA #831 fell to the floor. Resident #38 sustained a fractured hip which required surgical repair and had chronic pain post surgical repair. Actual harm occurred on 06/08/24 at 3:47 P.M. when during resident care, Resident #48 grabbed the multi-function side rail (U-bar) attached to her bed to pull herself over, the side rail gave way and Resident #48 rolled off the side bed landing on the floor face down sustaining a fracture to the left fibula fracture. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted on [DATE] with diagnoses including a displaced intertrochanteric fracture of the left femur, vascular dementia and diabetes. Review of Resident #38's care plans revealed an intervention dated 05/03/24 indicating staff education to use gait for transfers while toileting resident. Review of Resident #38's Minimum Data Set 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #38's progress note dated 09/25/24 timed 9:40 A.M. authored by Licensed Practical Nurse (LPN) #906 revealed LPN #906 was alerted to Resident #38's room by CNA #831 who stated she had to lower the resident to the floor because she was not able to get the resident's wheelchair behind him fast enough and the resident was unable to keep himself up. The resident stated he could not hold himself up anymore. Resident #38 was lowered to the floor by CNA #831 and a pillow was placed behind the resident's head. The floor was dry with no clutter and the resident was wearing tennis shoes that were tied and fit properly. Resident #38 complained of pain in the left leg and was transferred to the emergency room for evaluation. Review of the Fall Scene Investigation Report dated 09/25/24 revealed the gait assist at the time of the fall areas were left blank. There was no information the care planned gait belt was in place at the time of the fall. The form indicated the resident lost his balance and could not stay up. The investigation indicated the resident would be changed to a two-staff assist (following the incident). Review of the undated fall witness statement authored by CNA #831 revealed she transferred Resident #38 back to his chair (from the bedside commode) when they began to fall to the ground in slow motion. No cracking sounds or popping sounds were heard, he did not fall hard, and the floor was not wet. Resident #38 partially fell on CNA #831 while switching back from the resident's commode to the electric scooter approximately ten seconds after standing from the commode. Review of Resident #38's hospital documentation dated 09/25/24 revealed Resident #38 sustained a closed intertrochanteric fracture of left hip and had surgery for a intramedullary nail to the left intertrochanteric hip fracture. Review of Resident #38's hospital Discharge Summary form dated 09/27/24 revealed Resident #38 had a closed intertrochanteric fracture of the left hip, a closed displaced intertrochanteric fracture of the left femur and operations during the hospitalization included a intramedullary nail to the left intertrochanteric hip fracture. Review of Resident #38's progress note dated 09/27/24 at 2:55 P.M. authored by Registered Nurse (RN) #882 revealed the resident was readmitted to the facility with dressings to the hip which were intact. Review of the physician progress note dated 10/21/24 revealed the visit was a follow up for chronic pain of the left femur fracture and to continue medications, plan of care, physical therapy, occupational therapy and to monitor laboratory results. Interview on 10/30/24 at 9:12 A.M. with LPN #906 revealed she was called to Resident #38's room when CNA #831 lowered Resident #38 to the floor. LPN #906 revealed Resident #38 required assistance to transfer with one to two persons at the time of the incident. Observations on 10/30/24 at 10:15 A.M. revealed two CNAs coming out of Resident #38's room. The resident was in a wheelchair with a Hoyer (mechanical lift) pad underneath him. Interview on 10/30/24 at 10:18 A.M. with Resident #38 revealed the resident had recollection of the incident when CNA #831 transferred him from the bedside commode to a wheelchair and he was dropped to the floor. Resident #38 denied CNA #831 had used a gait belt during the transfer. Interview on 10/30/24 at 10:38 A.M. with Regional Director of Clinical Services #930 confirmed Resident #38's care plan indicated staff were required to transfer the resident using a gait belt and the fall investigation did not have evidence a gait belt was used. Telephone interview on 10/30/24 at 12:56 P.M. with CNA #831 revealed Resident #38 fell backwards when she was trying to get him off of the bedside commode to the wheelchair. CNA #831 said she did not use a gait belt when transferring the resident. She stated the facility did not have gait belts for staff use. Review of the Safe Lifting and Movement of Residents policy revised July 2027 revealed safe lifting and movement of residents was part of an overall facility employee health and safety program, which involved employees identifying problem areas and implementing workplace safety and injury-prevention strategies; providing training on safety, ergonomics and proper use of equipment; and continually evaluating the effectiveness of workplace safety and injury-prevention strategies. 45442 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified fracture of shaft of left fibula (06/12/24), congestive heart failure, type II diabetes mellitus, morbid obesity, hemiplegia and hemiparesis and bipolar disorder. Review of the care plan for Resident #48 dated 03/19/24 revealed self-care deficit related to decreased functional mobility. Interventions were one to two staff assist as required for bed mobility, toileting and transfers. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #48 revealed she was cognitively intact, incontinent of bowel and bladder, and was dependent on staff for activities of daily living. Review of the nursing progress note dated 06/08/24 authored by Licensed Practical Nurse (LPN) #812 timed at 12:54 P.M. revealed Resident #48 was assisted from the floor to the bed with person assist using a mechanical lift. Resident #48 stated she wanted to go to the hospital due to the knot on her left upper forehead. Review of nursing progress revealed clarification dated 06/08/24 timed 3:47 P.M. indicating Resident #48 rolled out of bed during patient care while bed was in low position. Review of the nursing progress note dated 06/09/24 timed at 4:52 A.M. authored by LPN #934 revealed Resident #48 was admitted to the hospital related to increased blood pressure and possible fracture to left ankle. Review of the fall incident report for fall dated 06/08/24 revealed LPN #812 was providing patient care for Resident #48. Resident #48 was using her grab bar (multi-function side rail) to roll over and the grab bar became detached, and Resident #48 fell out of bed onto the floor. Vitals and neurological checks were completed, and Resident #48 was sent to the emergency room for evaluation. Review of the witness statement from LPN #812 dated 06/08/24 revealed at approximately 11:00 A.M. on 06/08/24 she was providing incontinence care for Resident #48 and Resident #48 used her safety grab bar to roll over onto her left side which became detached, and Resident #48 fell face forward onto the floor in a prone position. Review of the witness statement from CNA #841 revealed she was not present when the fall occurred but assisted LPN #812 with the mechanical lift to transfer Resident #48 from the floor to her bed. Review of the witness statement dated 06/08/24 from CNA #841 revealed she did not observe Resident #48's fall but did respond to LPN #812's call for help and assisted her with the mechanical lift to get Resident #48 off the floor back into bed. Review of the hospital admission note for Resident #48 dated 06/09/24 revealed she sustained a left ankle fracture after falling out of bed at the nursing facility. Review of the x-ray report dated 06/10/24 for Resident #48 revealed limited exam due to decreased bone mineralization, patient positioning and superimposed artifact. There was questioned cortical irregularity at the lateral margin of the fibula with suspected lucency in the distal tibia, suspicious for nondisplaced fracture. Irregularity at the medial malleolus could be chronic. Degenerative changes were present. Soft tissue edema overlied the dorsum of the forefoot and anterior ankle. Interview on 10/30/24 at 8:33 A.M. with Regional Director of Clinical Services #930 confirmed Resident #48 rolled out of bed onto the floor during patient care because her grab bar (multi-function side rail) became loose when she was rolling onto her side, and Resident #48 fell face forward onto the floor. Regional Director of Clinical Service #930 revealed Resident #48 required one person assist as she was able to use the grab bar to roll and turn herself. A telephone interview on 10/31/24 at 9:48 A.M. with LPN #812 revealed she was providing incontinence care to Resident #48, who was a one person assist, and when Resident #48 rolled she put all of her weight on the grab bar which pushed it outwards, and the grab bar became detached causing Resident #48 to roll out of the bed onto the floor face first. LPN #812 assessed Resident #48 and then obtained assistance from CNA #841 and using the mechanical lift transferred Resident #48 off the floor back into her bed. Resident #48 was sent to the emergency room . Interview on 10/31/24 at 10:24 A.M. with the Administrator revealed the facility completed an annual check of the facility equipment, including side rails and staff were encouraged to report any observed concerns related to facility equipment to the maintenance department. Interview on 10/31/24 at 11:14 A.M. with Resident #48 revealed LPN #812 was providing incontinence care for her, Resident #48 stated she used the grab bar on her bed to assist her to roll over and when she bore her weight on it, the grab bar broke off and she fell out of bed onto the floor face first. LPN #812 assessed her, and another nurse assisted her with the mechanical lift back into bed and then she was sent to the hospital for treatment. Review of manufacturer's information for the expandable deck bariatric low bed with multi-function side rails, which was the type bed Resident #48 was on at the time of the fall, revealed the bed weight capacity was 600 pounds and was able to meet most patient needs with multi-function side rails that swung up and locked for patient assistance. Review of the April 2010 revised facility policy called; Work Order, Maintenance provided no specific information regarding the frequency which the facility was to complete maintenance checks to ensure bed rails were functioning properly and attached per manufacturer requirements. This deficiency represents non-compliance investigated under Complaint Number OH00158638.

