Every finding on record at Gardens of Paulding the

Based on observation, review of a cleaning checklist, staff interview, and policy review, the facility failed to ensure the kitchen was properly cleaned and maintained in a sanitary manner, and failed to ensure food items were stored in a manner to prevent contamination. This deficient practice had the potential to affect all 39 residents who received food prepared in the kitchen. The facility census was 39.Findings include:Observation on 05/20/25 at 8:40 A.M. revealed food debris, small pieces of paper and paper towel, and dirt accumulation at the entryway of the kitchen. Further observation of the kitchen revealed the interior of the microwave contained an unknown splattered yellow substance. The gas stove had loose charred substances in the corners of the burners along with rice-like debris scattered around the burner surfaces. The stand up refrigerator contained an unknown dried substance with visible streaking at the bottom of the unit and the exterior door had multiple unidentified splatters. Continued observation revealed the dry storage area contained multiple broken orange plastic pieces scattered across the floor along with visible dirt accumulation. A scoop was also observed stored inside the flour bin within the dry storage area.Review of the cleaning checklist dated 05/19/26 revealed all items were marked as completed by the night shift.Interview with Dietary Director (DD) #1 on 05/20/26 A.M., during the kitchen observations, revealed the entry area to the kitchen was only cleaned once per month an stated there was not enough time in the routine schedule to clean the area more frequently. DD #1 verified all observations noted above at the time of the findings.Review of the facility policy titled, Sanitation and Food Safety, dated 08/01/23, revealed the kitchen area shall be kept clen, free from litter, and rubbish.Review of the undated facility policy titled, Cleaning Instructions, revealed to store scoops in a covered container.This deficiency represents non-compliance investigated under Complaint Number 2966042.

Based on medical record review, observations, staff and Poison Control Center Representative interviews, and review of a Material Safety Data Sheet (MSDS), the facility failed to ensure medications were appropriately secured/stored resulting in a cognitively impaired resident ingesting an undetermined amount of antifungal powder. This affected one (#10) of three residents reviewed for medication storage. The facility census was 38. Findings include: Review of medical record for Resident #10 revealed admission date of 06/16/25. The resident was admitted to the facility under hospice with diagnoses including hypertensive heart disease with heart failure, dementia without behaviors and cerebral atherosclerosis. The resident remained in the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of three out of 15 indicating significantly impaired cognition. Resident #10 required supervision for eating, bed mobility, transfers and required moderate assistance with toileting hygiene. Interview on 12/15/25 at 11:40 A.M. with Housekeeper #102 revealed she was working on 12/07/25 when she observed Resident #10 in her room with a bottle of antifungal (Miconazole) powder up to her mouth. Housekeeper #102 stated she immediately got State Tested Nursing Assistant (STNA) #104 who was in the room next door. They entered Resident #10's room and took the bottle from her. Housekeeper #102 stated the bottle was antifungal powder is a product provided at the facility. Housekeeper #102 stated the bottle had a screw top and when she got the bottle and looked in it, there was water mixed with the powder. The bottle was half empty. Housekeeper #102 and STNA #104 brought the bottle to Licensed Practical Nurse (LPN) #106. LPN #106 was informed Resident #10 mixed water into the bottle and was observed drinking it. LPN #106 looked at the ingredients of the bottle and informed Housekeeper #102 there was nothing in the powder which would cause harm, and he threw the bottle away. Housekeeper #102 stated LPN #106 did not get up and go to Resident #10's room, but he told STNA #104 to keep an eye on Resident #10, and look in on her about every five minutes or so. Interview on 12/15/25 at 1:40 P.M. with STNA #104 revealed on 12/07/25 she was in a room when Housekeeper #102 came in and told her Resident #10 was drinking antifungal powder. STNA #104 went directly to Resident #10's room and stated she observed Resident #10 drinking from the bottle. STNA #104 stated when they looked in the bottle it looked like milk. STNA #104 was unsure where the bottle came from and added Resident #10's roommate had powders and creams on her side of the room. STNA #104 and Housekeeper #102 brought the bottle to LPN #106. LPN #106 was informed Resident #10 mixed water into the bottle and was observed drinking it. LPN #106 looked at the ingredients of the bottle and informed Housekeeper #102 there was nothing in the powder which would cause harm and he threw the bottle away. STNA #104 stated LPN #106 did not ask her to monitor Resident #10. Interview on 12/15/25 at 1:51 P.M. with LPN #106 revealed he worked on 12/07/25 and was informed toward the end of his shift (4:30 P.M. to 5:00 P.M.) by Housekeeper #102 and STNA #104 they had observed Resident #10 with a bottle of antifungal powder tilted up to her mouth. They presented the bottle to him. LPN #106 stated the bottle was full, and he observed the powder was settled at the bottom with the water full to the top. LPN #106 stated he went right in to assess Resident #10. LPN #106 stated there was no powder residue around or in Resident #10's mouth. LPN #106 stated Resident #10 did not present with any concerning symptoms and shared he did not have a concern she had consumed any of the powder. LPN #106 acknowledged he did not report the incident to anyone, including the oncoming nurse. LPN #106 verified he did not know how Resident #10 was able to obtain the antifungal powder. LPN #106 stated he was contacted by the Director of Nursing (DON) on Monday, 12/08/25 and asked about the incident. LPN #106 informed the DON that he did not make any notifications because he did not feel Resident #10 had consumed any of the powder. LPN #106 explained he did receive a written reprimand for the incident for lack of notification, which he signed. Interview on 12/15/25 at 2:26 P.M. with Poison Control Center Representative #107 revealed if Miconazole is ingested, it is not of high concern. Poison Control Center Representative #107 stated symptoms of ingesting Miconazole would be cramping, nausea, vomiting or diarrhea and which would not last long. Poison Control Center Representative #017 stated you would expect to see these symptoms to begin within an hour. Poison Control Center Representative #107 stated they would encourage a snack and drink if Miconazole is ingested. Interview on 12/15/25 at 3:18 P.M. with the DON revealed she was informed by Registered Nurse (RN) #103 on 12/08/25 that Resident #10's daughter had been told by a housekeeper, on 12/07/25 that Resident #10 had ingested antifungal powder. An investigation into the incident was initiated. The DON discovered Housekeeper #102 and STNA #104 had witnessed Resident #10 with a bottle of antifungal powder tilted up against her lips. The DON stated neither could verify if any of the product was consumed. The DON stated she interviewed LPN #106 who acknowledged he had been informed of the incident during his 12/07/25 shift. The DON stated LPN #106 was advised it would be the expectation the Physician, physician on call, herself and family would be notified of an incident or near miss incident. The DON added he was given a written reprimand. The DON also acknowledged the oncoming nurse was not notified of the incident. The DON verified the antifungal bottle was facility supplied, but was unable to conclude where or how Resident #10 obtained it because the resident did not have an order for the product. Review with the DON of physician orders (current and discontinued) for both Resident #10 and her roommate (Resident #11) revealed neither resident had an order for Miconazole powder or an antifungal powder. Observation of the facility provided anti-fungal powder revealed the warning if swallowed, get medical attention or contact poison control center right away. Review of the facility supplied MSDS for Miconazole for ingestion and of swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water. Do not induce vomiting unless directed to do so by a physician. This deficiency represents non-compliance investigated under Complaint Number 2692543.

Based on observation, staff interview, review of facility policy, and review of the Food and Drug Administration (FDA) guidelines, the facility failed to label refrigerated foods and practice proper hand hygiene during food service. This had the potential to affect all residents. The facility census was 39. Findings include: 1. Observation on 09/08/25 at 8:20 A.M. of the walk-in refrigerator revealed the following food items not labeled or dated: a gallon size plastic bag of sliced cheddar cheese, bag of bologna, and container of coleslaw. Interview on 09/08/25 at 8:28 A.M. with Dietary Manager (DM) #217 verified the three food items in the walk-in refrigerator were unlabeled and undated.Review of the facility policy titled, Food Storage, dated 2023, revealed leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 2. Observation on 09/10/25 at 10:40 A.M. revealed [NAME] #207 was pureeing the lunch meal. [NAME] #207 was observed to have fingernails painted with a thick layer of polish. While completing the task, [NAME] #207 was observed to wipe her hands on her pants twice and scratch her face after washing her hands. Interview on 09/10/25 at 10:50 A.M. with [NAME] #207 verified having nail polish on and touching her pants and face during the food service preparation. Review of the facility policy titled, General Hazard Analysis Critical Control Points Guidelines for Food Safety, dated 2023, revealed food and nutrition staff will be educated and monitored in hand washing.Review of the FDA Food Code Recommendations, dated 2022, revealed food employees, unless wearing intact gloves in good repair, may not wear fingernail polish or artificial fingernails when working with exposed food.

Based on medical record review, staff interview, and policy review, the facility failed to ensure recommended nutritional supplements were implemented. This affected one (#4) of three residents reviewed for nutrition. The facility census was 39. Findings include:Review of Resident #4's medical record revealed an admission date of 04/10/25. Diagnoses included dementia, muscle weakness, depression, altered mental status, and Type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/14/25, revealed Resident #4 had severe cognitive impairment. Review of the care plan, dated 04/10/25, revealed Resident #4 had a nutritional problem or was at risk for potential nutrition impairment/dehydration related to his diagnoses. Interventions in place included to provide and serve dietary supplements as ordered, monitor intake and record each meal, and a registered dietitian (RD) should evaluate and make diet change recommendations as needed. Review of a Nutritional Assessment, dated 07/15/25, revealed the RD recommended a trial of magic cup (nutritional supplement) with twice daily, with lunch and dinner for nutritional support.Review of Resident #4's physician orders for the month of July 2025 and August 2025 revealed no orders for a magic cup.Interview on 09/11/25 at 11:47 A.M. with RD #301 confirmed that on 07/15/25, a recommendation was made to trial a magic cup supplement with lunch and dinner for added nutrition support for Resident #4. Interview on 09/11/25 at 1:55 P.M. with the Director of Nursing (DON) verified RD #301's recommendation from 07/15/25 was not followed-up on and the magic cup nutritional supplement was not implemented for Resident #4. Review of the facility policy titled, Medical Nutrition Therapy Recommendations, undated, revealed medical nutrition therapy recommendations from the registered dietitian would be implemented, or the reason for non-implementation will be documented in a timely manner.

