Every finding on record at Grand the

Based on observations, staff interviews, and review of facility policy review, the facility failed to ensure food was protected from potential contamination and/or spoilage. This had the potential to affect all residents in the facility, as the facility identified all residents received food from the kitchen. The facility census was 119.Findings include:Observation and interview of the kitchen with Culinary Services Manager #217 on 07/15/26 from 11:50 A.M. to 12:10 P.M. revealed cooked turkey burger patties were holding in a hot food storage container on the tray line at 111 degrees Fahrenheit during lunch tray service. Observation of the walk-in cooler revealed one tray of cooked pot roast stored partially covered with aluminum foil, leaving the pot roast open to air. A container of diced chicken was observed stored in the walk-in cooler with a labeled discard date of 07/09/26, and a container of diced ham was observed in the walk -in cooler with a labeled discard date of 07/12/26. Culinary Services Manager #217 verified the above findings at the time of observation. Observation and interview with Dietary Services Manager #217 on 07/15/26 at 12:17 P.M. of the kitchen prep table on the main food preparation line, directly across from the stove revealed one opened individual serving bag of potato chips was on the lower level of the table. Dietary Services Manager #217 was observed to speak to Dietary [NAME] #216 then confirmed the potato chips were Dietary [NAME] #216's and confirmed they should not be in the food preparation areaObservation and interview with Culinary Services Manager #217 on 07/15/26 at 5:03 P.M. revealed one tray of cooked peas was holding at 126 degrees Fahrenheit during dinner tray service. This temperature was verified with Culinary Services Manager #217 at the time of observation. Observation on 07/15/26 at 5:10 P.M. revealed the high temperature sanitization dish washing machine final rinse temperature was reading at a maximum temperature of approximately 156 degrees Fahrenheit as measured by two high temperature testing devices that were placed on trays and sent through the dishwasher. The dish machine's digital screen was observed to read probe error.Interview on 07/15/26 at approximately 5:12 P.M. with Regional Dietary Manager #313 revealed the high temperature sanitization dishwashing machine should test at a final rinse temperature greater than the temperatures observed, and that the observed temperatures would not be adequate for sanitization of kitchen utensils/food service equipment. Review of the facility policy titled Trayline Food Temperatures, issued 08/09/05 and last revised 08/01/24 revealed the facility will hold and serve food at acceptable temperatures that deter bacterial growth. Per review of definitions contained in this policy, the temperature danger zone for bacterial growth is recognized as temperatures between 41 and 135 degrees Fahrenheit. Further review of this policy revealed the internal temperatures of potentially hazardous foods must be kept at 135 degrees Fahrenheit or above for hot foods at all times.Review of the facility policy titled Food Storage, approved 04/01/22 revealed guidelines for food labeling and dating must be adhered to by all food service personnel and closely monitored by the food service manager. Further review of this policy revealed refrigerated foods kept as leftovers should be immediately labeled and dated for later use, and these foods must be discarded within 72 hours.Review of the facility policy titled Employee Sanitary Practices, effective as of 01/29/19 and last reviewed 06/26/20 revealed there should be no eating or drinking in the kitchen at any time unless directly related to a work task or directed by the food service manager or designee. Further review of this policy revealed acceptable instances of eating in the kitchen would include tasting a recipe for proper seasoning and/or texture.Review of the facility policy titled Warewashing, issued 08/07/24 revealed all food contact services must be cleaned and sanitized before use, including pots, pans, utensils, dinnerware, flatware, beverage ware and food carts. Further review of this policy revealed if hot water is used as a sanitizer in high-temperature dishwashers, the temperature should be tested before each use, and at the end of the cycle through the dishwasher, the temperature should be at least 160 degrees Fahrenheit to ensure proper sanitization.This deficiency represents non-compliance investigated under Complaint Number 3045197.