Based on closed medical record review, staff interview and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #1, who was found unresponsive, without a pulse/heartbeat and was identified as a full code status. This resulted in Immediate Jeopardy that was actual harm when Resident #1 did not receive CPR and EMS was not contacted for medical services. Resident #1 subsequently expired. This affected one resident (Resident #1) of four residents reviewed for death in the facility. The facility census was 64 residents. On [DATE] at 3:52 P.M., the Regional Director of Clinical Services (RDCS) #111, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) #100, Unit Manager (UM)/LPN #121 and Registered Nurse (RN)/Assistant Director of Nursing (ADON) #122 were notified Immediate Jeopardy began on [DATE] at approximately 5:00 A.M. when LPN #104 entered Resident #1's room and Resident #1 was audibly rattling with his respirations and staring off into space with his arms limp and hanging over the sides of the bed. Resident #1's color was described as yellow, his feet were mottling (purplish) and his oxygen cannula was out of his nose. LPN #104 readjusted his nasal cannula, but Resident #1 did not respond. LPN #104 documented Resident #1 had crackles (sound heard when the small air sacs in the lungs fill with fluid) in his lungs so LPN #104 indicated she made him comfortable and called hospice staff at 5:13 A.M. LPN #104 said State tested Nursing Assistants (STNAs) #117, #116 and #131 provided incontinence care to Resident #1 shortly thereafter. At 5:30 A.M., LPN #104 went back to check on Resident #1 and he was not breathing or moving. LPN #104 had LPN #115 check Resident #1 for a pulse and heartbeat and neither were heard. LPN #104 documented she called hospice and informed them Resident #1 had expired. LPN #104 did not contact the physician for any medical treatment, initiate CPR or call 911 for emergency care because she assumed Resident #1 was a do not resuscitate (DNR) since he was receiving hospice services. Resident #1 expired at approximately 5:55 A.M. at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 9:00 A.M., UM/LPN #121 notified the facility Medical Director, Physician #107, of Resident #1's death. · On [DATE], RDCS #111 reviewed three previous resident deaths in the facility since February 2022 and no other negative outcomes were noted. · On [DATE] at 2:00 P.M., Human Resource Manager (HRM) #130 reviewed and audited all licensed nurses' files for current CPR status. This will be performed by HRM #130/Director of Nursing (DON)/Designee upon hire and every six months and as needed. · On [DATE] at 4:10 P.M., the DON/designee educated all licensed nurses on the facility's policy and procedure for initiating CPR, location of code status for each resident, and the steps to verify code status in Point Click Care (PCC) and the physical medical record. Education was completed on [DATE] at 6:30 P.M. which included a verbal response confirming understanding of the policy/procedures in person or via telephone. Licensed nurses would not be permitted to work a shift until education was completed. Licensed nurses on leave would receive education prior to their next scheduled shift by the DON/Designee. Currently, the facility does not utilize agency nurses, however if this becomes necessary, education would be provided to the licensed nurses per policy prior to their first shift by the DON/Designee. · On [DATE] at 4:10 P.M. the interdisciplinary team, including ADON/RN #122, the DON, RDCS #111, LPN/MDS #100 and UM/LPN #121 reviewed the facility policies and procedures on CPR, code blue and advance directives. RDCS #111 revised the CPR policy and procedure to include step-by-step directions on how to verify resident code status within the physical chart and the electronic medical record. Step by step instructions on verifying code status were as follows: * Upon admission, the code status must be verified with physician by the licensed nurse and verify the current order for code status is present, current, and verified in the electronic medical record/Point Click Care (PCC). * If the resident has a Do Not Resuscitate (DNR) order the licensed nurse is to verify the form is signed in the physical chart by the physician and resident or family/guardian. * Locate the code status order at the top of the resident page in PCC under the resident's picture. * Locate code status sheet in the front of the physical chart under advance directives tab. The sheet of paper will be bright green if the resident is a full code and white if the resident is a DNR. · On [DATE] at 6:15 P.M., LPN #104, who did initiate CPR for Resident #1, was suspended pending investigation by HRM #130. · On [DATE] by 7:00 P.M., RN/ADON #122/Designee completed a chart audit on every resident and compared the advance directives to the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No negative outcomes were observed upon completion of this audit. · On [DATE], the DON completed the investigation related to LPN #104 not initiating CPR and not calling 911 for Resident #1. LPN #104 was terminated, and the DON reported the findings to the Board of Nursing. · On [DATE], the DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP). The DON/Designee will monitor for code status compliance by interviewing licensed nurses regarding facility CPR policies and procedures and observing a demonstration of the facility's CPR process. Compliance checks will be conducted three times weekly for one month and then as needed by DON/Designee. Findings will be reviewed monthly at the QAA Committee meeting. · On [DATE], the DON/Designee began to audit all new resident admissions, at minimum five new admissions as available, to compare the resident's advance directives against the physician orders for accuracy. This audit will continue five days a week for one month to meet the minimum number of five new admissions and as needed. Findings will be reviewed at the monthly QAA Committee meeting. · On [DATE] at 11:51 A.M., the DON and RDCS #111 performed a Mock Code Blue drill with nine licensed nursing staff. Additional mock code blue drills will occur on [DATE] between 3:30 P.M. and 4:30 P.M. (for second shift staff) and on [DATE] by DON/Designee between 3:00 A.M. and 7:00 A.M. (for third shift staff) by the DON/Designee until every nurse has participated in at least one drill. Drills would include a post test for all nurses confirming understanding of the facility policy and how to properly verify code status/advanced directives on each resident. The estimated date of completion is [DATE]. Code blue drills will be conducted monthly for three months and as needed. Findings will be reviewed at the monthly QAA Committee meetings. · On [DATE] from 2:05 P.M. to 2:12 P.M. interviews with LPN #133, LPN #102, LPN #132 and RN #134 revealed they were in-serviced on the CPR policy, performing a code blue and were knowledgeable on where to locate a resident's advanced directives/code status per the revised policy and procedure. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of the closed medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital paperwork prior to admission indicated he was a full code. Review of Resident #1's information in the electronic medical record/PCC revealed he had no code status listed under his photo. Review of the physician's order dated [DATE] revealed Resident #1 was a full code. Review of the physician's order dated [DATE] revealed Resident #1 was admitted to hospice services. The order was clarified on [DATE] to reflect a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the physical chart, the face sheet and the nursing admission checklist dated [DATE] indicated Resident #1 was a full code. Review of profile data revealed Resident #1 was his own responsible party and had two daughters listed as emergency contacts. Review of a brief interview for mental status (BIMS) assessment completed [DATE] revealed Resident #1 was alert, oriented and cognitively intact. Review of a care plan dated [DATE] revealed Resident #1 had an advanced directive and was a full code. Interventions listed included for staff to review/complete advanced directives upon admission, quarterly, annually and with significant changes to ensure Resident #1's wishes were maintained. Review of hospice documentation and a physician order sheet dated [DATE] did not indicate any changes in code status as a result of Resident #1's admission to hospice. Hospice admission documents dated [DATE] indicated Resident #1 remained a full code. Review of a hospice note dated [DATE] written by Hospice RN (HRN) #108 revealed Resident #1 was a full code and wanted to remain a full code. Review of a hospice note dated [DATE] written by Hospice Case Manager (HCM) #113 revealed Resident #1 was a full code and he wanted to speak to his children prior to signing a Do Not Resuscitate - Comfort Care (DNR-CC) advanced directive. Review of a nurse's note dated [DATE] at 5:40 A.M. written by LPN #104 revealed Resident #1 had crackles with breathing, his extremities (which could include arms/hands/legs/feet) were cold to the touch and mottled (patchy, irregular purplish coloring of the skin due to decreased oxygen supply). Resident #1 had labored breathing. LPN #104 indicated she contacted the hospice provider at 5:13 A.M. No medical treatment was initiated by LPN #4. Review of a nurse's note dated [DATE] at 5:57 A.M. written by LPN #104 revealed Resident #1 was found deceased at 5:55 A.M. and the hospice provider was notified. This note did not indicate CPR was initiated or that 911 was called. Review of a hospice note dated [DATE] at 8:17 A.M. written by HRN #126 revealed Resident #1's time of death was 6:00 A.M. His daughters were notified and were very distraught. Physician #107 was notified to sign the death certificate and post-mortem care was provided. Review of a counseling form dated [DATE] revealed LPN #104 failed to respond appropriately for a resident who was a full code. LPN #104 did not properly identify the resident's code status. The facility action was listed as education/counseling, further infraction will result in formal write-up. The form was signed by LPN #104 and the DON. There were no staff statements or formal investigation of the circumstances surrounding Resident #1's death and no other disciplinary action was documented. Phone interview on [DATE] at 1:07 P.M. with LPN #104 revealed she worked the overnight shift from [DATE] into [DATE] and was the nurse for Resident #1. LPN #104 stated she went to check on Resident #1 during her morning medication pass and said his status had changed. She said Resident #1's breathing was rattled, he was staring off into space and his arms were limp and hanging off each side of his bed. LPN #104 said Resident #1 was yellow in color and his feet were mottled. LPN #104 said Resident #1's oxygen cannula was off to the side of his nose so she put it back into his nose. LPN #104 said she made Resident #1 comfortable and called the hospice nurse. LPN #104 left the room and the STNAs (not named) went and provided incontinence care for Resident #1. At 5:30 A.M., LPN #104 said she went back to see Resident #1 and he was not moving or breathing. She said she got LPN #115 to check Resident #1 for a heartbeat or pulse and they could not find either. LPN #104 said she called the hospice staff and was told a hospice nurse would come to the facility. LPN #104 stated she assumed Resident #1 was a DNR so did not initiate CPR, call a code blue or call 911. LPN #104 indicated she had a meeting with the DON on [DATE] regarding the incident and was told Resident #1 was a full code and CPR and lifesaving interventions should have been initiated. Phone interview on [DATE] at 1:48 P.M. with STNA #117 revealed she had worked the overnight shift from [DATE] into [DATE]. STNA #117 explained all STNAs working provided care for all residents on the second floor and they were not assigned specific residents. STNA #117 said she was last in Resident #1's room about 30 minutes before he passed away, around 5:00 A.M. STNA #117 stated Resident #1 was in and out stating he was ready to die. STNA #117 stated LPN #104 was in the room with her. STNA #117 said she and STNA #131 and STNA #116 provided incontinence care for Resident #1, and he was mumbling. STNA #117 said they left the room around 5:15 A.M. STNA #117 verified a code blue was not called and CPR was not provided for Resident #1. Phone interview on [DATE] at 1:57 P.M. with LPN #115 revealed she worked the overnight shift from [DATE] into [DATE] but was not