Based on medical record review and staff interview, the facility failed to ensure accurate resident medical records. This affected one (#10) of two residents residents reviewed for accurate medical records. The facility census was 39.Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, neuromuscular dysfunction of bladder, essential hypertension, Type II diabetes with diabetic polyneuropathy, major depressive disorder, and carpal tunnel syndrome. Review of the Minimum Data Set (MDS) assessment, dated 06/25/25, revealed the resident was cognitively intact. Review of a physician order, dated 11/13/24, revealed an order for insulin lispro subcutaneous solution pen-injector 100 unit/milliliters (ml), inject 10 units subcutaneously before meals related to Type II diabetes mellitus with diabetic polyneuropathy., hold if (blood sugar [BS]) was less than 150. Review of the Medication Administration Record (MAR) for June 2025 revealed twelve instances when Licensed Practical Nurse (LPN) #234 documented Resident #10's the insulin was administered when the BS was less than 150. Review of the MAR for July 2025 revealed twelve instances when LPN #234 documented Resident #10's insulin was administered when the BS was less than 150. Review of MAR for August 2025 revealed 15 instances when LPN #234 documented Resident #10's insulin was administered when the BS was less than 150. Review of MAR for September 2025 revealed five instances when LPN #234 documented Resident #10's insulin was administered when the BS was less than 150. Interview on 09/09/25 at 1:56 P.M. with LPN #234 verified an inaccurate medical record for Resident #10. LPN #234 stated she did not administer insulin as documented in the MAR, adding she was not familiar with how to documented the BS was outside of parameters.

Based on medical record review, observation, staff interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned prior to providing care for a resident who required Enhanced Barrier Precautions (EBP). This affected one (#17) of one resident reviewed for EBP. The facility census was 39. Findings include:Review of Resident #17's medical record revealed an admission date of 07/30/25. Diagnoses included depression, paroxysmal atrial fibrillation, aneurysm of artery of lower extremity, hypothyroidism, and anxiety disorder. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition.Review of Resident #17's care plan dated 07/30/25 revealed Resident #17 had an alteration in skin related to an abscess to her right groin with interventions to administer medications as ordered, administer treatments as ordered, and monitor for effectiveness.Observation on 09/08/25 at 3:41 P.M. revealed Certified Nursing Assistant (CNA) #254 was assisting Resident #17 into her bed and into a comfortable position. CNA #254 did not don PPE prior to assisting Resident #17. Interview on 09/08/25 at 3:44 P.M. with CNA #254 verified she did not don PPE, including a gown and gloves, prior to providing direct contact care with Resident #17. CNA #254 stated if she were assisting with changing the wound dressing or proving care, she would wear PPE, but PPE was not needed just for assisting Resident #17 with a transfer into bed. Review of the facility policy titled, Enhanced Barrier Precautions (EBP), last revised in April of 2025, revealed EBP should be employed when transferring a resident. Review of the CDC guidance titled, Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms [MDROs]), dated 04/02/24 and located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html#cdc_generic_section_2-enhanced-barrier-precautions-in-nursing-homes-video-posters-pocket-guide, revealed the use of gown and gloves for high-contact resident care activities was indicated for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP included, but not limited to, dressing, bathing/showering, transferring, providing hygiene, and providing wound care.

Based on medical record review, resident and staff interview, review of the facility submitted Self-Reported Incident (SRI), review of the facility investigation, and review of facility policy, the facility failed to ensure a complete and thorough investigation of alleged resident abuse. This affected one (#17) of four residents reviewed for abuse. The facility census was 39. Findings include:Review of Resident #17's medical record revealed an admission date of 07/30/25. Diagnoses included depression, paroxysmal atrial fibrillation, aneurysm of artery of lower extremity, hypothyroidism, and anxiety disorder. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Review of Resident #17's care plan dated 07/30/25 revealed Resident #17 had an alteration in skin related to an abscess to her right groin with interventions to administer medications as ordered, administer treatments as ordered, and monitor for effectiveness. Interview on 09/08/25 at 3:46 P.M. with Resident #17 revealed on 08/22/25 she was struck by Licensed Practical Nurse (LPN) #234 on her hand after attempting to hold her abdominal fold up for LPN #234 to have easier access to complete wound care. Resident #17 stated she reported the incident to the administrator the next day (08/23/25). Interview on 09/09/25 at 8:15 A.M. with Resident #16 revealed on 08/22/25 she heard her roommate (Resident #17) be struck by LPN #234 from behind the privacy curtain. Resident #16 stated LPN #234 yelled don't touch that. Interview on 09/09/25 at 10:10 A.M. with Resident #17 revealed she considered the incident to be abuse. Resident #17 stated sometimes she felt safe with LPN #234 and sometimes she did not. Resident #17 stated if her roommate was in the room, she had a witness of how she was treated by LPN #234. Review of Resident #17's medical record revealed an admission date of 07/30/25. Diagnoses included depression, paroxysmal atrial fibrillation, aneurysm of artery of lower extremity, hypothyroidism, and anxiety disorder. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition.Review of Resident #17's care plan dated 07/30/25 revealed Resident #17 had an alteration in skin related to an abscess to her right groin with interventions to administer medications as ordered, administer treatments as ordered, and monitor for effectiveness.Interview on 09/08/25 at 3:46 P.M. with Resident #17 revealed on 08/22/25 Licensed Practical Nurse (LPN) #234 slapped her on her hand after attempting to hold her abdominal fold up for LPN #234 to have easier access to complete wound care. Resident #17 stated she reported the incident to the administrator the next day (08/23/25). Interview on 09/09/25 at 8:15 A.M. with Resident #16 revealed revealed the resident was cognitively intact. Further interview revealed that on 08/22/25 she heard LPN #234 slap her roommate (Resident #17). The privacy curtain was pulled, so she did not visually see what occurred. Resident #16 stated LPN #234 stated don't touch that. Interview on 09/09/25 at 1:51 P.M. with LPN #234 revealed she denied slapping Resident #17. Interview on 09/09/25 at 3:59 P.M. with the Administrator and Assistant Director of Nursing (ADON) #204 revealed the facility submitted a Self-Reported Incident (SRI) related to Resident #17's allegation of abuse.Review of the SRI dated 08/24/25 revealed Resident #17 alleged LPN #234 slapped her hand during wound care and yelled don't touch that your' re going to get it infected. Resident #17 had no pain, discomfort, redness or discoloration to her hands. LPN #234 stated that during wound care, she thought the resident was going to touch the adhesive tape and she nudged her hand away from the area and told her not to touch it and then told the resident of potential for infection. LPN #234 denied slapping the resident. Review of the facility investigation revealed no evidence a witness statement was obtained from Resident #16, who was present in the room at the time of the incident. Additionally, the investigation did not include any staff statements. Interview on 09/11/25 at 8:56 A.M. with the Director of Nursing (DON) verified the facility did not get a witness statement from Resident #16 who was Resident #17's roommate and present in the room at the time of the incident and further confirmed no additional staff statements were obtained.Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed the person investigating the incident should interview the resident, the accused, and all witnesses. Witnesses generally included anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and/or the alleged victim the day of the incident.

Based on observation, resident representative interview, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with shaving. This affected one (#41) of two residents reviewed for activities of daily living (ADLs). The facility census was 39.Findings include:Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnosis of early onset cerebellar ataxia, physical debility and vascular dementia.Review of the Minimum Data Set (MDS) assessment, dated 07/20/25, revealed Resident #41 was cognitively intact and required supervision/touching assistance with personal hygiene.Review of care plan dated 08/06/25 revealed Resident #41 had a ADLs self-care deficit. Interventions included supervision with personal hygiene.Review of the Certified Nursing Assistant (CNA) personal hygiene task charting for the past 30 days revealed Resident #41 was marked as dependent 18 times, marked as requiring substantial assistance three times, marked as requiring supervision or touching assistance eight times.Observation on 09/08/25 at 11:15 A.M. of Resident #41 revealed the resident appeared disheveled with an unkempt beard and mustache covering his top lip. Interview on 09/08/25 at 11:23 A.M. with Resident #41's responsible party revealed Resident #41 was not able to shave himself and he used to shave the resident in the past; however, the resident preferred the aides to do it. Observation on 09/09/25 at 11:02 A.M. of Resident #41 revealed their mustache was still long, unkempt and protruding over the resident's lips.Observation on 09/10/25 at 10:20 A.M. of Resident #41 revealed his mustache was still long, unkempt and protruding over his lips. Additional observation revealed food remnants located in the resident's mustache.Interview on 09/10/25 at 10:26 A.M. with Certified Nursing Assistant (CNA) #264 verified Resident #41's mustache was long and unkempt.Observation on 09/10/25 at 11:50 A.M. revealed Resident #41 was in the dining room after eating lunch. Resident #41 was observed to have his mustache dirty with food and covering his top lip. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed August 2021, revealed that appropriate care and services would be provided for residents who were unable to carry out ADLs independently including hygiene, bathing dressing grooming and oral care.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place. This affected one (#10) of one residents reviewed for falls. The facility census was 39. Findings include:Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, neuromuscular dysfunction of bladder, essential hypertension, Type II diabetes with diabetic polyneuropathy, major depressive disorder, and carpal tunnel syndrome.Review of the Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #10 was cognitively intact and had no falls since admission. Review of the care plan, updated 09/08/25, revealed Resident #10 was at risk for falls. Interventions included non-slip strips in front of the shower (initiated on 08/29/25). Review of the unwitnessed fall documentation, dated 08/29/25, revealed Resident #10 had slipped on a towel on the bathroom floor. The root cause was determined to be the resident slid on a wet towel when stepping out of the shower. The intervention included skid strips in front of the shower. Observation on 09/08/25 at 12:05 P.M. revealed Resident #10's bathroom flooring did not have non-skid strips outside of the shower. Interview on 09/08/25 at 12:13 P.M. with Licensed Practical Nurse (LPN) #246 verified there were no non-skid strips in Resident #10's bathroom outside of the shower. Review of the facility fall policy, reviewed April 2025, revealed staff would identify interventions related to the resident's risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on record review, staff interview, observation, and policy review, the facility failed to follow infection control policy and procedures when providing incontinence cares. This affected one (#7) out of three residents reviewed for incontinence care. The facility census was 43. Findings included: Review of the medical record for Resident #7 revealed an admitted [DATE] with medical diagnoses of congestive heart failure, diabetes mellitus, obesity, hypertension, and atrial fibrillation. Review of the medical record for Resident #7 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #7 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bathing, and transfers. The MDS also indicated Resident #7 was frequently incontinent of bladder and bowel. Observation on 03/05/24 at 10:24 A.M. revealed Registered Nurse (RN) #241 provided incontinence care to Resident #7. RN #241 washed her hands and applied gloves prior to initiating incontinence care. Resident #7 was incontinent of bladder and bowel. RN #241 cleansed Resident #7 with warm wash clothes and disposed of the soiled clothes in a trash bag. RN #241 removed the soiled depends and disposed of it in the trash. RN #241 proceeded to apply barrier cream to Resident #7's buttock and applied a clean depends. RN #241 repositioned Resident #7 in bed, disposed of the soiled trash, removed gloves, and washed her hands. Interview on 03/05/24 at 10:30 A.M. with RN #241 confirmed when she provided incontinence care for Resident #7, she did not remove her gloves and wash her hands after providing the incontinence care and discarding the soiled clothes prior to applying the barrier cream and clean depends. Review of the facility policy titled, Infection Control reviewed August 2022, stated gloves are to be worn before and removed after contact with blood or bodily fluids and staff are to change gloves and perform hand hygiene after contact before moving from a contaminated body site to a clean body site during resident care. This deficiency represents non-compliance investigated under Complaint Number OH00151065.