Based on observations, staff interview, and a review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all 121 residents who received food from the kitchen. The facility census was 121 residents. Findings include:An observation of the kitchen walk in freezer on 03/09/26 at 6:22 A.M. revealed that a ten pound box of breakfast sausage, a twenty pound box of burger patties, and a ten pound box of cod were partially used and unsealed, open to the freezer air. An observation of the kitchen walk in freezer door on 03/09/26 at 6:30 A.M. revealed that the freezer door would not close fully due to ice build up around the perimeter of the frame of the door. Observation of the walk in freezer revealed ice build up on several containers of ice cream. An interview and observation with Dietary Aide #557 on 03/09/26 at 6:30 A.M. confirmed that the breakfast sausage, burger patties and cod were opened and unsealed, open to the freezer air, and there was ice build up on freezer content and the perimeter of the freezer door, causing it not to shut. Dietary Aide #557 was observed chipping the ice away from the freezer door frame with a kitchen scraper tool, allowing the door to close again. Review of the facility policy titled Food Storage Guidelines, dated 02/02/11, revealed food is stored by methods designed to prevent contamination. Foods should be covered, labeled and dated.

Based on observations, staff interviews and policy review, the facility failed to ensure proper medication storage and handling practices. Five medication carts were observed out of ten total medication carts and four medication carts were observed of eight total medication rooms in the facility. This had the potential to affect all 121 residents residing in the facility who receive medications from the facility. Findings include:Observation and interview on 03/12/26 at 10:10 A.M. of the medication room on Unit C2 with Licensed Practical Nurse (LPN) #11 revealed multiple expired supplies, including a total of 47 Ultrasite needleless connectors (CMS 5000) with expiration dates of 09/30/25, 11/30/25, and 12/31/25. There were 23 heparin flush syringes (500 units (u)/5.0 milliliter (ml) expired 11/2025 and were found stored in an unlabeled container mixed with various medical supplies in the bottom drawer of a cabinet. The medication refrigerator in the medication room had one tuberculin vial with the dust cover cap removed, no open date documented, a needle puncture in the septum and had an expiration date of 09/2027. LPN #11 confirmed the needleless connectors and heparin flushes were expired. LPN #11 stated the heparin flushes were intended to be returned to the pharmacy; however the drawer where the expired heparin was stored contained no label or signage indicating it was designated for pharmacy return and therefore could be easily accessed for use.Observation on 03/12/26 at 10:30 A.M. of hallway C1 medication cart with LPN #20 revealed in the second drawer, there were three loose pills, identified as pantoprazole sodium delayed release 40 milligrams (mg), gabapentin 100 mg and fluoxetine hydrochloride 40 mg.Observation on 03/12/26 at 10:35 A.M. of the Unit C1 medication refrigerator revealed one tuberculin vial with the dust cover cap removed, no open date documented, a needle puncture in the septum and an expiration date of 06/2027.Interview on 03/12/26 at 10:48 A.M. with Unit Manager #91 confirmed expired medications should not be located in the medication room, tuberculin vials should be labeled with an open date, and the bottom drawer where the expired heparin was stored lacked signage indicating medications were to be returned to the pharmacy.Observation and interview on 03/12/26 at 11:01 A.M. of the medication cart on Unit B with LPN #8 revealed three loose pills in the second drawer, identified as citalopram hydrobromide 20 mg, diclofenac sodium delayed release 50 mg and furosemide 40 mg. LPN #9 confirmed the three looses pills in the second drawer.Observation and interview on 03/12/26 at 11:34 A.M. of the Unit A1 medication room with Unit Manager #92 revealed two intravenous start kits expiring 09/08/25, ten Ulticare TB syringes expiring 02/28/26 and three Safety Needle 23 Gauge by one unit expiring 01/20/25. Unit Manager #92 confirmed intravenous start kits, Ulticare TB syringes and Safety Needles were expired.Observation and interview on 03/12/26 at 11:50 A.M. of the Unit CL1 medication cart with LPN #6 revealed an EpiPen with an expiration date of 08/31/25 and a bisacodyl suppository 10 mg with an expiration date of 01/2025. LPN #6 verified the EpiPen and bisacodyl suppository were expired.Observation and interview on 03/12/26 at 12:00 P.M. of the Unit CL1 medication room with LPN #6 revealed one tuberculin vial with the dust cover cap removed, an open date of 04/03/25, a needle puncture in the septum, and an expiration date of 04/2026. LPN #6 confirmed the tuberculin vial should have been disposed of.Review of the medication and treatment storage policy dated 02/03/26 revealed multi use vials are to be dated when first accessed and discarded within 28 days unless otherwise specified by the manufacturer. The policy also stated expired, discontinued, or deteriorated drugs or biologicals are to be returned or destroyed per pharmacy return/destruction guidelines, and medication and treatment carts are to be kept clean of dirt, spillage, grime, and other foreign materials.Review of the Aplisol (tuberculin purified protein derivative) package insert revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.