assigned to Resident #1. LPN #115 recalled hearing LPN #104 on the phone with hospice staff around 5:45 A.M. as LPN #104 had the call on speakerphone. LPN #115 recalled hearing LPN #104 say Resident #1 had been calling out and had mottling. LPN #115 stated LPN #104 did not ask for help until Resident #1 had already died and had asked her to confirm he was absent of any vital signs around 6:00 A.M. on [DATE]. LPN #115 verified CPR was not provided to Resident #1 and 911 was not called. Phone interview on [DATE] at 2:21 P.M. with Family Member (FM) #119 and on [DATE] at 3:18 P.M. with FM #118 revealed they were Resident #1's daughters. Both daughters indicated their father was a full code and were aware the facility staff did not provide CPR or call 911 for their father even though he was a full code. Phone interview on [DATE] at 3:57 P.M. with Hospice Branch Director (HBD) #12, Hospice Administrator (HA) #124, Hospice Social Worker (HSW) #122, Physician #107, Hospice Clinical Team Lead (HCTL) #125 and HRN #108 revealed their hospice company did not have a requirement for a specific advanced directive (i.e. DNR) for admission to hospice care. These staff verified Resident #1 was admitted to hospice and remained a full code. These staff said on [DATE] at 5:14 A.M. LPN #104 called the hospice answering service regarding a change in condition for Resident #1 saying he was actively dying and to please send a nurse. HRN #126 responded to the call at 5:24 A.M. and began to drive to the facility. LPN #104 reported to hospice staff that Resident #1 expired at 5:56 A.M. and HRN #126 was still en route to the facility at that time. Physician #107 stated he was not made aware of Resident #1's initial change in condition and was contacted by text message about Resident #1's death sometime after 6:00 A.M. on [DATE]. Interview on [DATE] at 5:05 P.M. with RDCS #111 revealed LPN #104 was not suspended after her failure to initiate CPR and call 911 for Resident #1. RDCS #111 indicated the DON was doing an investigation, but it was not complete. Interviews on [DATE] at 8:06 A.M. and 8:30 A.M. with the DON revealed LPN #104 had been suspended. The DON was not aware if any staff statements had been collected as part of an investigation into Resident #1's death as she was off work on [DATE]. The DON stated the Administrator had been present on [DATE] and was not sure why this did not go further. The DON provided the surveyor with LPN #104's time punches which indicated she continued to work with residents after the incident with Resident #1. In an email on [DATE] at 9:57 A.M., the DON verified the only documentation the facility had was LPN #104's counseling form and education. The DON verified no staff statements were obtained. Interview on [DATE] at 11:19 A.M. with ADON/RN #122 revealed she worked on [DATE] and midnight shift staff informed her, the DON and UM/LPN #121 via text-message that Resident #1 passed away. After morning meeting or about 9:45 A.M. ADON/RN #122 said they realized Resident #1 was a full code. ADON/RN #122 indicated the Administrator was made aware of the situation and thought she had started an investigation. ADON/RN #122 indicated the DON was informed Resident #1 was a full code and CPR had not been initiated. ADON/RN #122 verified LPN #104 was not suspended immediately after this was discovered. Phone interview on [DATE] at 11:59 A.M. with STNA #116 revealed she worked the overnight shift from [DATE] into [DATE]. STNA #116 revealed she was in Resident #1's room around 5:00 A.M. and he had mottling and was breathing but not well during care provided for him. STNA #116 had LPN #104 come and see Resident #1 and she called hospice. STNA #116 stated she, LPN #104 and LPN #115 went to go check on Resident #1 again around 5:45 A.M. and he was not breathing. STNA #116 stated no one checked Resident #1's chart for his code status, 911 was not called and CPR was not initiated. STNA #116 said LPN #104 left the room to call hospice staff and notify facility administration Resident #1 had died . A follow-up interview on [DATE] at 12:27 P.M. with the DON revealed she was not working [DATE]. The DON learned Resident #1 had died on [DATE] via text message from LPN #104. The DON stated she was informed on [DATE] that LPN #104 did not act appropriately since she had not called a code for Resident #1 on [DATE]. The DON called LPN #104 into her office on [DATE] and became aware LPN #104 assumed Resident #1 was a DNR because he was on hospice. LPN #104 verified she had not checked Resident #1's code status. The DON stated after LPN #104 saw Resident #1 was not breathing, she should have checked for a pulse, then checked his code status and called a code, which would include CPR and calling 911. Phone interview on [DATE] at 1:33 P.M. with the Administrator revealed she started her employment at the facility on [DATE]. She worked on [DATE] and had started her day between 7:00 A.M. and 7:30 A.M. and indicated she did not learn about Resident #1's death until the facility's team meeting around 9:15 A.M. The Administrator stated no one told her Resident #1 was a full code and no concerns were brought up surrounding his death. The Administrator had not been aware LPN #104 and the DON had a counseling session regarding failure to provide CPR to Resident #1. Review of the original facility policy, Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2019, revealed personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation, for victims of sudden [CONDITION(S)]. If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order specifically prohibits CPR/external defibrillation for that individual or there are obvious signs of irreversible death (e.g. rigor mortis). If the first responder is not CPR-certified that person will call [DATE] and follow the operator's instructions until a CPR-certified staff member arrives. The emergency procedure was listed for cardiopulmonary resuscitation when an individual was found unresponsive, staff were to briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely staff were to begin CPR: 1. instruct a staff member to activate the emergency response system (code) and call [DATE]; 2. Instruct a staff member to retrieve the AED; 3. Verify or instruct a staff member to verify the DNR or code status of the individual; and 4. Initiate basic life support sequence of events. Staff were to continue with CPR until emergency medical personnel arrived. The original policy did not specify where staff were to look for the resident's code status. The facility revised the policy on [DATE] and directed staff where to check for the resident's code status. This deficiency substantiates Complaint Number OH 697.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], review of Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo, review of the facility COVID-19 visitation policy, mask policy, hand hygiene policy and handling of medical waste policy, observations, interviews and medical record review the facility failed to implement effective and recommended infection control practices to prevent the transmission of COVID-19 in the facility. This resulted in Immediate Jeopardy on [DATE] when the facility failed to implement the use of appropriate Personal Protective Equipment (PPE) including N95 respirator masks and goggles/face shields while caring for residents and failed to ensure proper hand hygiene and proper changing and disposal of PPE. The facility failed to ensure proper isolation for five residents (Resident #22, #23, #40, #43 and #45) on the second floor COVID-19 unit, allowing them to travel throughout the non-COVID-19 unit of the second floor, and use the common elevator to go to the first floor and through the first floor hall without proper PPE, failed to conduct consistent and appropriate screening for visitors upon entering the facility including visiting the COVID-19 unit and did not investigate to determine a root cause of the spread. The lack of effective infection control practices to prevent the spread of COVID-19 placed all facility residents at risk for the likelihood of harm, complications/and or death. The facility census was 63. Review of the facility Line List revealed a COVID-19 outbreak began on [DATE] when Physical Therapist (PT) #108 tested positive for COVID-19 which initiated twice weekly testing of all staff and residents. By [DATE] there were 26 residents (Residents #8, #31, #34, #12, #38, #40, #39, #36, #42, #64, #43, #47, #16, #65, #17, #14, #41, #46, #37, #22, #11, #15, #44, #13, #45 and #23) who tested positive both on the second floor, on the first-floor secured dementia unit and on the first floor Medbridge hall. One of the residents (Resident #64) expired with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:16 A.M., Infection Preventionist (IP) #101, Administrator, Director of Nursing (DON) and Regional Clinical Director (RCD) #119 were notified Immediate Jeopardy started on [DATE] when PT #108 tested positive for COVID-19 and the facility did not implement CDC guidance with their COVID-19 policy and procedure including donning and doffing of PPE, appropriate use of PPE, isolation of COVID positive residents and staff working the COVID positive unit wearing same PPE in other areas of the facility in order to minimize resident risk of being exposed to the virus. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 2:00 P.M., IP #101 trained all staff including the two receptionists (Receptionist #100 and #109) to ensure all visitors were educated, as soon as entering the building through the main entrance, about current COVID-19 status and proper PPE needed to be worn during the visit, including completing the computer check in system COVID-19 questionnaire with temperature checks. Then the visitor will be provided required PPE to be worn in order to enter the facility. Any visitor going to a COVID-19 unit will be escorted by designated staff who will be called by the receptionist when the visitor has completed the initial process and was safe to enter the facility. Any time the reception area was unattended the main entrance doors would be locked and visitors would have to ring bell and be let in by trained staff to process the visitor. · On [DATE] at 2:00 P.M., Licensed Practical Nurse (LPN) #106 educated all residents on the COVID-19 protocol, the importance of handwashing, proper PPE placement and best practices for COVID safety while residing in the facility. · On [DATE] at 4:00 P.M., the IP #101 educated all staff that any new COVID-19 positive smokers would be placed on the first floor COVID-19 unit which had direct access to their own outside smoking area unless the resident decided to use alternative [MEDICATION(S)] derivates and/or declined to smoke while in isolation/quarantine. · On [DATE] at 4:00 P.M., current COVID-19 positive smokers who remain in isolation (Resident #22 until [DATE] and Resident #45 until [DATE]) were moved to the first floor COVID-19 dedicated unit which had a private outside smoking area exiting through the dedicated unit. Resident #40 completed isolation and returned to his room on [DATE]. · On [DATE] at 4:00 P.M., the IP #101 completed audits to ensure proper mask wearing/placement by all staff, ensured the correct masks were worn (N95), and ensured sanitizing products were readily accessible. IP #101 will continue on-going audits five to seven days a week for one week, then three times a week for three weeks. · On [DATE] at 8:00 P.M., the DON educated the Housekeeping Supervisor (HKS) #111 and all housekeepers on ensuring adequate infection control supplies were readily available including PPE and sanitizing products. All housekeeping staff were also educated on ensuring adequate supplies and storage for discarding used PPE. · On [DATE] at 8:30 P.M., the Corporate Facility Director installed donning and doffing areas on the second floor COVID unit. · On [DATE] at 6:00 A.M., IP #101 educated all staff on proper infection control practices related to donning and doffing of PPE including proper wearing of masks/strap placement. While working the COVID-19 units staff would doff all PPE prior to going to any other part of the facility and/or when leaving the facility. · On [DATE] at 10:00 A.M., the DON educated all staff on the procedure to enter the building using only the main entrance, get screened then obtain proper PPE according to the COVID-19 status in the facility. All staff will obtain a new N95 every time a N95 was doffed and no N95s would be stored for reuse. N95s would be readily accessible in the designated areas. Face shields/goggles would be supplied at the main entrance, in designated areas along with approved cleaning chemicals to be used when exiting each resident's room and as needed. · The DON and/or Administrator will oversee by completing random competencies for all staff to ensure they were following the COVID-19 policy. · The Administrator/designee will complete audits twice a week for four weeks beginning [DATE] to ensure all visitors are educated, have appropriate PPE and are escorted to the proper area as planned. · The HKS #111/designee will audit all resident areas every other day for four weeks to ensure hand sanitizer and sanitizing cleaning materials for cleaning resident equipment were available for direct care staff in resident areas. Audits will also include monitoring to ensure trash and PPE are discarded properly. · The Administrator/designee to ensure audits were completed as planned twice a week, starting [DATE], for four weeks and ongoing as needed. · The Administrator/designee will oversee to ensure any COVID-19 positive smokers were given the opportunity to be moved to the first floor COVID-19 unit in order to continue smoking or receive a [MEDICATION(S)] derivative with every positive case for the duration of isolation/quarantine. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Tour on [DATE] at 9:35 A.M., with Registered Nurse (RN) #103, of the first floor revealed there was a secured dementia unit which included a separate seven bed dedicated COVID-19 positive area, and all beds were filled. RN #103 was observed without any eye protection and wore a KN95 on the non-COVID-19 side as well as the Medbridge unit, which currently had two COVID-19 positive residents (Resident #22 and #23) and two non-COVID-19 residents (Resident #24 and #25). No hand sanitizer/cleaner was available for staff in the area of Resident #22 and #23's room who were both COVID-19 positive on the Medbridge unit. Resident #22 and #23's rooms were observed with a small waste basket overflowing on the floor with used PPE including disposable gowns and trash and another trash bag was on the floor next to the waste basket that contained used PPE. Interview with RN #103 on [DATE] at 9:45 A.M., verified the seven bed COVID-19 positive area had a dedicated STNA that did not leave the unit, but the nurse was responsible for the entire unit in addition to the Medbridge unit. There was no separation from the main hall which had a lot of traffic including the path the smokers (both COVID-19 positive and negative) took for outside smoking. During the interview RN #103 verified she did not have on any eye protection, she thought she was wearing an N95 then verified it was a KN95 and thought it was okay to wear either including when working with COVID-19 positive residents. Further interview verified she wore the mask the entire day and did not have a safe place to rest the mask when on break and/or leaving the facility, nor did she monitor how many times the mask was donned/doffed. She did not cover the mask when interacting with a COVID-19 positive resident with a surgical mask. The facility did not have a dedicated area where masks were kept safe, monitored and/or provided to staff. There was no system for monitoring the frequency of use of any masks for staff or residents. RN #103 verified there was no hand sanitizer near Resident #22 or #23's room for staff/visitors to ensure proper hand hygiene when entering/exiting the room. 2. Observation of Visitor #102 on [DATE] at 9:55 A.M., on the Medbridge unit revealed she exited Resident #25's room and sat at the nurses station that connected it with the secured unit. Visitor #102 did not perform hand hygiene, did not have on eye protection and had on a surgical mask that was not changed. Interview with Visitor #102 on [DATE] at 10:00 A.M., with RN #103 present, revealed she was a counselor who was at the facility to see several residents. Visitor #102 stated she signed herself in on the computer system and was not approached by Receptionist #100 and continued to walk to the Medbridge unit. Visitor #102 was not aware of the COVID-19 status in the building nor if she was visiting any positive residents. Visitor #102 verified she did not complete hand hygiene when exiting Resident #25's room, did not have on eye protection and did not change the surgical mask. Visitor #102 indicated she was not educated on proper PPE use while in the facility. 3. Observation of RN #104 on [DATE] at 10:40 A.M., revealed she was working the secured unit and the Medbridge unit. RN #104 was wearing an N95 and goggles. RN #104 was observed passing medication on the secured non-COVID-19 side of the unit and then went to the Medbridge unit where she entered Resident #23's room (who was COVID positive) with medication. When RN #104 exited the room, she proceeded back to the medication cart, did not perform hand hygiene, did not clean the goggles, did not change the N95. She had not covered the N95 mask with a surgical mask prior to entering the COVID-19 positive resident room. Interview with RN #104 on [DATE] at 10:45 A.M., verified the above concerns. RN #104 verified there was no hand sanitizer in the PPE bin. RN #104 she did not routinely clean goggles between resident rooms including COVID-19 positive residents and wore the same N95 all day without covering it prior to going into a COVID-19 positive room. RN #104 verified there was no dedicated place or system to ensure she doffed the N95 and did not get a new one even if donned more than five times in a day. RN #104 also stated the COVID-19 positive smokers on the second floor COVID-19 unit were able to freely roam the facility leaving the second floor using the elevator going through the Medbridge hall to the outside smoking area without wearing proper face coverings. 4. Observations on [DATE] of the smokers in the outside smoking area at 11:00 A.M., revealed Residents #40 and #45, who resided on the second floor COVID-19 positive unit, were smoking less than six feet away from Residents #54 and #34, who were both COVID-19 negative. Resident #34, who was COVID-19 negative and Resident #22, who was COVID-19 positive were sitting face to face about two feet apart having a conversation and blowing smoke towards each other for over 15 minutes. Interview with Activity Assistant (AA) #105 at 11:02 A.M., verified the above concerns and stated she reminded the residents to socially distance, but they did not listen. AA #105 was aware COVID-19 positive and negative residents were outside smoking together and indicated most of the residents could go outside freely. Staff did not monitor for hand hygiene, face coverings or sanitizing of the elevator. AA #105 verified she did not sanitize her goggles, had on a KN95 and thought it was an N95 but covered it with a surgical mask and changed the surgical mask if she went into the COVID-19 units but did not change it to go out with the smokers. AA #105 stated she used her KN95 for a couple of days and stored it in a plastic bag in her car but there was no monitoring of donning/doffing or ability to store the mask in the facility during breaks. Interview with Resident #40 at 11:05 A.M., verified he was moved to the second floor COVID-19 unit when he tested positive but was able to come and go as he pleased to go down to the first floor and smoke outside. Interview with Resident #45 at 11:07 A.M., verified he was moved to the second floor COVID-19 unit when he tested positive but was able to come and go as he pleased to go down to the first floor to smoke outside. Interview with Resident #34 at 11:18 A.M., verified when outside smoking she was about two feet from Resident #22, and she knew he was COVID-19 positive. Interview with Resident #22 at 11:22 A.M., revealed he was made to move to the COVID-19 unit on the second floor but refused to stay on the unit so they moved him to a regular first floor room on the Medbridge unit so he could go outside and smoke when he wanted and could also roam around the facility. Resident #22 did not wear a face covering. Observation of Residents #40 and #45, at 11:15 A.M., revealed they left the smoking area together with their face masks not covering their nose and mouth as they traveled up the elevator back to the COVID-19 positive unit. 5. Observation on [DATE] at 11:30 A.M., revealed Certified Nurse Practitioner (CNP) #110 was donning PPE to enter Resident #22's room which had a sign indicating droplet precautions posted on the door. Further observation of the room revealed the only trash container was overflowing with discarded PPE and CNP #110 had nowhere to discard her contaminated PPE. There was trash including PPE covering the floor around the basket. Housekeeping Supervisor (HKS) #111 was observed as she passed by without any eye protection in place. Interview on [DATE] at 11:35 A.M., with HKS #111 revealed eye protection was optional even when she entered residents' rooms. HKS #111 verified Resident #22's small trash basket was overflowing and CNP #110 did not have anywhere to dispose of her discarded PPE nor was there any hand sanitizer available in the area to use after discarding PPE. Observation on [DATE] at 11:44 A.M., of AA #112 in the hall on the second floor revealed she was working on a bulletin board with residents in the area. AA #112 did not have on any eye protection and had on a KN95. Interview on [DATE] at 11:45 A.M., with AA #112 verified she did not use eye protection and she had on a KN95 and wore it all day. AA #112 verified there was no system in place when doffing the mask to keep it safe and she kept it in her purse or car. Observation on [DATE] at 11:50 A.M., of State tested Nurse Aide (STNA) #113 revealed she had on a surgical mask that was covered with a KN95 that was loose fitting around her face. Interview on [DATE] at 11:51 A.M., with STNA #113 verified she applied the surgical mask first and then the KN95 and did not use a N95 nor did she sanitize her goggles. Observation on [DATE] at 11:55 A.M., of LPN #114 revealed she had on a surgical mask with a KN95 over the surgical mask. The masks were loose around her face. LPN #114 also had on goggles. Interview on [DATE] at 11:56 A.M., with LPN #114 verified she had worn a surgical mask under her KN95 for over a year now and no one had said anything different. LPN #114 also verified she did not sanitize her goggles and did not have a safe place to store her masks. 6. Observation of the second floor COVID-19 unit on [DATE] at 12:05 P.M., revealed 12 beds and two entrances and neither entrance had a designated area for donning/doffing PPE. There was no restroom on the unit for staff use. There were four staff observed on the unit, LPN #115, STNA #116, HK #117 and STNA #118, none of the staff had on any eye protection when near residents in the common area or when entering resident rooms. HK #117 was observed entering the room of a COVID positive resident to clean with only a surgical mask on and a gown that was not fully protecting her because the straps around the waist were not tied and the gown was hanging down around her arms. When HK #117 was finished cleaning the room she exited, removed the gown and placed it in the trash bin on her cart and did not perform hand hygiene. STNA #116 only had on a surgical mask. STNA #118 was observed exiting the room of a COVID positive resident without eye protection and with only a KN95. No hand hygiene was observed when going in and out of the resident's room. Interview on [DATE] at 12:15 P.M., with STNA #116 verified none of the staff were wearing eye protection or N95 masks on the COVID-19 designated unit. STNA #116 verified the staff had to go to the first floor to use the restroom because there was none available on the unit. STNA #116 verified there was no hand sanitizer readily available on the unit and no area dedicated for donning/doffing of PPE. Observation on [DATE] at 12:22 P.M., of LPN #115 revealed she was coming down the stairwell, grabbed the key to the public restroom on the first floor and entered the restroom with the same face coverings she had on while working on the COVID-19 positive unit. After exiting the restroom LPN #115 was returning to the unit without changing her face coverings. Interview on [DATE] at 12:25 P.M., with LPN #115 verified she had to come down to the first floor to use the restroom because there was no restroom available for staff on the second floor COVID-19 unit. LPN #115 verified she had the surgical mask on under a KN95 and did not use a N95 on the unit. LPN #115 verified she did not change the masks throughout the day and wore them to and from the first-floor restroom. LPN #115 