Based on observation, staff interviews, and review of the policy, the facility failed to maintain a functioning call light system to alert staff of a resident's need. This had the potential to affect all 35 residents residing in the facility. The facility census was 35. Findings include: Observations on 02/07/24 at 8:24 A.M., revealed call lights flashing in the hallway. Observation of the nurse station, where the call light board is located, revealed no sound could be heard but three red lights were flashing, indicating the call light had been activated. Interview on 03/07/24 at 8:27 A.M., with Licensed Practical Nurse (LPN) # 102 verified the three red flashing lights indicated residents needed assistance and verified no sound was coming from the panel. LPN #102 stated room [ROOM NUMBER]'s panel was not working, and those residents had bells to alert staff of needs. The panel in room [ROOM NUMBER] could not be reset. Interview on 02/07/24 at 1:45 P.M., with Maintenance Man #132 revealed he had no knowledge the call light panel was not working and had not received a maintenance slip. Interview on 02/07/24 at 2:00 P.M., with Administrator revealed she was unaware the call light panel was not emitting any sound to alert staff of a call light being on. Review of the undated policy titled Call Lights revealed staff were to notify maintenance if call lights were not functioning. This deficiency represents the noncompliance investigated for Complaint Number OH00150352.

Based on observation, medical record review, staff interviews, and policy review, the facility failed to ensure an incontinent resident was provided with resident specific and timely incontinence assistance. This affected one (#3) of three residents reviewed for the provision of incontinence care and The facility census was 34. Findings include: Review of Resident #3's medical record revealed an admitted [DATE], with the diagnoses including: cerebral palsy, seizure disorder, autistic disorder, mild intellectual disability, anemia, abscess of prostate, dysphagia, and sepsis. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #3 with severe cognitive impairment, unable to make needs known, dependent on staff for the completion of activities of daily living including toileting, and incontinent of bowel and bladder. Review of the nursing plan of care was initiated on 07/30/23, to address Resident #3 risk for decline in activity of daily living function and/or participation as evidenced by need for assistance with activities of daily living, transfers, and toileting related to cerebral palsy and cognitive impairment. Interventions included provide one to two staff assistance with bathing, dependent on toileting, change brief as needed to keep clean and dry. In addition a plan of care was initiated on 07/30/23 to address Resident #3 risk for alteration in elimination always incontinent of bowel and bladder. Interventions included; monitor voiding pattern as needed if resident is able to participate, provide incontinence care as needed. Observation on 10/12/23 at 8:41 A.M., observed Resident #3 dress and seated in a wheelchair in the corridor. Interview on 10/12/23 at 8:45 A.M., with State tested Nurse Aide (STNA) #200 revealed she assisted Resident #3 out of bed for the morning and provided incontinence care at approximately 6:40 A.M. STNA #200 and #201 stated Resident #3 requires every two hour incontinence checks and associated brief changes. Observation on 10/12/23 at 10:05 A.M., noted STNA #200 and #201 propel Resident #3 to his room. STNA #201 assisted Resident #3 to his bed and proceeded to remove his pants to access a soiled incontinence brief. A small amount of urine was contained inside the brief. STNA #201 provided incontinence care and placed a dry clean brief on the resident followed by pants. Interview with STNA #201 following the observation confirmed being assigned to Resident #3 care and the resident was last checked for incontinence at approximately 6:40 A.M. Interview on 10/12/23 at 10:14 A.M., with Licensed Practical Nurse (LPN) #500 confirmed Resident #3 requires every two hour incontinence checks and changes which is provided by the assigned STNA's. Review of the policy titled Activity of Daily Living (ADL's), Support, reviewed August 2021, revealed appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination (toileting, incontinence care). This deficiency represents non-compliance investigated under Complaint Number OH00146599.

Based on observations, staff interviews, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to implement proper shut the doors to the rooms and post signage outside the door for residents with droplet isolation precautions. This affected three (#2, #14, and #42) out of the three residents reviewed for droplet isolation precautions. The facility had 16 residents with droplet isolation precautions. The facility census was 39. 1. Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included atrioventricular block, malignant neoplasm of the prostate, and COVID-19. Review of the infection progress note, dated 07/30/23 at 1:50 P.M., stated Resident #14 tested positive for COVID-19. Review of the care plan for Resident #14 revealed an actual infection related to COVID-19 care plan, dated 07/31/23, with an intervention for contact/droplet precautions due to COVID-19. Review of the physician orders for Resident #14 revealed a physician order, dated 07/31/23, for single room contact/droplet isolation, positive for COVID-19. All meals, treatments, therapies, and activities are done in the room. Observation on 08/07/23 at 8:25 A.M. of Resident #14's room revealed the door to the resident's room to be open to the hallway. An isolation cart filled with personal protective equipment (PPE) outside of Resident #14's room and a contact/droplet isolation sign was posted on the wall outside of the resident's room. Interview on 08/07/23 at 8:27 A.M. with Minimum Data Set (MDS) Nurse #103 confirmed Resident #14 was COVID-19 positive and the door to the resident's room was opened to the hallway with staff members walking past. MDS Nurse #103 stated the door to Resident #14's room should have been closed due to droplet isolation precautions. Interview on 08/07/23 at 10:27 A.M. with Resident #14 stated he had not left his room since he tested positive for COVID-19 and staff leave his door open during the day but close it at night. 2. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, morbid obesity, diabetes mellitus, and COVID-19. Review of the infection progress note, dated 08/01/23 at 10:19 P.M., which stated Resident #2 tested positive for COVID-19. Review of the care plan revealed an actual infection related to COVID-19 care plan, dated 08/01/23, with an intervention for contact/droplet precautions due to COVID-19. Review of the physician orders for Resident #2 revealed a physician order, dated 08/01/23, for single room contact/droplet isolation, positive for COVID-19, all meals, therapies, treatments, and activities are done in the room. Observation on 08/07/23 at 8:15 A.M. of Resident #2's room revealed the door to the room open to the hallway. An isolation cart filled with PPE was sitting outside of Resident #2's room. There was no signage posted outside of the room alerting staff to the isolation precautions. Interview on 08/07/23 at 8:31 A.M. with MDS Nurse #103 confirmed Resident #2 was COVID-19 positive and the door to Resident #2's room was opened to the hallway with staff members walking past. MDS Nurse #103 confirmed Resident #2 did not have any signs/information posted outside of Resident #2's room to alert staff or visitor of droplet precautions. MDS Nurse #103 stated the door to Resident #2's room should have been closed due to the droplet isolation precautions. Interview on 08/07/23 at 10:11 A.M. with Resident #2 stated the door to her room was usually open, even after testing positive for COVID-19. Resident #2 stated staff informed her she could keep her door open. 3. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included subarachnoid hemorrhage, depression, COVID-19, and lymphedema. Review of an infection progress note, dated 07/30/23 at 2:04 P.M., stated the resident tested positive for COVID-19. Review of the care plan for Resident #42 revealed an actual infection related to COVID-19 care plan, dated 07/31/23, with an intervention for contact/droplet precautions due to COVID-19. Review of the physician orders for Resident #42 revealed a physician order, dated 07/30/23, for single room contact/droplet isolation, positive for COVID-19, all meals, therapies, treatments, and activities are done in the room. Observation on 08/07/23 of Resident #42's room revealed the door to the room to be open to the hallway. An isolation cart filled with PPE was located outside of Resident #42' s room along with sign posted on the wall related to isolation precautions. Interview on 08/07/23 at Registered Nurse (RN) #135 confirmed Resident #42 was COVID-19 positive and the door to the resident's room was opened to the hallway. Interview on 08/07/23 at 10:20 A.M. with Resident #42 stated the door to her room has always been open to the hallway even since she tested COVID-19 positive. Review of facility policy titled, Infectious Diseases, revised September 2022, stated to place a resident who exhibits symptoms of the infection disease in an isolation room and the facility are to implement isolation protocol in the facility as recommended by local, state, or deferral public health authorities. Review of the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) revealed a patient with suspected or confirmed COVID-19 infection should be placed in a single room and the door should be kept closed. This deficiency represents non-compliance investigated under Complaint Number OH00145252.