Based on record review, policy review, pharmacy and staff interview, the facility failed to follow an antibiotic stewardship program and ensure antibiotics were not prescribed without adequate clinical indication. This affected two (#6 and #13) of four residents reviewed for antibiotic stewardship practices. The facility census was 121.Findings include: 1. Review of Resident # 13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, intestinal obstruction unspecified as to partial versus complete obstruction, partial intestinal obstruction, acquired absence of the digestive tract, and malignant neoplasm of the endometrium. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderate cognitive impairment and required partial/moderate assistance with toileting. The care plan dated 05/27/25 revealed Resident #13 was at risk for an alteration in gastro-intestinal status related to history of intestinal obstruction, bouts of nausea and vomiting at times, as well as effects of medications. Review of the physician orders revealed on 07/14/25, an order for Imodium A-D oral tablet two milligrams (mg) give one tablet by mouth every four hours as needed for loose stool. On 11/13/25, an order for Lomotil oral tablet 2.5-0.025 milligrams (mg) give one tablet by mouth three times a day for loose stools. Review of the eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers dated 03/03/26 by Licensed Practical Nurse (LPN) #20 revealed Certified Nurse Practitioner (CNP) #625 was contacted for diarrhea and the nurse received an order for metronidazole (antibiotic). The physician order dated 03/03/26 revealed an order for metronidazole (Flagyl) oral capsule give 500 mg by mouth two times a day for diarrhea until 03/11/26. The progress note dated 03/03/26 by CNP #625 revealed Resident #13 has been on several medications to control diarrhea. Resident #13 was having several loose stools as reported by staff. Resident #13 had no abdominal pain or fevers. CNP #625 recommended a trial a course of Flagyl. The progress notes revealed antibiotic was monitored for Resident #13 on 03/04/26, 03/07/26, 03/08/26, and 03/10/26. The progress note dated 03/07/26 indicated the antibiotic was for Clostridioides difficile (C.Diff) infection. The medical record do not reflect that an antibiotic time out was conducted to determine the appropriateness of the antibiotic. Interview with Resident #13 on 03/09/26 at 10:35 A.M. revealed the resident had frequent diarrhea. Resident #13 reported recently starting a medication for the diarrhea. Resident #13 could not report if the medication was improving the diarrhea and the staff told her it would take a while for the diarrhea to improve. Interview with Certified Nursing Assistant (CNA) #145 on 03/09/26 at 12:34 P.M. reported Resident #13 had diarrhea daily, usually two to three times on day shift and two to three times on night shift. CNA #145 had not noticed any change in Resident #13's stools since the metronidazole was started. Interview with Assistant Director of Nursing (ADON) #121 on 03/11/26 at 9:13 A.M. confirmed residents with suspected infectious diarrhea would have a stool culture sent and would be placed under contact precautions. Interview with Unit Manager #91 on 03/11/16 at 9:50 A.M. revealed Resident #13's stool was not sent for culture although this would normally be done. Unit Manager #91 further revealed a stool culture was not sent because the diarrhea was chronic in nature. Interview with the Director of Nursing (DON) on 03/11/26 at 10:00 A.M. revealed Resident #13 had chronic diarrhea and an infection was not suspected. The DON revealed the antibiotic was started by the CNP to reset the gut. The DON revealed that a stool culture was completed in the past. The DON provided a physician progress note dated 02/28/25 that revealed Resident #13 had a diagnosis of radiation enteritis (inflammation and damage to the intestines caused by radiation therapy). The DON revealed radiation enteritis was the suspected cause of Resident #13's chronic diarrhea. Interview with CNP #620 on 03/11/26 at 1:45 P.M. revealed the antibiotic was prescribed for Resident #13 with the goal of disrupting the flora of the gut and to re-bulk stools. Resident #13 may have undiagnosed Irritable Bowel