verified she was not using eye protection on the unit. Interview was conducted on [DATE] at 12:35 P.M., with IP #101 to discuss all the above concerns. IP #101 verified surgical masks should not be worn under KN95/N95 masks, all staff should be wearing N95 masks, the facility did not have a system to monitor the use of the masks or ensure safe storage and use did not extend past five doffings. IP #101 stated all staff should be wearing goggles or a face shield and verified there was no system in place to ensure staff sanitized eye protection as required including providing sanitizing products for cleaning between rooms. IP #101 verified she was not able to provide any recent training of staff related to COVID-19 infection prevention measures that occurred since the outbreak beginning of [DATE]. IP #101 confirmed residents and staff continued to test positive as of the most recent testing on [DATE]. IP #101 verified the management team did not determine the root cause of the outbreak and put effective interventions in place to decrease the spread of the virus. On [DATE] at 11:08 A.M. RCD #119 verified COVID-19 positive smokers (Resident #22, #23, #40, #43 and #45) were able to leave the designated COVID? unit on the second floor and take the common elevator down to the first floor through the Medbridge unit, which currently had two COVID-19 positive residents (Resident #22 and #23) and two non-COVID-19 residents (Resident #24 and #25). and out the back door to smoke with COVID-19 negative residents. The first-floor nurse was responsible for all smoking? residents regardless of COVID-19 status. Further interview revealed the facility did not have a system for monitoring mask usage at the facility including safe storage when not in use, appropriate masks to don or monitor use in a designated location for residents, staff or visitors. Staff took their masks to their cars and were not provided any type of storage or system to ensure the mask was not overused. The DON verified visitors going to either of the COVID-19 units should be assisted by the receptionist and don full PPE. There was no system in place to ensure PPE was worn and supplied to visitors, nor were staff educated to monitor visitors and ensure visitors donned full PPE when entering the COVID-19 unit. 7. Observation on [DATE] from 10:50 A.M. to 11:50 A.M., revealed Receptionist #109 coming and going from the main entrance area including taking lunches that were delivered from the outside to various staff, leaving the area unattended and the doors open for anyone to enter. Receptionist #109 did not wear eye protection when going on the any of the units. Interview on [DATE] at 11:25 A.M., with Receptionist #109 verified when she was away from the main entrance reception area anyone could come into the facility without being screened because the doors were open. Receptionist #109 also verified she worked Monday-Friday 8:00 A.M. until 4:30 P.M. and no one covered the area in the evening, or on the weekends. The main doors remained open until 7:00 P.M. when they were locked and re-opened at 6:00 A.M. Receptionist #109 verified she left the area to deliver items to residents and meals for staff leaving the area unattended allowing anyone to enter the facility without screening or wearing proper PPE. 8. Observation on [DATE] at 12:00 P.M., of STNA #120 revealed she had both straps of her masks down around her neck causing the mask to be below her nose and not fitting securely, she wore no goggles but covered her mask with a surgical mask when entering Resident #23's room, who was COVID-19 positive. She took a machine into the room, placed the blood pressure cuff around the resident's arm and remained in the room talking to the resident closer than six feet for 11 minutes. She was not wearing gloves. Upon exiting the room, she went to Resident #22's room, who was also COVID-19 positive, without completing hand hygiene, cleaning the machine or changing any PPE and without her nose covered by the N95. On [DATE] at 12:12 P.M. STNA #120 verified the above concerns. 9. Observation on [DATE] at 1:05 P.M., revealed Visitor #121 walking towards the exit with a surgical mask on. Interview on [DATE] at 1:07 P.M. With Visitor #121 verified he visited his wife (Resident #42) daily for most of the day except for leaving to get lunch and returning. Visitor #121 verified his wife was currently on the second floor COVID-19 unit. Visitor #121 stated he was not educated on what PPE he needed to wear or about proper hand hygiene. Visitor #121 stated the main entrance doors were always open when he came and he came and went as he pleased wearing only a surgical mask, sometimes the same one for more than a day. Interview on [DATE] at 1:12 P.M., with Receptionist #109, who heard the conversation, verified the above. Review of the facility COVID-19 mask policy, updated ,d+[DATE], revealed the use of the N95 mask shall be worn as part of the COVID-19 personal protective equipment protecting against both contact and droplet precautions and hazards. The N95 masks are to be worn by any individual who is caring, treating or otherwise in the presence of a COVID-19 positive or COVID-19 unknown individual. The N95 mask should not be re-used when moving between COVID-19 positive and COVID-19 suspected. Care should be taken during removal of the N95 mask to ensure it is not contaminated, keeping the inside of the mask protected. The N95 mask should be inspected before each use to ensure physical integrity was intact. The N95 masks would be replaced after five donnings and only to use the mask for one day. In addition, the use of surgical and N95 masks as source control, in counties where there is substantial to high community transmission, staff shall wear eye protection (goggles or face shield that covers the front and sides of the face) during all resident care encounters. The eye protection should be removed and cleaned after leaving he resident room or care area. Reusable eye protection must be cleaned/disinfected prior to reuse unless following protocols for extended use/reuse. Observation unit and COVID-19 positive units are set up to provide for the separation of residents who may have been exposed to COVID-19 or who are positive for COVID-10. All staff are expected to wear all PPE (eye protection, N95 mask, isolation gown and gloves with each resident encounter. For the observation unit an N95 mask is to be worn by the same employee when encountering more than one resident known to be infected with the same infectious disease when these residents housed in the same location i.e. COVID-19 residents in an isolation cohort. Due to the possible spread of COVID-10 a surgical mask shall be placed over the N95 to extend the use of the N95 mask. The surgical mask will be discarded between each resident encounter. These should be disposed of in available trash containers in the corridors. A new surgical mask will be donned over the N95 prior to entering another resident room for a resident encounter. For a COVID-19 positive unit the employees are expected to wear all PPE including face shield, N95 mask, gown and gloves as appropriate. The employees may wear the same PPE each shift and between residents so long as there are no residents with other communicable diseases. The face shield must cover from the forehead to end of the chin to ensure full coverage of the N95 mask. Review of the facility COVID-19 visitation policy, revised [DATE], revealed to screen all visitors entering the facility, encourage hand hygiene, use of proper face covering depending on outbreak status, physical distancing of at least six feet. When visiting the facility needed to educate the visitor and have appropriate PPE available including isolation gowns, gloves, eye protection and an N95 mask. Review of the facility COVID-19 handwashing/hand hygiene policy, revised [DATE], revealed all staff needed trained on the procedures, proper hand hygiene products and supplies needed to be readily available and encourage visitors to abide by the policy. The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility handling medical waste policy, revised [DATE], revealed disposable items believed to be contaminated due to an infectious resident must be placed in a red plastic bag, sealed and stored until leaving the premises. Review of CDC guidance, Infection Control for Nursing Homes, updated [DATE], revealed because of the high risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any healthcare personnel (HCP) or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Recommended precautions should be continued for residents until no new cases of [CONDITION(S)]-CoV-2 infection have been identified for at least 14 days. Review of CDC guidance for nursing homes dated [DATE] revealed the CDC recommended limiting the number of donnings for an N95 to no more than five per device. It could be possible to don some models of N95s more than five times. One study reported that fit performance decreased over multiple, consecutive donning's and fit varied among the different models of N95s examined. If manufacturer guidance on how many times a particular N95 could be donned was not available, the CDC recommended limiting the number of uses to no more than five per device based on published data on changes in N95 fit from a limited number of N95s models over multiple donning's. Review of the CMS QSO memo ,d+[DATE]-NH revised [DATE] revealed the following core principals of COVID-19 Infection Prevention: 1. Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status). 2. Hand hygiene (use of alcohol-based hand rub is preferred). 3. Face covering or mask (covering mouth and nose) and social distancing at least six feet between persons, in accordance with CDC guidance. 4. Instructional signage throughout the facility and proper visitor education on COVID- 19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). 5. Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit. 6. Appropriate staff use of Personal Protective Equipment (PPE). 7. Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care). Review of CMS QSO-,d+[DATE]-NH requirement, revised [DATE], 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. 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 [DATE], 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 (NAs) 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 [TRUNCATED]

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, staff interview, medical record review, review of the facility investigation and review of the Elopement Policy, the facility failed to provide adequate supervision for one cognitively impaired resident (Resident #1) to prevent elopement from the facility. This resulted in Immediate Jeopardy when Resident #1 who was at risk for elopement, voiced and exhibited exit seeking behaviors and resided in the secured dementia unit, left the facility unknown to staff. Resident #1 was at risk for serious harm, impairment or death as he walked along a heavily trafficked four lane road and was found by a police officer who returned him to the facility. This affected one (Resident #1) of three residents reviewed for exit seeking behaviors. The facility identified eight additional residents (Residents #2, #3, #4, #5, #6, #7, #8 and #9) who were ambulatory or independently mobile and assessed as being at risk for wandering and elopement or exhibited exit seeking behaviors. On 07/07/20 at 1:55 P.M. the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 05/31/20 at 7:20 P.M. when Resident #1 left the facility without staff knowledge. Resident #1 was last seen in the building on 05/31/20 at 7:00 P.M. before exiting through an alarmed door, into a secured courtyard where he scaled a six- foot fence using his wheeled walker. The local police were notified and at 8:15 P.M. found Resident #1 walking along a busy four lane road. Review of the police report revealed the resident was approximately 0.7 miles from the facility. There was a tear in his blue jeans and he had several small open scratches to his arms and a small cut on his head. The resident asked the officer to take him home so he could see his wife and feed his dog. The Immediate Jeopardy was removed and corrected on 06/02/20 at 5:30 P.M. when the facility implemented the following corrective actions: · On 05/31/20 at 8:15 P.M. Resident #1 was returned to the facility by local police. Assessment revealed the resident reopened old skin tears on the top of his left wrist and had a small laceration on his right forearm. Review of the nurse aide bath/shower report dated 04/27/20 indicated he had open areas to his right forearm and the top of his left wrist upon admission to the facility. · The resident was provided one to one direct supervision and monitored for further elopement behaviors. · On 05/31/20 at 8:00 P.M. the Administrator educated staff currently working on the importance of checking alarms and elopement policies. · On 05/31/20 at 8:30 P.M. the Administrator tested all 15 doors that have the alert system. Three of the 15 were located in the secured unit. The gate and the patio doors were also tested . All of the door alarms were determined to be functional. · On 05/31/20 at 9:00 P.M. the DON began assessments on all cognitively impaired residents in the facility to determine if they were at risk for elopement or had a change in condition. Care plans were updated and new interventions were implemented as needed. · On 06/01/20 at 10:00 A.M. the elopement book was updated by the Administrator to include adding Resident #1. The elopement book included a picture of the resident and their face sheet for staff and law enforcement to aid in search if a resident was missing. · On 06/02/20 at 9:00 A.M. physician orders [REDACTED].