Based on medical record review, family and staff interviews, observations, review of hospital records and review of the facility policy, the facility failed to ensure Resident #35 was properly monitored and interventions were applied to address constipation. This resulted in actual harm when Resident #35 went multiple days with no recorded bowel movements, went to the local hospital emergency room (ER) and was subsequently admitted to the hospital for a small bowel obstruction. This affected one resident (#35) of three residents reviewed for constipation. The facility also failed to ensure an order for a wound dressing treatment was in place prior to the application of wound dressing. This affected one resident (#11) of four residents reviewed for skin conditions. The Facility census was 39. Findings Include: 1. Review of Resident #35's medical record revealed an admitted [DATE]. Diagnoses included, but not limited to, epilepsy, dysphagia, cerebral palsy, mild intellectual disabilities, and autistic disorder. Review of Resident #35's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not assessed. A Staff Assessment for Mental Status revealed Resident #35 had short and long-term memory problems. Resident #35 was totally dependent on staff for eating and toileting, and required extensive or limited assistance with other activities of daily living (ADLs). Review of Resident #35's physician's orders dated 01/26/23, revealed the resident was ordered to receive Bisacodyl rectal suppository insert 10 milligrams (mg) rectally every 24 hours as needed (PRN) for constipation. Physician orders dated 01/26/23 and discontinued 03/23/23, revealed the resident was ordered to receive Senna S Oral tablet 8.6 -50 mg give two tablets via peg (gastric) tube every twelve hours as needed (PRN) for constipation. The physician's orders dated 01/31/23 and discontinued on 03/18/23, revealed the resident was ordered to receive routine Senna oral tablet one tablet via peg tube two times a day for constipation and the corresponding MAR for the month of March 2023 revealed the routine medication was administered as ordered. Review of Resident #35's care plan revised 04/17/23, revealed the resident had tube for feeding, was at risk for falls, had a seizure disorder, self-care deficit, impaired cognitive function, mild intellectual disabilities, and a risk for constipation. Interventions for constipation included the staff were to follow the facility bowel protocol for bowel management, monitor/document and report to the physician as needed signs and symptoms of complications related to constipation, record bowel movements pattern each day and describe the amount, color, and consistency. Review of a facility document titled ADL Flow Record for Resident #35 revealed the resident had no documented bowel movements from 03/03/23 through 03/11/23 (eight days). On 03/11/23 a 1 was recorded on the ADL Flow Record and through interviews with staff, this indicated the resident had a bowel movement; however, there was no description for the bowel movement. Resident #35 then went from 03/12/23 to 03/14/23 with no recorded bowel movements. Review of Resident #35's handwritten progress notes dated 03/07/23 at 5:00 P.M., revealed Resident #35 was not eating meals well and had an emesis. Review of Resident #35's handwritten progress notes dated 03/08/23, revealed the resident was having increased seizure activity. Review of Resident #35's handwritten progress notes dated 03/12/23, revealed the resident had two episodes of emesis. Review of Resident #35's handwritten progress notes dated 03/13/23, revealed the resident's abdomen was flat, soft and non-tender with hypoactive bowel sounds. Review of Resident #35's handwritten progress notes dated 03/14/23, revealed the resident vomited large brown emesis with small seizure activity. Resident #35's mother was present in the room and Resident #35 was transferred to the hospital. Review of Resident #35's hospital documentation dated 03/14/23 through 03/18/23, revealed Resident #35 presented to hospital ER with a several days history of constipation, hiccoughing (spasms of the diaphragm) which was noted to be worsening over the last several weeks and the resident was vomiting a dark/brown material. Resident #35 had a Computed Tomography (CT) scan of his abdomen and pelvis with contrast due to five days of constipation and vomiting. There was marked distension of bowel throughout the abdomen with multiple air-fluid levels which affected Resident #35's small bowel. A generous amount of stool was in the resident's rectosigmoid colon and findings were consistent with distal small bowel obstruction. After the ER's interventions, the resident had recorded bowel movements on 03/14/23 and the resident's vomiting improved. Resident #35 was admitted to the hospital for a small bowel obstruction with a planned surgical intervention to eliminate the small bowel obstruction. The hospital notes indicated on 03/17/23, the resident had a general surgery consult. The consult information revealed the resident had another large bowel movement in the afternoon on 03/16/23, the resident ate food and did not seem to be having belly pain per his mother and no surgical interventions were noted. Resident #35 returned to the facility on [DATE]. Review of Resident #35's progress notes dated 03/18/23, revealed a staff member from a local hospital called the facility to give a report for Resident #35. The hospital staff reported Resident #35 had three bowel movements after arriving at the ER. Resident #35 was placed on Osmolite tube feeding nutrition at 45 milliliters (ml) per hour from 9:00 P.M. to 6:00 A.M. to increase fiber nutrition. Resident #35 was to continue a regular diet during the day. It was noted eating had been difficult for Resident #35. No signs of seizure activity were noted, and the residents Dilantin (anti-seizure) medication was changed to three times a day with no change in dosage. Review of the March 2023 medication administration record (MAR) dated 03/07/23 through 03/15/23 for Resident #35, revealed there was no evidence of the PRN Bisacodyl documented as being administered and one dose of the PRN Senna documented as being administered on 03/13/23. Interview on 04/18/23 at 10:05 A.M. with Resident #35's responsible party/mother, revealed Resident #35 was hospitalized approximately three weeks ago due to being backed up. Resident #35's mother reported Resident #35 had not had a bowel movement in five or more days and ended up being hospitalized . She stated Resident #35 had since returned to the facility and things had improved but she continued to make sure to ask every day about his bowel movements. Interview on 04/18/23 at 2:20 P.M. with State tested Nursing Assistant (STNA) #352, revealed Resident #35 was not able to make his needs known so he was checked and changed every couple hours. STNA #352 reported Resident #35 received a tube feeding at night which the nurses connected and disconnected, and staff assisted the resident with eating during the day. STNA #352 reported Resident #35 was dependent on staff for toileting and all his bowel movements were to be documented in his medical record. Interview on 04/19/23 at 2:55 P.M. with STNA #355, verified Resident #35 had no bowel movements (BM) documented from 03/03/23 through 03/11/23 (eight days). STNA #352 stated the handwritten bowel movement tracking dated 03/11/23, indicated Resident #35 had one BM. STNA #352 verified Resident #35 went from 03/12/23 to 03/14/23 with no documented bowel movements. Interview on 04/19/23 at 3:42 P.M. with the Director of Nursing (DON) verified Resident #35 was admitted to the hospital on 03/14/23 for a small bowel obstruction. The DON indicated she was not familiar with how the STNAs tracked the bowel movements on the handwritten documentation and was not able to decipher what was written. The DON provided a handwritten MAR documentation which showed Resident #35 received one dose of his PRN Senna on 03/13/23 and also verified there no other PRN constipation interventions provided to address the resident's lack of bowel movements from 03/03/23 through 03/11/23 and 3/12/23 through 03/14/23. Review of the facility policy titled, Bowel Elimination Policy and Procedure, revised August of 2022 revealed it was the standard of practice for residents to achieve or maintain their own patterns of elimination and be free from complications. The bowel activity of each resident was to be monitored and assessed by the nursing staff every shift. If a resident was without a BM for 48 hours, 120 milliliters (ml) of prune juice or bran mixture would be offered. Continued monitoring was to occur. If a resident was without a BM for 72 hours the nurse would consider administering osmotic laxative such as milk of magnesia per physician orders. If a resident was without a BM for eight hours after milk of magnesia the nurse would follow established PRN order for a stimulant laxative such as a suppository. If a resident is without a BM eight hours after the suppository was given the nurse would administer an enema as ordered by the physician. Should no result occur, resident assessment and interventions would be reported to the primary care provider for further measures to be taken until bowel elimination occurs and the resident had no acute symptoms of constipation. 2. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included, but not limited to, type II diabetes, urinary incontinence, uterine cancer, dysphagia, major depressive disorder, anxiety disorder, epilepsy, and obesity. Review of Resident #11's MDS assessment dated [DATE], revealed a BIMS score of 15 indicating Resident #11 was cognitively intact. Resident #11 had moisture associated skin damage (MASD) at the time of the review. Assessment revealed the resident had a pressure reducing device for her chair and bed, nutrition interventions to manage skin problems, and applications ointments/medications. Review of the physician's orders dated 07/01/21 for Resident #11, revealed the resident was ordered to receive Nystatin powder applied to skin folds topically every shift for skin care. Review of the physician's orders dated 07/09/21 for Resident #11, revealed the resident was ordered to receive Zinc Oxide Cream 10 percent (%) applied to buttocks topically every eight hours PRN for bilateral buttock skin protectant. Review of the physician's orders dated 01/06/23 for Resident #11, revealed the resident was ordered to receive peri-guard to buttocks, labia, and posterior thighs twice a day for skin care. Review of Resident #11's care plan revised on 02/09/23, revealed the resident had a self-care deficit, bladder incontinence, presence of a colostomy, and potential/actual impairment to skin integrity. Interventions for impaired skin integrity included to administer medications as order, turn and reposition every two hours, administer treatments as ordered, apply peri-guard to buttocks, labia, posterior thighs as ordered, avoid scratching, and keep hands and body parts from excessive moisture, keep fingernails short, keep skin clean and dry. Review of active April 2023 physician's orders for Resident #11, revealed no orders for the current dressing being completed on Resident #11's skin impairment. Review of the April 2023 nurses progress notes for Resident #11, revealed no documented evidence of any physician orders for the dressings being utilized or any documentation related to the staff completing the dressing changes. Review of April 2023 treatment administration records (TARs) for Resident #11, revealed no documented evidence of any wound dressings being ordered and/or completed. Interview on 04/17/23 at 7:10 P.M. with Resident #11 found her to be alert and aware. Resident #11 reported she had an open area on the back of her left leg that the facility changed dressings on. Resident #11 reported it was an open area that really hurt her. The resident reported the dressing was last changed a couple of nights ago. Interview on 04/17/23 at 8:53 P.M. with the Assistant Director of Nursing (ADON) #500 verified there was no active order for a dressing change for Resident #11 and she was not aware of any current open areas or wounds. ADON #500 reported she was the wound nurse at the facility. Interview on 04/18/23 at 2:27 P.M. with State tested Nursing Assistant (STNA) #352 verified she had observed Resident #11 to have skin issues on the back of her legs, under her chest and under her arms. STNA #352 reported the aide applied powder to Resident #11 when the areas were not open and a cream when the areas were open. STNA #352 reported Resident #11 had cream applied because the areas were open. STNA #352 reported the aides only applied the powders and creams and the nurses applied any dressings. STNA #352 stated she had reported Resident #11's skin changes to the nurse. Observation on 04/18/23 at 3:17 P.M. of Resident #11, revealed ADON #500 assisted Resident #11 to roll to her right side to expose her left, posterior, upper thigh and buttock. Observation revealed a bordered foam dressing dated 04/16/23. ADON #500 removed the dressing to reveal an area five centimeters (cm) by eight cm. The area was covered with a white, dry paste. ADON #500 gently removed the paste with toilet tissue paper and no bleeding was noted. The area was assessed ADON #500 as being MASD. Resident #11 stated the area was very painful. The areas of skin folds at the lateral side of the left breast, below the right breast, at the right medial thigh, and abdominal folds were reddened appearing to be consistent with yeast. Resident #11 had been heavily incontinent of urine. The incontinence brief and the cloth incontinence pad were both wet. ADON #500 verified Resident #11 had MASD and had a dressing in place with no physician's order. Review of the facility policy titled, Wound Care, revised August 2022 revealed the staff was to verify there was a physician's order for the procedure and document the treatment was completed in the electronic medical record.