Syndrome (IBS). CNP #620 confirmed the antibiotic was not prescribed for Resident #13 to treat an active infection. CNP #620 revealed she thought Resident #13 had a stool culture performed in the past. A copy of Resident #13's stool culture was requested from the facility on 03/11/26 at 10:00 A.M. and 1:45 P.M. but the facility did not provide a copy of the results. Telephone interview with LPN #20 on 03/11/26 at 4:05 P.M. revealed CNP #620 was contacted for orders on 03/03/26 because of the chronic nature of the diarrhea. LPN #20 reported Resident #13 was not experiencing an increase in the amount of diarrhea. LPN #20 reported Resident #13 was experiencing the usual amount of diarrhea. Review of the facility's McGeer Criteria Worksheet on 03/12/26 at 8:39 A.M. revealed the McGeer criteria serve as the basis for an antibiotic stewardship program, and Resident #13 needs to meet criteria for an infection before being started on antibiotic therapy. The resident did not have three or more liquid or watery stools above what is normal within a 24-hour period, two or more vomiting episodes in a 24-hour period, or stool sample testing. Interview with ADON #121 on 03/12/26 at 8:32 A.M. confirmed the use of metronidazole for Resident #13 does not meet McGeer criteria. ADON #121 revealed the facility prescribers will prescribe antibiotics for other infections as well, such as urinary tract infections, that do not meet McGeer criteria for infection. ADON #121 revealed education was provided to the prescribers regarding antibiotic stewardship. Interview with Consultant Pharmacist #610 on 03/12/26 at 9:49 A.M. revealed antibiotics, such as metronidazole, can cause gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. Consultant Pharmacist #610 revealed metronidazole may help resolve diarrhea if used to treat infection. Consultant Pharmacist #610 confirmed that metronidazole is not used to disrupt the flora of the gut and re-bulk stools if infection is not present but noted that the medication can disrupt normal gut bacteria and cause loose stools. Review of the policy and procedure titled Antibiotic Stewardship dated 02/04/26 revealed the program includes antibiotic use protocols and a system to monitor antibiotic use with protocols that included laboratory testing and the use of McGeer's Criteria to define infection and determine whether to treat an infection with antibiotics. 2. Review of Resident #6's medical record revealed she was admitted to the facility on [DATE] and diagnoses included end stage renal disease. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had she had intact cognition and received an antibiotic within the lookback period. Review of the hospital records dated 02/21/26 revealed Resident #6 was seen on 02/21/26 in the hospital for a fall. Imaging showed the resident had acute cystitis. Resident #6 was prescribed Cephalexin (antibiotic). There was no evidence of a culture and sensitivity being completed in the hospital. Resident #6 was discharged from the hospital on [DATE]. Review of Resident #6's physician orders dated 02/22/26 revealed Resident #6 was prescribed Cephalexin 500 milligrams (mg) one capsule by mouth daily for five days. Review of the McGeer Criteria Worksheet dated 02/22/26 revealed Resident #6 was prescribed Cephalexin in the hospital for urinary symptoms due to cystitis and this did not meet McGeer's Criteria for infection. There was no evidence the facility completed a culture and sensitivity on Resident #6 to ensure the correct antibiotic was ordered to treat Resident #6's acute cystitis. An interview with Assistant Director of Nursing (ADON) #121 on 03/11/26 at 9:58 A.M. confirmed that the antibiotic course for Resident #6 was completed without a sensitivity to bacteria and without a confirmed infection. Review of the facility's McGeer Criteria Worksheet revealed the criteria serve as the basis for an antibiotic stewardship program. The patient needs to meet the criteria for an infection before starting on antibiotic therapy. Review of the facility policy titled Antibiotic Stewardship dated 06/03/25 revealed the facility uses McGeer's criteria to define infections. McGeer's criteria may be used to determine whether to treat an infection with antibiotics.