#1 through #9) who were identified as at risk for elopement by the DON to ensure appropriate interventions were in place. · On 06/02/20 at 5:30 P.M. the Administrator and DON and Human Resource Director (HRD) #94 completed education with all 70 staff on supervision of residents, elopement policy, missing persons, and responding to door alarms. This was verified with staff in-service sign in sheets. · On 06/02/20 elopement drills were conducted successfully on each shift. · On 07/07/20 interviews from 9:00 A.M. to 11:15 A.M. with State tested Nurse Aide (STNA) #89, STNA #90, LPN #91 and on 07/08/20 from 10:05 A.M. to 10:34 A.M. with Registered Nurse (RN) #96, Licensed Practical Nurse (LPN) #85 and STNA #95 revealed all had been in-serviced and were knowledgeable of supervision of residents, the elopement policy, door alarm response, residents at risk for elopement and proper use of alert bracelets. All of these staff worked routinely on the secured dementia unit. STNA #89 and STNA #90 were present when Resident #1 successfully eloped from the facility. · On 06/22/20 the quarterly Quality Assurance meeting minutes indicated the facility self-implemented a quality assurance plan including door audits daily for 30 days then monthly thereafter completed by the maintenance director and chart audits daily for 30 days by the director of nursing. Findings include: Review of the medical record revealed Resident #1 as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a court ordered admission and placed on the secured dementia unit after police completed a wellness check at his home where he resided with his wife. Resident #1 was found in his bathtub [MEDICAL CONDITION] his back from the hot water. Resident #1 was discharged to the hospital on [DATE] following a fall and did not return to the facility. Review of the admission Minimum Data Set (MDS) 2.0 dated 05/01/20 indicated Resident #1 had short and long-term memory problems and was severely cognitively impaired in daily decision making. Resident #1 rejected care on one to three days of the assessment period but wandering was not exhibited. Review of activities of daily living indicated the resident required the supervision of one person for transfers, walking in the corridor on the unit and off the unit. His balance was steady at all times. He had no functional limitation in range of motion and used a walker for mobility. The assessment indicated Resident #1 had a fall with a fracture in the month prior to admission to the facility. Review of the elopement risk assessment dated [DATE] indicated Resident #1 was physically capable of leaving the facility and was confused to time and place. The list of interventions put into place was left blank leaving the determination of whether the resident was at risk for elopement unclear. However, review of the resident's care plan completed on admission and dated 04/25/20, indicated Resident #1 was at risk for elopement. The form was marked to interview the resident/family about whether there was a history of the resident attempting to leave his home or other facilities. The form also indicated Resident #1 had behaviors and to observe the resident's behaviors for the first 72 hours after admission, report any behaviors that could affect the resident's quality of life and/or affect other residents, and in the event he displayed disruptive behavior, redirect the resident and report the behavior. Review of the care plan related to Resident #1 being at risk for alteration in mood and behavior revealed resistance to care, verbal abuse and placing himself on the floor. Interventions included acknowledging the resident moods, one to one interactions, convey acceptance of the resident and provide repeated honest appraisals of his strengths, discuss feelings about placement and options of appropriate channeling of those feelings, encourage loved one to contact/visit, monitor mental and mood status changes when new medications were added and observe and report changes in mental status. Review of the progress notes since Resident #1's admission revealed he was frequently agitated, refused to sign forms or be assessed. The progress note authored by LPN #85 on 05/28/20 at 11:26 A.M. indicated Resident #1 was up in the hallway with his walker, exit seeking. The note did not identify specifics of Resident #1's actions. Review of the progress note documented as a late entry for 05/31/20 at 7:20 P.M. by the DON on 06/01/20 at 1:41 P.M. indicated Resident #1 was last observed on 05/31/20 at 7:00 P.M. and was noted absent from his room as evening snacks were being passed. A search was initiated. Resident #1 was found approximately 20-25 minutes later walking on a sidewalk on a main street. Review of the witness statements contained in the investigation revealed RN #88 entered the secured dementia unit to bring Resident #1 a snack. RN #88 was not able to find Resident #1 and asked STNA #89 and #90, currently assigned to work the unit, where Resident #1 was because she had a snack for him. STNA #89 and #90 searched the unit and the adjacent secured courtyard. Resident #1's walker was found leaning against a six-foot wood fence in the secured courtyard. No alarm had sounded. The nurse called a code green for missing persons and 911 was called. The STNAs completed a head count of the residents on the unit. The police returned Resident #1 to the facility on [DATE] at 8:15 P.M. Resident #1 sustained a small laceration on his right forearm and re-opened old skin tears on his left wrist. Interview with the Administrator on 07/06/20 between 7:15 A.M. and 7:46 A.M. during tour of the facility reported Resident #1 successfully eloped from the facility on 05/31/20 by scaling a six-foot wood fence using his walker in the enclosed courtyard located off the secured unit. The Administrator reported the resident was found with no major injuries a short time later. He reported putting a self- imposed plan of correction in place including staff education, and resident assessment, and updating of resident care plans. Observation of the secured unit on 07/06/20 between 7:15 A.M. and 7:46 P.M. with the Administrator revealed a keypad with a code was required to enter or exit the unit. Only staff had the code. If the doors were pushed on for 15 seconds an alarm would sound alerting staff someone was attempting to leave. Not all residents on the secured dementia unit had alert bracelets only those identified at risk for elopement. When residents wearing alert bracelets were in close proximity to exit doors including those to the courtyards, the alarms would sound. A code had to be punched into the keypad to silence the alarm. The doors were tested and found to alarm after being pushed for 15 seconds. The alarms were intensely loud. Once outside in the large courtyard there was a six-foot vertically slatted wood fence that was intact and encompassed two exit doors from the secured unit. No cameras were in the secured unit or the courtyard. Interview with the DON on 07/07/20 at 9:10 A.M. revealed Resident #1 was a court ordered admission and placed in the secured unit due to dementia related behaviors including yelling and resisting care, not for the purpose of preventing elopement. The DON denied the resident was at risk for elopement. The DON acknowledged the resident had verbalized he did not want to be in the facility, and he was going to get out, but said that alone did not make Resident #1 an elopement risk. She said he made no physical attempts to leave the facility prior to 05/31/20. The 05/28/20 nurse's note at 11:27 A.M. was reviewed with the DON which indicated Resident #1 was physically exit seeking. The DON then verified Resident #1 should have been reassessed for elopement risk at that time and a care plan with individualized interventions to prevent elopement should have been developed and implemented for the resident. Interview with STNA #89 on 07/07/20 at 10:31 A.M. revealed Resident #1 had significant negative behaviors. Resident #1 resisted care, swore, was loud, threatening, mad, did not want to be in the facility and wanted to go home since his admission. STNA #89 recalled the events of 05/31/20 indicating Resident #1 was having a particularly bad day and was talking about wanting to go home. They tried taking a walk with him in the courtyard and called his daughter to try and calm him. STNA #89 stated the resident cussed the daughter out. STNA #89 reported she was shocked and surprised that Resident #1 used his walker, scaled a six-foot fence and eloped from the facility. STNA #89 reported not one alarm was sounding at the time the resident was missing and prior to that the alarms went off non-stop and were loud. Interview with STNA #90 on 07/07/20 at 11:15 A.M. indicated Resident #1 refused care, was loud and rude. STNA #90 recalled the events of 05/31/20 indicating Resident #1 was set on trying to exit, pushed on the doors until they alarmed and yelled out that he was going to leave. STNA #90 reported they had him talk with his daughter and he cussed her out. STNA #90 said RN #87 was at the nurse's desk when RN #88 came looking for Resident #1 to give him a snack. When RN #88 was not able to locate Resident #1 they began to look and found his walker up against the fence in the courtyard. STNA #90 reported when the police returned Resident #1 to the facility he was very angry and was swearing. STNA #90 provided him a pair of disposable pants because his were ripped and he had a little spot of blood on his arm. Resident #1 was provided one to one supervision at that time. Interview with the responding police officer (Officer #100) on 07/08/20 at 3:04 P.M. indicated on 05/31/20 at 7:40 P.M. a call came in about a missing person. The officer spoke to RN #99 who reported Resident #1 was in a fenced courtyard, and used his walker as a step to get over a fence and fell . RN #99 reported he may have scrapes and bruises. Officer #100 found Resident #1 at an intersection of a very busy roadway. The officer reported it was a pretty good hike for an older man. Officer #100 said Resident #1 was confused and asked for a ride home to see his wife and feed the dog. The officer reported Resident #1's pants were completely ripped and he had some scrapes on his hands and probably his knees. Resident #1 was medically cleared by Emergency Medical Services (EMS) on the scene and they transported him back to the facility. The officer recalled the resident did not want to go back to the facility. Review of the maintenance log since May 2020 revealed the exit doors were tested on a monthly basis. Review of the elopement policy dated December 2007 indicated If an employee discovered a resident was missing from the facility, he/she shall: Determine if the resident is out on an authorized leave or pass; If the resident was not authorized to leave, initiate a search. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries; Contact the Attending Physician and report findings and conditions of the resident; notify the resident's legal representative; Notify search teams that the resident has been located; Complete and file an incident report; and Document relevant information in the resident's medical record. Review of the safety and supervision of residents policy dated July 2017 indicated the facility would assess, determine and implement targeted interventions and monitor interventions for effectiveness. This deficiency substantiates Complaint Number OH 813.