Based on observations, resident interview, staff interviews, and review of facility policy, the facility failed to ensure residents who required staff assistance with activities of daily living (ADLs), received adequate and timely care to maintain good personal hygiene including shaving and nail care and timely repositioning. This affected four residents (#4, #26, #9, and #190) of five residents reviewed for ADLs. The facility census was 39. Findings Include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included history of Coronavirus (COVID-19), need for assistance with personal care, cognitive communication deficit, major depressive disorder, and bipolar disorder. Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #4 was cognitively intact. Resident #4 required extensive assistance with bed mobility, and dressing. Resident #4 was totally dependent on staff for transfers, toileting, and personal hygiene. Resident #4 required physical help in part of bathing. Review of Resident #4's care plan revised 02/26/23, revealed supports and interventions for risk for nutrition and hydration deficit, potential for pain, risk for falls, and self-care deficit. Interventions for self-care deficit included encourage an independent level of functioning as possible within the confines of her disease process. Provide hands on assistance with these tasks daily, as needed, and when exhibiting increased weakness. Review of Resident #4's State tested Nursing Assistant (STNA) Tasks for the last 30 days, revealed Resident #4 was totally dependent on staff for personal hygiene which was to include shaving. Resident #4 was documented as being provided assistance with personal hygiene on 03/29/23, 03/30/23 04/01/23, 04/03/23, 04/14/23 and 04/16/23. Observation on 04/17/23 at 6:54 P.M. of Resident #4, revealed the resident to have approximately one-inch-long white hairs all across her chin. Interview on 04/17/23 at 6:59 P.M. with Resident #4, revealed the resident was alert and aware. Resident #4 reported she was not getting the help she needed. Resident #4 reported she did not like her chin hair and wanted to be shaven, but she was not getting the personal care she wanted. Resident #4 stated she was not able to shave herself. Observation on 04/18/23 at 7:41 A.M. of Resident #4, revealed the resident was seated in the dining room with nine other residents. Resident #4's hair was uncombed, and she continued to have approximately one-inch long white hairs on her chin. Observation on 04/18/23 at 11:52 A.M. of Resident #4, revealed the resident was seated in the dining room with nine other residents. Resident #4 was unshaven with approximately one-inch-long set of hairs across her chin. Interview on 04/18/23 at 2:17 P.M. with STNA #352, verified Resident #4 had long white hairs on her chin. STNA #352 indicated the resident was not able to shave herself and had not been shaven. STNA #352 asked Resident #4 if she would like to be shaven and the resident smiled, and responded yes, she would like that. 2. Review of Resident #26's medical record revealed an admitted [DATE]. Diagnoses included dysphagia, cerebrovascular disease, speech, and language deficit, need for assistance with personal care, cerebral palsy, epilepsy, and aphasia. Review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score was not able to be completed. A staff assessment for mental status was completed and indicated Resident #26 had short term and long-term memory problems. Resident #26's cognitive skills for decision making were severely impaired. Resident #26 required extensive assistance with bed mobility and eating. Resident #26 was totally dependent on staff for transfers, dressing, toileting, and personal hygiene including nail care. Review of Resident #26's care plan revised 04/16/23, revealed supports and interventions for cerebral palsy, impaired cognitive function, risk for skin breakdown, and self-care deficit. Interventions for self-care deficit included staff were to provide two-person assistance with activities of daily living (ADLs) as needed. Observation on 04/17/23 at 7:01 P.M. of Resident #26, revealed the resident was seated in his wheelchair wearing a padded helmet in the common area outside the nurse's station. His fingernails were noted to be long but clean. Observation on 04/18/23 at 2:00 P.M. of Resident #26, revealed the resident was clean and dressed seated in his wheelchair outside the nurse's station. Resident #26's fingernails were observed to be long but clean. Interview on 04/18/23 at 2:30 P.M. with STNA #352, revealed Resident #26 was not able to make his needs known and was totally dependent on staff for all ADLs. Observation on 04/19/23 at 7:45 A.M. of Resident #26, revealed the resident was seated in his wheelchair in the common area by the nurse's station. Resident #26 was observed to have scratches on the side and top of his nose. Resident #26's fingernails were observed to be long and a red brown substance, which appeared to be blood, was noted around the cuticles of both his hands. Interview on 04/19/23 at 7:48 A.M. with STNA #343 verified Resident #26's fingernails were longer than they should be and should have been trimmed. 44815 3. Review of the medical record for resident #9 revealed an admitted [DATE] with a diagnosis of hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 had impaired cognition and required extensive assistance of two people for personal hygiene and was totally dependent on two people for bathing. Observation on 04/20/23 at approximately 12:25 P.M., revealed Resident #9 sitting in her wheelchair in the hallway shortly after consuming lunch in the dining room. An attempt to interview Resident #9 at that time was unsuccessful. However, Resident #9 held out her left hand and revealed all five fingernails were dirty with debris under them. Further observation at that time revealed approximately 3/4 inch long, thick facial hair along Resident #9's chin and jawline. Observation and interview on 04/20/23 at approximately 1:00 P.M. with Licensed Practical Nurse (LPN) #325 confirmed all five fingernails on Resident #9's left hand were dirty and had debris under them. LPN #325 confirmed Resident #9's facial hair was longer than just a couple of days growth and the hairs were on her chin and along her jawline. LPN #325 stated Resident #9 definitely needed to be shaved. Interview on 04/20/23 at 2:44 P.M. with STNA #352 revealed Resident #9 would swat at staff when they attempted to shave her or clean her fingernails. STNA #352 indicated she assisted Resident #9 with a shower about a month ago and Resident #9 allowed staff to shave her without much difficulty. STNA #352 revealed she was not usually assigned to Resident #9 on her shower days and had only showered the resident twice. 4. Review of the medical record for Resident #190 revealed an admitted [DATE] with diagnoses of dementia, dysphagia, and neuromuscular dysfunction of bladder. Review of the five-day MDS assessment dated [DATE], revealed Resident #190's cognition was not assessed. Further review revealed Resident #190 required total dependence on two people for bed mobility. Observation on 4/18/23 at 7:45 A.M., revealed Resident #190 lying in bed on his back with his neck and head leaning to the right. Resident #190's shoulders and hips appeared flat, without any pillows or bolsters for positioning. Observation on 04/18/23 at 8:56 A.M., revealed Resident #190 lying in bed on his back with his shoulders and hips flat against the mattress and his head and neck leaning to the right. Interview on 04/18/23 at 11:40 A.M. with STNA #356, revealed she had not repositioned Resident #190 since approximately 7:00 A.M. because she was answering call lights for other residents. STNA #356 further confirmed she had not checked Resident #190 for incontinence since approximately 7:00 A.M. because Resident #190 had a urinary catheter and doesn't normally have a stool on first shift. Continued interview with STNA #356 confirmed dependent residents should be checked and repositioned every two hours. A follow-up interview with STNA #356 on 04/18/23 at approximately 11:50 A.M., revealed Resident #190 was not soiled at that time. Observation on 04/19/23 at 10:45 A.M., revealed Resident #190 lying flat in bed with his hips and shoulders flat against the mattress. His head and neck leaned to the right. Observation on 04/19/23 at 2:13 P.M. revealed Resident #190 lying flat in bed with his hips and shoulders flat against the mattress. His head and neck leaned to the right. Interview on 04/19/23 at 5:39 P.M. with STNA #346 revealed her shift began at 2:00 P.M. and she placed a pillow between Resident #190's feet at approximately 3:30 P.M. STNA #346 stated she did not reposition Resident #190's hips or shoulders because he required two staff for bed mobility and STNA #346 did not find another aide to assist her. Observation on 04/20/23 at 7:55 A.M. revealed STNA #344 and STNA #355 providing incontinence care to Resident #190. Observation at that time revealed Resident #190 had intact skin. Review of the undated facility policy titled, Activities of Daily Living, revealed a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming and personal hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00142143.