Based on observations, record reviews, policy review, staff interviews and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure proper hand hygiene and infection control procedures were followed during incontinence care and ensure staff were aware to follow enhanced barrier precautions (EBP) for a resident with an indwelling medical device. This affected two residents (#14 and #18). The facility census was 121.Findings include:1. Review of the medical record for Resident #14 revealed an admission date of 08/07/25. Diagnoses included dementia, anxiety, major depressive disorder, chronic respiratory failure with hypoxia, panic disorder, arthritis, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition and was dependent on staff for toileting hygiene. Review of the care plan dated 08/07/25 revealed Resident #14 required enhanced barrier precautions (EBP) related to history of multi-drug resistant organisms with interventions included EBP will be used for the duration of the residents' stay at the facility or until resolution of the wound pr discontinuation of the indwelling medical device that placed them at risk, and staff will wear gowns and gloves during high contact resident activities. Observation on 03/12/26 from 10:20 A.M. to 10:39 A.M. revealed Certified Nursing Assistant (CNA) #525 was going to provide bathing, and incontinence care for Resident #14. CNA #525 gathered items for a bed bath. CNA #525 obtained two washcloths, put one washcloth in the basin with soap and one washcloth in the basin with no soap. CNA #525 washed Resident #14's chest area and armpits, then she used the non-soapy water to rinse Resident #14 and then dried Resident #14 with a towel. Then using the same soapy washcloth, CNA #525 washed Resident #14's peri-area. CNA #525 opened the washcloth on her open palm and made several swipes with the open washcloth along Resident #14's abdominal area, and then washed downward in the vagina and then came back upwards in the vagina. CNA #525 then rolled Resident #14 over and CNA #525 used the same washcloth to wash Resident #14's backside. Resident #14 had a bowel movement and CNA #525 offered the bedpan and Resident #14 refused. Then CNA #525 used the non-soapy washcloth and wiped Resident #14's backside and stated she would have to get more washcloths. CNA #525 left the room and came back with more washcloths. CNA #525 did not cover Resident #14 when she went for more washcloths and left Resident #14 on her left side with her backside exposed while getting more washcloths. CNA #525 did offer the bedpan again and placed Resident #14 on the bedpan. Interview on 03/12/2026 at 10:21 A.M. with CNA #525 confirmed she only had two washcloths and acknowledged she should have had a different washcloth for pericare. CNA #525 confirmed she had open palm with the washcloth and wiped instead of using a clean section of the washcloth each time and confirmed she only had two washcloths for cleaning entire body. Interview on 03/12/26 at 10:21 A.M. with Unit Manager #76 verified Resident #14 had recently had a urinary tract infection and had been on antibiotics. Unit Manager #76 stated there were some educational opportunities here for CNA #525 for proper incontinence care. Review of the facility policy titled Incontinence Care-Urinary and Fecal dated 02/03/26 revealed the policy was to provide guidelines for cleansing the perineum and buttocks after an incontinent episode or with daily care. The guidelines stated if feces are present, remove with toilet paper or disposable wipe from the front of the perineum toward the rectum. Cleanse the peri-area and buttocks with disposable bathing wipe or washcloth and incontinent cleansing spray or soap and water, wiping from the front of the perineum toward the rectum. Use a separate area of the cloth or new disposable wipe for each stroke. Turn the resident side to side to cleanse the entire affected areas, as needed. Rinse with water, if needed, or per incontinent product instructions. For a female: gently separate the labia and wash the area using downward strokes from pubic area to the rectal area. Cleanse skinfolds. Use alternate sites of the cloth or new disposable wipe with each downstroke. Rinse using the same procedure with a clean washcloth as needed. Pat dry. 2. Review of Resident #78's medical record revealed he was re-admitted to the facility on [DATE]. Diagnoses included cholecystitis and chronic respiratory failure. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 had intact cognition. Review of the care plan dated 02/15/26 revealed Resident #78 required enhanced barrier precautions (EBP) related to indwelling medical device and peripherally inserted central catheter (PICC) line (a think tube inserted through a vein in the upper arm). Interventions included enhanced barrier precautions (EBP) will be used for the duration of the resident's stay. Review of the re-admission assessment on 02/27/26 revealed Resident #78 was admitted with a right upper quadrant Jackson Pratt (JP) drain (a soft, bulb-shaped surgical device used to remove fluids from a wound via gentle, active suction to promote healing and reduce infection risk) and a left upper quadrant JP drain. Review of Resident #78's physician orders dated 03/02/26 revealed the output on his right upper quadrant JP drain and left upper quadrant JP drain should be recorded each day on each shift. An order dated 03/02/26 revealed Resident #78 should have a PICC line assessment to right upper extremity each day on every shift. There were no physician orders for EBP. Observation of Resident #78 on 03/09/26 at 7:06 A.M. and 8:14 A.M. revealed Resident #78 had JP drains on his abdomen and his door did not have EBP signage. An interview with Licensed Practical Nurse (LPN) #15 on 03/09/26 at 8:24 A.M. confirmed there was no EBP signage outside of Resident #78's room and confirmed there should be EBP signage for a reminder for staff to wear PPE for high contact resident care activities. Review of CDC guidance titled Implementation of PPE (personal protective equipment) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on medical record review, observation, and staff interview, the facility failed to ensure the resident's menu followed the nutritional needs of the resident. This affected one (Resident #45) of 11 residents reviewed for nutrition. The facility census was 121. Findings include:Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with diabetic chronic kidney disease, type II diabetes mellitus with diabetic retinopathy without macular edema, and morbid (severe) obesity due to excess calorie.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact, received a therapeutic diet and required supervision with meals.Review of the physician orders dated 02/07/26 revealed an order for a renal/diabetic diet with regular texture and thin consistency.During an observation and interview on 03/11/26 at 9:56 A.M., Resident #45's breakfast tray contained an egg on a biscuit, hashbrowns, oatmeal with milk, apple juice, and eight ounces of milk. The renal diet menu on Resident #45's ticket indicated the resident should receive only four ounces of milk, and the biscuit and hashbrowns were not included on the renal diet menu. Resident #45 stated she consumed one bite of the hashbrowns but ate the biscuit. Certified Nursing Assistant (CNA) #149 confirmed Resident #45 did not receive the correct renal diet.During an observation and interview, on 03/11/26 at 12:22 P.M., Resident #45's lunch tray contained sweet potato fries instead of cauliflower, which was listed on the renal diet menu for that meal. During an interview at 12:26 P.M., CNA #149 confirmed the resident did not receive the correct renal diet when sweet potato fries were served instead of cauliflower.During an observation and interview on 03/12/26 at 8:23 A.M., Resident #45's breakfast tray contained eight ounces of milk, although the renal diet menu indicated the resident should receive only four ounces of milk. CNA #153 confirmed Resident #45 received eight ounces of milk instead of the four ounces listed on the renal diet menu.

Based on medical record review, resident, physician and staff interviews, observation, and review of facility policy, the facility failed to accurately assess and provide timely ongoing monitoring of a resident with significant weight loss. This affected one (Resident #39) of 11 residents reviewed for nutrition. The facility census was 121.Findings include: Review of the medical record for Resident #39 revealed he was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, muscle weakness, chronic respiratory failure, congestive heart failure, chronic kidney disease stage III, and chronic obstructive pulmonary disorder. Review of Resident #39's initial nutrition assessment dated [DATE] revealed Resident #39 was at risk of malnutrition related to congestive heart failure and chronic kidney disease. The registered dietitian (RD) recommended house med pass (high caloric nutritional supplement) 120 ml twice per day. On 08/10/25, Resident #39 was 106 lbs. The nutritional recommendations were not implemented until 20 days later on 08/13/25, when the physician ordered the house med pass supplement 237 ml by mouth twice daily. The physician orders also revealed Resident #38 was on prednisone (steroid) 10 milligrams (mg) daily, starting on 08/13/25 and Lasix (diuretic) 40 mg one per day starting on 08/11/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact, required supervision or touching assistance with