Based on observation, resident and staff interviews, Review of the medical record, facility investigation, police report, hospital records, abuse, neglect, mistreatment and prevention policy and procedure and review of the missing patient document, the facility failed to implement adequate supervision to prevent elopement of one resident (Resident #82). This resulted in Immediate Jeopardy when Resident #82, who had a [DIAGNOSES REDACTED]. Resident #82 was at risk for serious harm, impairment or death as she crossed two four lane roads at night and was reported as a suspicious person when she walked into a motel 0.5 mile away from the facility. The local sheriff found the resident after being reported by the motel staff. Resident #82 admitted she was confused and requested to go the hospital. The average low temperature for the night of the elopement. 05/04/18, was 51 degrees Fahrenheit. This affected one of three residents reviewed for exit seeking behaviors. The facility identified four additional residents (Residents #39, #60, #65 and #79) who were ambulatory or independently mobile and assessed as being at risk for wandering and elopement or exhibited exit seeking behaviors. On 05/09/18 at 2:00 P.M. the Administrator, Director of Nursing (DON), Registered Nurse (RN) #83 and Quality Assurance Consultant #84 were notified Immediate Jeopardy began on 05/04/18 at 9:00 P.M. when Resident #82 was last seen in the building before exiting without knowledge of the staff and was found by the local sheriff 0.5 miles away from the facility. The Immediate Jeopardy was removed on 05/07/18 when the facility implemented the following corrective actions: On 05/04/18 at 11:00 P.M. Resident #82 was located by the DON at the local hospital. · On 05/05/18 a meeting of the quality assurance committee was held to review the investigation process and develop additional recommendations for correction. · On 05/05/18 an exit seeking audit tool was developed. The DON completed an audit on 05/05/18 and would complete an audit weekly for four weeks of new admissions. · On 05/05/18 at 12:38 A.M. Resident #82 returned to the facility. She was placed in the secured unit and an alert bracelet was applied. She was provided one to one supervision throughout the night on the day of return and her care plan was updated. · On 05/05/18 at 1:00 A.M. RN #83 verified alert bracelets were validated for placement and functioning for Residents #39, #60, #65 and #79. · On 05/05/18 at 9:30 A.M. maintenance director #77 completed a door check on all doors to ensure the secure alert system was functioning. · On 05/05/18 at 12:00 P.M. the receptionist binder and the happy feet board (a bulletin board in the employee dining room identifying residents at risk for elopement) were updated to match by the DON, including pictures and resident information. Residents were removed or added as necessary. · On 05/05/18 at 10:00 P.M. RN #83 completed elopement re-assessments on all 81 residents. The facility census was 81. · On 05/06/18 at 9:58 A.M. Resident #82 was sent out of the facility for a geriatric psychiatric evaluation where she remains. · From 05/05/18 at 12:45 A.M. to 05/07/18 at 7:00 P.M. the DON and/or the Administrator completed re-education of all facility staff members (103 members) on missing persons, elopement/door alarm logs, wandering and exit seeking residents, personal security bracelets and the behavior practice guide including assessment and care planning. The training was completed over a three-day time span. This was verified via staff attendance records. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a 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 action and monitoring to ensure compliance Findings include: Review of the electronic record revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 ((MDS) dated [DATE] indicated Resident #82 had moderate impaired cognition with behavioral symptom of wandering that occurred on one to three days of the assessment period. Review of the admission assessment dated [DATE] indicated Resident #82 verbalized a desire to exit. The interventions included calmly redirecting the resident to an appropriate area, check the alert bracelet placement every shift and the functioning every day, encourage socialization with others, provide recreational programming and engage in activity/tasks to keep the resident occupied. Review of the plan of care for exit seeking/elopement risk initiated on 04/09/18 included the intervention to check alert bracelet every shift and the functioning every day. The alert bracelet was placed on the resident's left ankle. Review of the admission progress note revealed on 04/09/18 at 1:45 P.M., Resident #82 expressed being upset that she was brought to a nursing facility. She verbalized wanting to leave the facility but agreed to have an alert bracelet. Review of the progress notes by RN #80 revealed on 05/01/18 at 11:20 P.M. Resident #82 stated the alert bracelet fell off. The resident was checked every 15 minutes that shift. RN #80 noted she was not able to locate the alert bracelet. Review of progress notes dated 05/02/18 at 6:14 A.M. revealed Resident #82 was monitored all shift and remained in her room all night. On 05/02/18 at 6:52 P.M. Resident #82 refused to wear the alert bracelet. RN#80 noted she would re-attempt to apply. On 05/03/18 at 11:13 A.M. Resident #82 refused to have the alert bracelet applied three times saying, I told you I am not wearing that thing, I'm not going nowhere. On 05/4/18 at 9:45 P.M. Licensed Practical Nurse (LPN) #25 entered Resident #82's room to administer medication as ordered. Resident #82 was out of the room. The roommate was unaware of resident's location. The smoking area was checked. The resident was not in the smoking area. The charge nurse, RN #80, was notified. A code green (missing person code) was called. The interior and exterior portions of the facility were searched. The guardian, physician and the local police were notified. On 05/04/18 at 11:00 P.M. Resident #82 was found at the local emergency room with no injuries. On 05/05/18 at 12:38 AM. Resident #82 returned to the facility. An alert bracelet was applied and Resident #82 was admitted to the secured unit. The resident apologized for leaving the facility stating she needed minutes for her phone. Review of the progress notes dated 05/05/18 at 11:20 A.M., LPN #39 revealed Resident #82 asked why she had to have the alert bracelet on, I cut it off before I'll do it again. It was noted the resident said she did not belong in the facility and wanted to go to court. Despite multiple redirections, Resident #82 continued to ask the same questions repeatedly. Resident #82 asked who was her guardian and when could she leave. Review of the statement by State tested Nurse Aide (STNA) #43 revealed Resident #82 was last seen after the smoke break on 05/04/18 at 9:00 P.M. heading towards her room. Review of RN #80's statement indicated Resident #55 reported seeing Resident #82 out in front of the facility with Resident #56. Review of RN #80's statement indicated Resident #56 returned indoors when it got dark and Resident #56 witnessed Resident #82 headed toward the shopping mall. RN #80 did not witness Resident #82 leaving the facility. RN #80 could not be interviewed during the investigation. Interview with the Administrator on 05/09/18 at 7:55 A.M. revealed he received a call on Friday 05/04/18 at 10:15 P.M. indicating Resident #82 could not be located. He said the staff had begun to search the perimeter. The administrator indicated Resident #82 had cut off her alert bracelet. The Administrator stated Resident #82 was found by the sheriff and taken to the local hospital emergency department. Resident #82 was immediately released back to the facility and placed in the secured unit. The resident was not injured. According to an interview with the administrator on 05/09/18 at 8:00 A.M., when Resident #82 was originally admitted to the facility, the guardian wanted her in the least restrictive environment and agreed to have the resident wear an alert bracelet. When the resident returned from the hospital on [DATE] at 12:38 A.M., according to the administrator, Resident #82 was initially remorseful about leaving the facility but when she got up the next morning she began raising cane. She threatened to cut the alert bracelet off again and threatened to leave saying she felt like she was in prison. The guardian visited and witnessed the behavior. Record review on 05/09/18 revealed on 05/06/18 at 12:07 P.M. LPN #39 the guardian and nurse practitioner gave verbal consent for Resident #82 to be sent for a geriatric psychiatric evaluation. There were no formal written orders in the record to confirm the verbal orders. Interview with the DON on 05/09/18 at 8:15 A.M. revealed she was immediately notified when Resident #82 could not be located and joined in the search. Once the resident was returned to the facility, she was placed in the secured unit and an alert bracelet was put in place upon notification from the guardian and an order from the physician. A one to one staff person was in place all night on 05/05/18. She said a meeting of the quality assurance committee was held on 05/05/18 to review the investigation process and develop additional recommendations for correction. The DON stated she had not been made aware the resident removed the alert bracelet on 05/01/18 and no additional interventions were implemented. Interviews with RN #42, LPNs #9, #39, #45, #51 and #97 and STNAs #16, #22 and #79 on 05/09/18 between 8:30 A.M. and 9:15 A.M. indicated they received training on missing persons and elopement prior to coming on duty that morning. None of these staff were present during the incident on Friday 05/04/18. All staff received training by telephone if they were not in the facility by 05/07/18 at 7 P.M. Once they arrived, prior to their shift starting, they signed the in-service record and received paper copies of the in-service information. Interview with LPN #51 on 05/09/18 at 9:00 A.M. reported she was made aware Resident #82 cut off her alert bracelet on Tuesday or Wednesday last week because the nurse requested she obtain one for her. LPN #51 said Resident #82 was independently ambulatory and had some confusion. Interview with LPN #39 on 05/09/18 at 9:10 A.M. indicated Resident #82 was steady on her feet. She wandered all the time but could be verbally redirected. LPN #39 stated resident #82 was a supervised smoker. She wore an alert bracelet and they checked it on the way out for her smoke break. Interview with Resident #55 on 05/09/18 at 11:45 A.M. said he witnessed Resident #82 go out the front door with Resident #56 on Friday night 05/04/18 but didn't think anything of it. He said he heard from other residents she burned the ankle bracelet off during a smoke break. Interview with Resident #56 on 05/09/18 at 11:55 A.M. revealed Resident #82 was outside with him on Friday 05/04/18. He said he came back inside because it was dark and he said she headed toward the shopping mall. Review of the sheriff's report dated 05/04/18 at 10:21 P.M. indicated a nurse flagged down the sheriff saying a resident from the facility walked away from the nursing home. The report indicated the resident was later found and transported to a nearby hospital. Review of the sheriff's report dated 05/04/18 at 9:45 P.M. Resident #82 walked into a hotel requesting her room. She was told by the hotel staff she did not have a room there. She left the hotel and returned three more times. The hotel called the sheriff to report a suspicious person. The sheriff found Resident #82 walking into another hotel 0.5 miles away from the facility. The sheriff noted she was confused and requested to go to the hospital. Review of the behavior practice guide, phase I assessment dated (YEAR) indicated when unsafe wandering or elopement risk had been identified a behavioral symptoms user defined assessment (UDA) was completed in the electronic record. Residents might be identified as a risk when one or more of the following risk factors were present: verbalizes the desire to exit, demonstrates behavioral symptoms indicating the desire to exit, physically attempts to exit center, wanders into potentially unsafe areas, has history of similar behavior patterns. The personal security bracelet served as an alert to the resident of safe boundary limits and as an alert to staff if the resident was close to an alarmed door. Education would be provided to the resident; responsible party and a physician order [REDACTED]. Bracelet validation would be obtained every shift in accordance with manufacturer recommendations. Review of the missing patient document dated (MONTH) (YEAR) revealed it was intended to provide guidelines for patient accountability, searching for missing patients and communication with outside agencies. This deficiency substantiates complaint OH 823

Based on record review and interview the facility failed to implement the necessary care and services to prevent a decline in bladder function for Resident #134. Harm occurred to Resident #134 when the facility failed to properly assess and identify the resident's increase in incontinence resulting in a decline in continence status. Resident #134 was assessed to be occasionally incontinent of urine on the Minimum Data Set (MDS) 3.0 assessment dated [DATE] and frequently incontinent of urine on MDS dated [DATE]. This affected one resident (Resident #134) of 21 residents reviewed for assessments. The facility identified 66 residents who were incontinent of urine. Finding include: Record review revealed Resident #134 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 07/16/15 revealed Resident #134 had severe cognitive impairment. Further review of MDS revealed Resident #134 was occasionally incontinent of bowel and bladder. The quarterly MDS dated [DATE] revealed Resident #134 was not on a toileting program and was frequently incontinent of bladder and continent of bowel. Review of care plans revealed there was not a plan of care in place for bladder incontinence. Review of progress note dated 07/10/15 at 10:42 P.M. revealed Resident #134 toileted self during admission assessment. Progress note dated 07/11/15 at 6:52 A.M. revealed Resident #134 was continent during night shift. A three day bladder tracking from 07/11/15 to 07/13/15 revealed Resident #134 was continent of urine. Review of progress notes dated 07/15/15 and 07/16/15 revealed Resident #134 was continent of bowel and bladder. Urinary incontinence assessment dated [DATE] revalued Resident #134 was continent of urine. Review of progress notes date 09/26/15 and 09/30/15 revealed Resident #134 had soiled pants. Review of toileting documentation from 12/24/15 to 01/04/16 revealed Resident #134 was incontinent of urine 79 out of 98 times. Review of physician orders [REDACTED]. A care plan was implemented for the diuretic medication but did not address urinary incontinence. On 01/07/16 at 9:16 A.M. an interview with Licensed Piratical Nurse (LPN) #63 revealed she did not do previous MDS assessments. LPN #63 stated she had not done an assessment on Resident #134. LPN #63 further stated if a decline in urinary continence was noted, then LPN #79 would do a three day urinary tracking. LPN #63 stated the resident would be placed on a toileting program or scheduled incontinence care. LPN #63 verified there was not a care plan in place for urinary incontinence for Resident #134. On 01/07/16 at 9:27 A.M. interview with LPN #79 stated a three day bowel and bladder tracking would be done if there was a change in a residents bowel or bladder continence. On 01/06/16 at 2:20 P.M. an interview with LPN #80 revealed Resident #134 was admitted to secure unit then moved to another unit and then back to secure unit. LPN #80 stated Resident #134 would let staff know when his/her bowels need to move. LPN #80 stated the moving from one unit to another may have caused an increase in incontinence. LPN #80 was not aware of resident being on a toileting program or scheduled incontinence care. Review of urinary incontinent flow sheet dated 2012 revealed a care plan, management, and education for resident and staff should be in place. Resident #134 was identified as occasionally incontinent of urine on admission and frequently incontinent of urine on the most recent MDS assessment. Resident #134 did not have a care plan for urinary incontinence. Resident #134 experienced a decline in urinary continence. The facility failed to prevent the decline or implement a program to attempt to restore normal bladder function.

Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall resulting in fracture for one of two residents (Resident #6). This resulted in actual harm to Resident #6 who sustained a fractured finger. The facility also failed to ensure adequate staff assistance was provided to prevent a fall for Resident #4. This affected two residents (Resident #6 and Resident #4) of four residents reviewed for falls. The facility census was 124. Findings include: On 05/13/13 at 11:51 A.M., the Administrator revealed she would read the information on the facility's fall investigations to the surveyor due to the actual fall investigations were a part of the facility quality assurance. 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6, who resided in the secured unit for residents with dementia and behaviors, was assessed on 01/17/13 as alert but confused and at risk for a fall. A plan of care for fall risk was initiated on 9/22/2008 and indicated the resident had poor safety awareness and decision making skills. The care plan was revised on 12/26/12 with the added intervention to keep the resident in a supervised area at all times. On 05/13/13 at 11:51 A.M., review of a fall investigation and interview with the Administrator revealed on 02/06/13 the staff were assisting residents in the TV room. Upon leaving the TV area at 5:30 P.M., Resident #6 was found on the floor in the hall by the nurses' station. The fall was not witnessed by any staff member. The resident was laying on her left side with her left arm under her. Review of an assessment revealed the left fifth finger was swollen, discolored and misaligned. The resident was sent to the emergency room for an evaluation and an X-ray. The X-ray revealed the left fifth finger was fractured. The resident returned to the facility with a splint in place. On 05/13/13 at 3:45 P.M., an interview with the Administrator verified staff failed to provide supervision for Resident #6 who sustained a fall and fractured fifth digit of the left hand. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an assessment completed on 03/16/13 revealed the resident had mild confusion but was able to make decisions and make needs known. In addition, the resident required extensive assist of two persons for turning side to side in bed and extensive assist of one to two persons for dressing. Review of a care plan for activities of daily living, initiated on 08/22/12, revealed the resident required the assistance of one to two people for dressing. Review of a resident care card, used by the State tested Nurse Aides (STNAs), also indicated the resident was at risk for a fall and required extensive assistance of one to two persons with dressing. On 05/13/13 at 11:51 A.M., review of a fall investigation and interview with the Administrator revealed on 04/02/13 at 9:35 A.M., Resident #4 sustained a fall during resident care. The State tested Nurse Aide's (STNA#25) statement indicated she was getting the resident dressed, while in the bed and attempted roll the resident from her left side onto her back. Resident #4 thought she was falling and grabbed suddenly for the bedside stand and continued rolling forward toward STNA #25. STNA #25 could not hold the resident's weight and lowered the resident to the floor on her knees. The resident sustained [REDACTED]. The wound was cleansed and steri trips and a bandage was applied. The resident complained of right shoulder pain and an X-ray was negative for any dislocation or fracture of the right shoulder. On 05/13/13 at 1:30 P.M., an interview with STNA #25 revealed she recalled Resident #4's fall. STNA#25 recounted the same events described in her statement. When asked why she attempted to complete care by herself and how she determined whether she needed help or not, STNA #25 explained Resident #4 as a nervous person and said her demeanor fluctuated and was unpredictable. As far as needing one or two persons to complete activities such as dressing, STNA #25 said she thought she could dress Resident #4 herself but could not say how she came to that decision. Everything was fine until she attempted to roll the resident from her side back onto her back and the resident suddenly grabbed at the bedside stand and had to be lowered to the floor using her body because the bed was at working level. On 05/13/13 at 3:45 P.M., an interview with the Administrator verified the staff failed to provide assistance of two persons for bed mobility for Resident #4 who was lowered onto the floor and sustained a laceration of the right arm. This citation substantiates complaint #OH 996.