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to provide appropriate infection control techniques during a dressing change. This affected one resident (#29) of two residents reviewed for wounds. The facility also failed to ensure meal trays were delivered to residents in a sanitary manner. This directly affected 12 residents (#02, #08, #10, #12, #17, #18, #20, #21, #27, #29, #34, and #91) who received trays in their rooms. Additionally, the facility failed to ensure staff utilized appropriate hand hygiene when assisting residents with meals. This affected one resident (#9) of the 39 residents reviewed during the dining task. The facility census was 39. Findings include: 1 Review of the medical record of Resident #29 revealed an admitted [DATE]. Diagnoses include atherosclerotic heart disease of native coronary artery without angina pectoris, osteomyelitis of sacral and sacrococcygeal lumbar region, personal history of transient ischemic attack and cerebral infarction without residual deficits, paroxysmal atrial fibrillation, and essential hypertension. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 was cognitively intact and required total assistance for all care. Review of the care plan updated 04/17/23, revealed Resident #29 has a sacral pressure ulcer Stage III. Interventions included to monitor the ulcer for progression or declination, notify provider if no sign of improvement, pressure redistribution mattress to bed, and provide wound care treatment as ordered. Review of the physician's order dated 03/22/23, for Resident #29 revealed the resident was ordered to receive a wet to dry Dakin's (topical antiseptic) dressing applied and covered with a dry foam dressing twice a day and as needed (PRN) to the resident's coccyx for wound maintenance. Observation on 04/20/23 at 2:00 P.M. with Licensed Practical Nurse (LPN) #325 who was providing a dressing change for Resident #29's pressure ulcer was observed to wash her hands and don a pair of gloves. LPN #325 removed the soiled dressing from Resident #29's coccyx and used a dry portion of toilet tissue to remove stool from the skin and around the wound. LPN #325 applied the Dakin's saturated gauze dressing into the wound by using a sterile cotton tipped applicator and her gloved hand. LPN #325 then applied a foam dressing to Resident #29's coccyx. LPN #325 did not remove her soiled gloves and perform hand hygiene before starting the clean portion of the dressing change. Interview with LPN #325 immediately following this observation, verified she did not change gloves and perform hand hygiene after removing the soiled dressing and wiping the stool from the skin and before completing the new dressing. 37451 2. Observation on 04/18/23 from 8:01 A.M. to 8:12 A.M. of breakfast trays being delivered to the resident's room, revealed State tested Nursing Assistants (STNAs) (#341 and #344) were noted to touch personal items of residents as well as the residents while delivering the breakfast trays. Continued observations revealed neither STNA performed any hand hygiene after assisting the residents and before delivering the next breakfast tray. Interview on 04/18/23 at 8:13 A.M. with STNAs (#341 and #344) verified they did not perform the appropriate hand hygiene between the resident's trays being delivered. 3. Review of the medical record for resident #9 revealed an admitted [DATE] with a diagnosis of hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 had impaired cognition and required limited assistance of one staff for eating. Observations of the dining room on 04/20/23 at 12:00 P.M., revealed Resident #9 sitting at the assistance table with two other residents and STNA #356. Observations between 12:00 P.M. and 12:12 P.M. revealed STNA #356 assisted Resident #35 who had begun to drool. STNA #356 used a towel to wipe Resident #35's face and then used her bare hands to reposition his wheelchair. Continued observations of the dining on 04/20/23 at 12:13 P.M., revealed STNA #356 stood up from her chair, walked over to Resident #9, picked up her dinner roll from her meal tray and buttered it and placed it back on Resident #9's plate. At no time did STNA #356 wash and/or sanitize her hands after she assisted Resident #35 and before buttering Resident #9's roll. Interview on 04/20/23 at 12:13 P.M. with STNA #356, verified she assisted Resident #35 by wiping his face then repositioned resident in his wheelchair then buttered Resident #9's dinner roll without performing any hand hygiene. STNA #356 stated she had hand sanitizer in her pocket but did not use it. During a follow-up interview on 04/20/23 at approximately 1:02 P.M., STNA #35 verified Resident #9 ate some of the buttered dinner roll she had touched with her contaminated hands. Review of the facility policy titled Hand Hygiene revealed all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors which applied to all staffing working in all locations within the facility. Hand hygiene should be performed between resident contact and either soap and water or an alcohol-based hand rub (ABHR) is used with the ABHR being the preferred method.

Based on observations, resident interview, and staff interview, the facility failed to ensure resident's rooms were maintained in a clean and homelike manner. This affected one resident (#13) of 39 residents reviewed for their environment. The facility census was 39. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/04/23, revealed Resident #13 had intact cognition and mobilized independently. Observation on 04/18/23 at 9:04 A.M. of Resident #13's room, revealed an unfinished, white drywall patch on the yellow wall behind his recliner chair. The patch was dented in, and the dust came off and onto the side of Resident #13's recliner chair. Further observation revealed 7 to 10 colored plastic pieces of holiday grass on the floor around Resident #13's room. Interview with Resident #13 at the same time, revealed the resident did not like the unpainted drywall patch behind his recliner. Interview on 04/18/23 at approximately 9:20 A.M. with Maintenance Supervisor (MS) #332 confirmed he patched Resident #13's wall and had to wait for it to dry before he could finish the repair. MS #332 stated Resident #13 continued to recline his chair into the patch which resulted in continued damage and dust transfer. MS #332 further stated repairs were usually completed once a resident moved from the room. Observation on 04/19/23 at 8:12 A.M., revealed Resident #13's room still had plastic colored grass on the floor and dust on the left side of his recliner chair and along the floor at the baseboard. Interview on 04/19/23 at 9:58 A.M. with Housekeeper #322, revealed she was responsible for cleaning the rooms in the hall where Resident #13 resided. Housekeeper #322 stated housekeeping staff did not have to clean all rooms when staffing was low but would only clean noticeably dirty rooms. Interview on 04/19/23 at 10:13 A.M. with MS #332 revealed he was also the Housekeeping Supervisor. MS #332 indicated he advised the housekeeping staff, on the days when only one housekeeper was scheduled in the facility, they were to only clean the common areas. Review of the housekeeping schedule for 04/18/23 with MS #332 confirmed only one housekeeper was scheduled. An observation conducted during this ongoing interview with MS #332, revealed Resident #13's recliner chair had plaster dust along the left side from the drywall patch, plaster dust was accumulated on the top of the baseboard and along the floor, and plastic colored grass was on the floor along with other debris suspected to be small food items. Observation and interview on 04/19/23 at 10:43 A.M. with MS #332 after Resident #13's room was cleaned by Housekeeper #322 revealed plaster dust remained on the left side of Resident #13's recliner chair and plaster dust remained on the baseboard and floor behind the chair. MS #332 moved the recliner chair to improve access to the baseboard and floor behind it and popcorn and other debris were identified under the recliner.

Based on medical record review, staff interview, and facility policy review the facility failed to ensure resident's baseline care plans were accurate and complete. This affected two residents (#91 and #190) of three reviewed for baseline care plans. The facility census was 39. Findings include: 1. Review of the medical record of Resident #91 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, essential hypertension, migraine without aura, hyperlipidemia, hereditary and idiopathic neuropathy. Diagnoses added on 04/19/23 included localized edema, bipolar disorder, anxiety disorder, and metabolic syndrome. Review of the Baseline Care Plan dated 04/12/23 revealed mental health needs related to bipolar; however, there were no interventions documented for the diagnosis. The form indicated the skin was intact and a pressure reducing mattress would be utilized. Medications included antipsychotics and antidepressants without documenting specific ones. The form did not indicate the resident had a diagnosis of anxiety or depression. Review of the skin assessment dated [DATE] at 10:35 P.M., revealed Resident #91 had a pressure wound to the left buttock measuring 5 centimeters (cm) in length, 3 cm in width with no depth and indicated as a Stage II. Review of the description revealed Resident #91 had two small, scabbed areas on left upper buttocks, and on the left buttock, near bifurcation was an open area measuring 5 cm by 3 cm by 0 cm. No drainage was noted, the area appeared to be healing well, and barrier cream was applied. Review of the active April 2023 physician orders for Resident #91, revealed an order for Aripiprazole (antipsychotic), duloxetine (antidepressant), and hydroxyzine (anti-anxiety). Interview on 04/20/23 at 3:15 P.M. with Administrator verified the base line care plan was inaccurate with the skin impairment and residents' mental health diagnosis not being documented. 44815 2. Review of the medical record for Resident #190 revealed an admitted [DATE] with diagnoses of dementia, dysphagia, and neuromuscular dysfunction of bladder. Review of the five-day MDS assessment dated [DATE], revealed Resident #190's cognition was not assessed. Assessment revealed Resident #190 required total dependence on two people for bed mobility. Review of the undated baseline care plan for Resident #190, revealed the resident was non-verbal, was totally dependent on staff for care, required oxygen, required tube feeding, and had a urinary catheter. Interview on 04/19/23 at 11:47 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #500 verified the baseline care plan for Resident #190 was undated and could not verify whether the care plan was completed within 48 hours of admission. Review of the untitled facility policy regarding baseline care plans, reviewed August 2021, revealed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission to assure the resident's immediate care needs were met and maintained.

Based on observations, staff interview and review of facility policy, the facility failed to ensure residents who required assistance with eating were provided with a dignified dining experience. This affected one resident (#26) of one resident observed in the dining room who required assistance with eating. There were twelve residents in the dining room. In addition, the facility failed to ensure residents in the dining room received meals timely in relation to other residents. This affected one resident (#90) of eleven residents observed to be eating in the dining room. The facility census was 39. Findings Include: 1. Review of Resident #26's medical record revealed an admitted [DATE]. Diagnoses included dysphagia, cerebrovascular disease, speech and language deficit, need for assistance with personal care, cerebral palsy, epilepsy, and aphasia. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was not able to be completed. A staff assessment for mental status was completed and indicated Resident #26 had short term and long term memory problems. Resident #26's cognitive skills for decision making were severely impaired. Resident #26 required extensive assistance with bed mobility and eating. Review of Resident #26's care plan revised on 04/16/23 revealed supports and interventions for cerebral palsy, impaired cognitive function, risk for skin breakdown, and self-care deficit. Interventions for self-care deficit included provide two person assistance with activities of daily living (ADLs). Observation on 04/18/23 at 7:46 A.M. of the dining room revealed Resident #26 was seated at the assistance table. The table was u-shaped and there were two chairs available for staff. During continued observation on 04/18/23 at 7:49 A.M. of the dining room revealed Resident #26's breakfast tray was set up on the table next to him. State tested Nursing Assistant (STNA) #361 stood next to Resident #26 and provided him with a bite of his cream of wheat. STNA #361 continued to stand over Resident #26 and provide him with bites of his breakfast and sips from his cup. Two chairs continued to be available, but STNA #361 continued to stand. Observation at 7:54 A.M. revealed STNA #361 continued to stand over Resident #26 to provide eating assistance. Interview on 04/18/23 at 7:59 A.M. with STNA #361 verified she was standing to feed Resident #26. STNA #361 reported she always stood when she assisted residents with eating. She said it was a me thing and did not sit to feed residents. Observation on 04/18/23 at 8:09 A.M. of Resident #26 found STNA #361 continued to stand over Resident #26 and assist him with taking drinks from his cup. 44815 2. Review of the medical record of Resident #90 revealed an admitted [DATE]. Diagnoses included, but not limited to, hypertension and muscle weakness. Review of the physician's order dated 04/10/23, revealed Resident #90 was ordered to receive a regular diet with regular textures and thin liquids. Review of the nursing admission assessment dated [DATE], revealed Resident #90 had intact cognition and could eat independently. Observation on 04/20/23 at 12:00 P.M., revealed there were ten residents in the dining room eating lunch and Resident #90 was sitting at a table alone with a cup of coffee. Interview on 04/20/23 at 12:00 P.M. with Resident #90, revealed she had not received her meal tray. Interview on 04/20/23 at 12:02 P.M. with STNA #356, confirmed all ten residents in the dining room were consuming their meals, and Resident #90 had not received a tray. Further interview with STNA #356 revealed Resident #90's tray was always on the last meal cart delivered from the kitchen whereas the rest of the trays for residents eating in the dining room were delivered on the first meal cart. Interview on 04/20/23 at approximately 12:10 P.M. with Resident #90, revealed she was hungry and often had to wait for her meals. Interview on 04/20/23 at approximately 12:11 P.M. with Resident #90 and STNA #356, revealed they previously reported to dietary staff the concern regarding Resident #90's long wait time for meals in the dining room. STNA #356 revealed she served the residents in the dining room from the first meal cart and proceeded to assist dependent residents with eating. Continued observations on 04/20/23 from 12:00 P.M. until 12:17 P.M., revealed there were ten residents eating their meals and Resident #90 without a meal. STNA #356 assisted three residents with eating throughout the observation and made no attempt to notify the kitchen regarding Resident #90's meal. Observation on 04/20/23 at 12:17 P.M., revealed STNA #352 delivered Resident #90's meal tray to her in the dining room. Interview on 04/20/23 at 2:12 P.M. with Dietary Manager (DM) #316 revealed she was unaware Resident #90 was eating in the dining room or waiting for her tray in the dining room for several minutes after other trays were delivered. Further interview revealed DM #316 had not met with Resident #90 since her admission on 04/10/23 to obtain her meal preferences. Review of the undated facility policy titled, Resident Bill of Rights revealed residents were to be treated with courtesy and respect in full recognition of dignity and individuality.

Based on medical record review, observations, resident interview, staff interview and review of the facility policy, the facility failed to ensure a resident's physician was notified of changes in skin conditions. This affected one resident (#11) of the three residents reviewed for notifications. The facility also failed to ensure the physician was notified when a resident's blood sample for testing was not able to be completed. This affected one resident (#17) of the three-residents reviewed for notification. The Facility census was 39. 1. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes, urinary incontinence, uterine cancer, dysphagia, major depressive disorder, anxiety disorder, epilepsy, and obesity. Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #11 was cognitively intact. Resident #11 had moisture associated skin damage (MASD) at the time of the review. Review of Resident #11's care plan revised on 02/09/23, revealed supports and interventions for risk for self-care deficit, bladder incontinence, presence of a colostomy, and potential/actual impairment to skin integrity. Interventions included the facility was to monitor and document location, size, and treatment of skin injury, report any abnormalities, failure to heal, signs and symptoms of infection and any maceration to the physician. Interview on 04/17/23 at 7:10 P.M. with Resident #11 found her to be alert and aware. Resident #11 reported she had an open area on the back of her left leg that the facility changed dressings on. Resident #11 reported it was an open area that really hurt her. The resident reported the dressing was last changed a couple of nights ago. Interview on 04/17/23 at 8:53 P.M. with the Assistant Director of Nursing (ADON) #500 verified there was no active order for a dressing change for Resident #11 and she was not aware of any current open areas or wounds. ADON #500 reported she was the wound nurse for the facility. Interview on 04/18/23 at 2:27 P.M. with State tested Nursing Assistant (STNA) #352 verified she had observed Resident #11 to have skin issues on the back of her legs, under her chest and under her arms. STNA #352 reported the aide applied powder to Resident #11 when the areas were not open and a cream when the areas were open. STNA #352 reported Resident #11 had cream applied because the areas were open. STNA #352 reported the aides only applied the powders and creams and the nurses applied any dressings. STNA #352 stated she had reported Resident #11's skin changes to the nurse. Observation on 04/18/23 at 3:17 P.M. of Resident #11, revealed the ADON #500 assisted Resident #11 to roll to her right side to expose her left, posterior, upper thigh, and buttock. Observation revealed a bordered foam dressing dated 04/16/23. ADON #500 removed the dressing to reveal an area five centimeters (cm) by eight cm. The area was covered with a white, dry paste. ADON #500 gently removed the paste with toilet tissue paper and no bleeding was noted. The area was assessed by ADON #500 as being MASD. Resident #11 stated the area was very painful. The areas of skin folds at the lateral side of the left breast, below the right breast, at the right medial thigh, and abdominal folds were reddened appearing to be consistent with yeast. Resident #11 had been heavily incontinent of urine. The ADON #500 verified Resident #11 had MASD and had a dressing in place with no physician's order for the dressing. Interview on 04/20/23 at 3:47 P.M. with the Administrator verified Resident #11's physician was not notified of the residents wound until 04/19/23. An order was then written for the dressing change. Review of active April 2023 physician's orders for Resident #11, revealed no orders for the current dressing being completed on Resident #11's skin impairment. Review of April 2023 treatment administration records (TARs) revealed no documented evidence of any wound dressings being ordered by the physician and/or the dressing being completed. Review of April 2023 progress notes for Resident #11, revealed no documented evidence the physician was notified regarding recent changes with Resident #11's skin condition. 35031 2. Review of the medical record of Resident #17 revealed the most recent admitted [DATE]. The initial admitted was 03/24/22. Diagnoses included, but not limited to, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease (ESRD), anxiety disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes, major depressive disorder, and dependence on renal dialysis. Review of the physician orders dated 02/06/23 for Resident #17, revealed an order for a urinalysis (UA), basic metabolic profile (BMP) and a complete metabolic profile (CMP) to be drawn. Review of the annual MDS assessment dated [DATE], revealed Resident #17 had minimal cognition deficit. The assessment further revealed she had a diagnosis of ESRD and received dialysis while a resident. Interview on 04/20/23 at 3:15 P.M. with Administrator who is also a Registered Nurse (RN) indicated the order was inconsistent with standard practices with both the BMP and a CMP ordered. The Administrator provided a document dated 02/08/23 from the facility laboratory data system, which indicated the ordered laboratory (labs) tests were a urinalysis, a BMP, and a complete blood count (CBC). The note indicated the phlebotomist was unable to obtain the specimen for the BMP and CBC and a second phlebotomist would be sent to facility. Further review of Resident #17's record with the Administrator verified there was no documented evidence the labs were completed and also no documented evidence the physician was notified when the ordered blood tests on 02/08/23 were not completed. Review of the undated facility policy titled, Notification of Change Policy, revealed the facility was to notify the physician of any change of condition of the resident.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, staff interview, review of a facility investigation, review of an employee personnel file, and review of facility in-services, the facility failed to ensure staff members utilized proper safety devices when assisting a resident with ambulation resulting in a fall. This resulted in actual harm when Resident #41 was walking with a nurse aide without the use of a walker or gait belt, and subsequently fell , hitting her head and causing excessive bleeding which required hospitalization . This deficient practice affected one (#41) of three residents reviewed for falls. The facility census was 40. Findings include: Review of Resident #41's medical record revealed an admitted [DATE] and a discharged dated of 02/19/23. Diagnoses included dementia and repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 02/18/22, revealed Resident #41 was identified with moderate cognitive impairment. The resident was assessed to require limited assistance of a one person physical assistance for toileting, her walking was not steady, and was only able to stabilize with staff assistance and used a walker. Resident #41 had a fall with fracture prior to admission and a fall with major injury since admission. Review of a baseline care plan dated 02/18/23 for Resident #41 revealed, for safety, the resident had a history of a fall and she had a subdural hematoma as history of a fall related injury. Interventions included to assist with ambulation and rounding; and for transfers and walking, Resident #41 was to be assisted with one person and equipment used were a wheelchair and a walker. Review of a fall risk assessment dated [DATE] revealed Resident #41 was assessed at high risk for falls with a score of 10. Further review of the assessment revealed a score of 10 or greater indicated the resident should be considered at high risk for falls. Review of a progress note dated 02/19/23 at 12:00 P.M., which was the late entry admission note, revealed Resident #41 arrived at the facility at approximately 4:45 P.M. on 02/18/23 with no family present. Resident #41 was alert but confused and had 13 staples present to the left side of the back of her head from an injury related to a previous fall. Per the hospital, Resident #41 was assisted by one person with a walker and all staff on the shift were notified of the need for assistive devices. Review of a nursing progress note dated 02/19/23 at 5:04 P.M. revealed at approximately 8:45 A.M., an aide alerted the nurse that Resident #41 fell and was bleeding badly from her head. The nurse was in assisted living for medication pass, and the nurse aide indicated another nurse on shift was with Resident #41 while she came to notify this nurse. The nurse asked the nurse aide if anyone called for emergency services and the nurse aide denied anyone called. The nurse and nurse aide ran to the area where Resident #41 fell . Upon arrival, the other nurse on the shift was kneeled down next to Resident #41 with a large amount of blood noted on the floor, and the nurse immediately called emergency services. Resident #41 was lying on the floor on her stomach in front of the nurse station. A nurse aide and another nurse used a blanket to help control the bleeding and were unable to determine the exact location of the bleeding due to amount of blood present. The bleeding appeared to be coming from the right side front of Resident #41's head. Resident #41 was crying saying she wanted to get up and her head hurt. The staff advised Resident #41 not to move and emergency services were on the way to the facility. Another nurse attempted to obtain vital signs, but was unable due to Resident #41 crying and attempting to move around. The nurse asked the nurse aide who was assisting Resident #41 and what happened. The nurse aide indicated she was walking with Resident #41 to the bathroom. The nurse asked the nurse aide if Resident #41 was using a walker, and the nurse aide replied Resident #41 did not have a walker and did not know she needed one. This nurse recalled telling the nurse aide who assisted Resident #41 and other staff several times that Resident #41 required a one staff member assist with a walker. The nurse aide indicated Resident #41 tripped over her own feet and fell . The nurse aide stated she attempted to catch Resident #41 as she fell , but was unable to. Resident #41 did have her own shoes on. The nurse aide stayed with Resident #41 while the nurse and another nurse on shift made phone calls to notify necessary persons of the incident and getting paperwork for the hospital. At approximately 8:53 A.M., Resident #41's granddaughter was notified and indicated she wanted Resident #41 transferred back to the hospital. At approximately 8:55 A.M., report was called to the hospital, and at approximately 8:56 A.M., emergency services arrived and assumed care. Emergency services applied a head wrap bandage around the area of bleeding to Resident #41's head and applied a cervical collar around her neck. Once Resident #41 was on the back board she complained of pain to there right side. Resident #41 left the facility at approximately 9:03 A.M. with emergency services. Review of the investigation form dated 02/19/23 at 8:45 A.M. revealed State tested Nurse Aide (STNA) #264 was walking Resident #41 from the dining room to the bathroom, and Resident #41 tripped over her feet and fell . STNA #264 was unable to catch Resident #41 and she fell and hit her head which began to bleed. Resident #41 was wearing her own shoes. The facility contacted emergency services and notified Resident #41's emergency contact, the physician, the director of nursing, and the administrator. Resident #41 was sent to the hospital and staff were educated. Review of a witnessed fall document, dated 02/19/23 at 8:45 A.M., revealed at approximately 8:45 A.M. a nurse aide alerted a nurse that Resident #41 fell and was bleeding badly from her head. The nurse aide indicated she was walking Resident #41 to the bathroom at the time of the fall. The nurse and nurse aide ran to the area where Resident #41 fell , and upon arrival, large amounts of blood were noted on the floor. Resident #41 was laying on her stomach in front of the nurses' station and blood appeared to be coming from the right side of her head. The nurse immediately called emergency services. Resident #41 was crying and indicated she she wanted to get up and her head hurt. Resident #41 also indicated she was in pain and was noted to have occasional labored breathing with a short period of hyperventilation. A nurse attempted to obtain vital signs, but was unable due to Resident #41 crying and attempting to move around. Resident #41 was not able to be consoled, distracted, or reassured. Further review of the document revealed predisposing physiological factors included confusion, recent illness, gait imbalance, and impaired memory; and predisposing situational factors included ambulating with assistance and admission to the facility in the last 72 hours. Review of an investigation interview with STNA #264, related to Resident #41's fall on 02/19/23, revealed she was walking with Resident #41 from the dining room to the toilet. The resident tripped over her own feet and fell . STNA #264 grabbed four blankets and helped the nurse place them under Resident #41's head by the right temporal area. After emergency services arrived, the nurse informed them Resident #41 was bleeding, and they were not able to stop it. Review of the investigation interview with Licensed Practical Nurse (LPN) #224 on 02/19/23 revealed she was alerted by STNA #264 that Resident #41 had fallen. Upon arrival to the nurses station, the other nurse was next to Resident #41 and there was a large amount of blood noted on the floor. LPN #224 asked the nurse aide who was assisting Resident #41 when the fall occurred, and the nurse aide indicated she was walking Resident #41 to the bathroom. LPN #224 asked the nurse aide if Resident #41 was using a walker and the nurse aide indicated Resident #41 did not have a walker and was not aware she needed one. LPN #224 recalled telling the nurse aide assisting Resident #41 that the resident required a one person assistance and a walker when ambulating. During an interview on 03/14/23 at 2:15 P.M., the Administrator stated Resident #41's fall was found to be a problem when it was discovered STNA #264 was walking Resident #41 without a gait belt or a walker. Resident #41 did not come to the facility with a walker from her previous nursing home, but the Administrator stated they were available in the facility. The Administrator verified physical therapy did not have the chance to evaluate Resident #41 for an appropriate walker. The Administrator stated the staff member who was with Resident #41 when she fell was disciplined with a consultation. The Administrator also stated the facility educated all the nursing staff for using gait belts and to always have one on their person. The Administrator also verified the facility did not have enough gait belts and immediately ordered more. Interview on 03/14/23 at 2:24 P.M. with the Director of Nursing (DON) verified the staff members were to be using gait belts for ambulation and transfers as a standard practice. The DON stated when Resident #41 fell and STNA #264 was not using a gait belt or walker, the facility put a gait belt policy into place and educated all the nursing staff. Review of education provided to nursing staff on 02/21/23 revealed a gait belt was part of the staff member's uniform and also a safety device used to help someone move. The gait belt helps provide support and helps prevent a fall. There was a note included with the education for staff to remember to use each resident's assistive device such as a walker, cane, or wheelchair. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice on 03/13/23: On 02/19/23, Resident #41 was sent to the hospital and did not return to the facility. Review of STNA #264's employee personnel file revealed on 02/20/23, STNA #264 was disciplined with a consultation for ambulating a resident without a gait belt and the resident fell . The violation was not using necessary equipment needed to increase resident safety. The education included using equipment needed to increase resident safety. Review of a Quality Assurance and Performance Improvement (QAPI) plan dated 02/20/23 revealed Resident #41 had a fall with injury. The root cause of the fall was staff did not use a gait belt, there were not enough gait belts available, and there was no access to a walker. The facility took corrective action steps to include educating the nursing staff, ordering more gait belts, auditing staff randomly for three weeks, auditing staff for three transfers and/or ambulation for use of gait belts, and each nurse will have treatment keys to access assisted devices after hours and weekends. All staff members were educated on the use of gait belts on 02/21/23. Review of education provided to nursing staff on 02/21/23 revealed a gait belt was part of the staff member's uniform and also a safety device used to help someone move. The gait belt helps provide support and helps prevent a fall. There was a note included with the education for staff to remember to use each resident's assistive device such as a walker, cane, or wheelchair. On 02/24/23, the DON or designee completed audits three times a week for using gait belts with transfers and ambulation to ensure the gait belts were with the staff member. The audits were completed through 03/13/23, with three aides being given gait belts and provided additional education. On 03/14/23, observations and interviews with four (#224, #244, #282, and #284) STNAs, during transfer activities with residents, revealed appropriate safety devices were utilized while providing transfers and ambulation. All four STNAs had gait belts in their possession and all four verified they received education and provided knowledge on use of gait belts and assistive devices. This deficiency represents non-compliance investigated under Complaint Number OH00140493.

Based on medical record review, review of hospital medical records, review of a facility investigation, staff interviews, and policy review, the facility failed to ensure Resident #29 was free from accidents hazards when staff transferred the resident using the improper amount of assistance. This resulted in Actual Harm when a staff member performed a pivot transfer independently and the resident subsequently sustained an avulsion injury (an avulsion injury is caused by trauma and usually happens when a bone is moving one way, and a tendon or ligament is suddenly pulled the opposite way) to the right patellar tendon. This affected one (#29) of three residents reviewed for accidents. The facility census was 39. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include [CONDITION(S)] in situ of unspecified bronchus and lung, solitary pulmonary nodule, muscle weakness, hypertension, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and collapse, and heart failure. Review of her Minimum Data Set (MDS) assessment, dated 07/02/22, revealed Resident #29 had a significant cognitive impairment. Further review of the MDS revealed Resident #29 required extensive, two person physical assistance for all transfers. Review of Resident #29's care plan dated 08/05/21 revealed the resident is at risk for falls and falls related to weakness and cognitive impairment. Interventions included to check on safety during daily care rounds, complete fall risk assessment quarterly and annually, following a fall/with a significant change assessment, and as needed in between, position frequently used items in close proximity and reminder to use call light. Further review of the care plan revealed Resident #29 has an Activity of Daily Living (ADL) deficit related to having generalized weakness, having motivational deficits which limit her ability to assist with various ADL tasks, and needing assistance with all lower upper body dressing/bathing tasks. Resident #29 required two assists from staff for transfers. Resident #29 is at risk for further decline in her functional ability because of a progressive disease process. Review of Resident #29's medical records revealed on 04/28/22, the resident complained of pain in her left knee. Resident #29 was not able to express how the pain started or where the potential injury occurred. An x-ray was completed on 04/28/22 and confirmed there was no fracture and/or injury to her knee; only osteopenia and [CONDITION(S)]. Pain management was completed, and the pain dissipated. Then, on 07/11/22, Resident #29 complained of pain in her right knee. An x-ray was completed on this day as well, and the presence of a fracture was not confirmed. Resident #29 continued to express discomfort and pain in her right knee, so a Magnetic Resonance Imaging (MRI) was completed on 07/18/22, which found a patellar tendon avulsion of the tibial tubercle with periosteal. An orthopedic consultation was not recommended at that time. Resident #29 was placed in an external stabilizer to assist with her knee healing. Review of Resident #29's hospital records sent to the facility, dated 07/18/22, revealed patellar tendon avulsion of the tibial tubercle with periosteal. Review of the facility investigation for Resident #29's avulsion injury, dated 07/11/22 to 07/18/22, revealed State tested Nursing Aide (STNA) #106 performed a one person pivot transfer with Resident #29, which caused the injury to Resident #29's right knee. Interview with Director of Nursing (DON) and Administrator on 07/29/22 at 1:45 P.M. confirmed Resident #29 was to be a two-person physical assist with all transfers at the time of her avulsion injury on 07/11/22. The DON and Administrator stated Resident #29 did not have an order to utilize a hoyer lift until after her injury on 07/11/22, but again, confirmed she was to be a two-person physical transfer at the time of her injury. The Administrator confirmed an agency staff (STNA #106) performed an independent pivot transfer with Resident #29 on 07/11/22, which is where they believe the injury occurred, based on their investigation. The DON and Administrator confirmed they obtained an x-ray on 07/11/22, which was inconclusive to a fracture. Due to continued pain and scheduling with the hospital, an MRI was not completed until 07/18/22, and that confirmed there was no fracture, but she had a patellar tendon tear. Review of the facility Transfer of Resident for Sit to Stand and Hoyer Lift policy, undated, revealed residents defined as incapable of transferring independently or assist of one are to always have a minimum of two nursing personnel involved in the transfer. This deficiency substantiates Complaint Number OH 193.