eating, and did not exhibit any refusal of care during the review period. The nutrition care plan dated 01/18/26 revealed Resident #39 was at risk of malnutrition related to increased kilocalorie (kcals) and protein needs and he was at risk of dehydration related to diuretic use. Interventions included monitoring meal intakes, supplements as ordered, notifying the resident and/or responsible party and physician of severe weight changes and monitoring and recording weights per the facility policy. The goal was for Resident #39 to consume greater than 50% of her meals and her nutritional supplement drinks. On 02/01/26, Resident #39 was 110.0 lbs. From 02/01/26 to 02/09/26, there was no mention of Resident #39 having increased edema nor were there any physician orders to increase his diuretic use (Lasix). Resident #39 remained on Lasix 40 mg starting 08/11/25.Resident #39 was admitted to the hospital on [DATE] for a gastrointestinal bleed. Review of the hospital records dated 02/09/26 to 02/12/26 revealed Resident #39 weighed 100 lbs. at time of his hospital admission [DATE]). This was a 9.0 percent severe weight loss in nine days. Resident #39 appeared to be euvolemic (a state of normal body volume, where blood volume and total body water are balanced) and her chest computed tomography (CT) exam revealed no findings of fluid overload. Resident #39 elected palliative care services. Resident #39 was discharged from the hospital and returned to the facility on [DATE]. There was no weight obtained for Resident #39 upon readmission to the facility. Review of the nutritional assessment dated [DATE] revealed it addressed Resident #39's weight of 100 lbs. on 02/09/26 at the hospital and the resident returned from the hospital with a significant weight loss but thought the weight loss was fluid related. (This is contradictory to the hospital and nursing assessments which indicated there was no additional fluid on Resident #39.) The RD recommendations included discontinuing the house liquid protein 60 ml once daily order. The RD did not initiate any additional monitoring or nutritional recommendations for Resident #39. There were no additional weights obtained from Resident #39 between 02/12/26 and 03/09/26. During an observation on 03/10/26 at 2:29 P.M., Certified Nursing Assistant (CNA) #142 obtained Resident #39's weight of 96.3 lbs. This was a weight loss of 3.7 lbs. since 02/09/26 Resident #39 agreed to obtain her weight. CNA #142 stated Resident #39 was normally very pleasant and agreeable to care and services. She denied Resident #39 refused to be weighed. During an interview on 03/10/26 at 5:11 P.M., RD #539 stated he attempted to get a re-weight from Resident #39 following the 02/12/26 weight change, but Resident #39 refused. (There was documentation of Resident #39 refusing to be weighed from 02/17/26 to 03/10/26.) RD #539 confirmed he did not request any additional attempts to reweigh Resident #39. RD #539 explained that he elected to not implement any nutritional interventions at this time because her caloric needs were being met. RD #539 said Resident #39's weight fluctuations were due to her physician ordering diuretics and steroids impacting her fluid balance. RD #539 explained with the calories and protein she was receiving between the ordered house med pass supplement 237 ml by mouth twice daily and her facility meals, she shouldn't have any nutritional deficits. RD #539 stated he reviews the nursing team's documentation of her meal and supplement consumption. RD #539 stated he has had issues obtaining resident weights due to inadequate staffing. RD #539 acknowledged it would have been optimal if he had obtained weekly weights for this resident. On 03/11/26, Resident #39's weight was 95.8 lbs. During an interview on 03/11/26 at 11:15 A.M., Resident #39 stated she was not aware of her weight loss and confirmed the facility staff had not discussed this with her. She confirmed she always refused the oral nutritional supplements because she was lactose intolerant. She also denied refusing to be weighed. She said no one had asked her to be weighed in a while.Review of the nutritional note dated 03/11/26 revealed Resident #39 was re-weighed. RD #539 conversed with the resident regarding possible dietary interventions and supplements. The resident was pleasant but declined all supplement options, noting that she likes Boost but it causes diarrhea. She expressed that she was not overly concerned about further weight loss and feels she has lived a good life. She requested discontinuation of her house med pass supplement but admitted she sometimes drinks it; RD #539 encouraged her to keep house med pass supplement available. She refused any additional supplements, including Magic Cup, but promised to keep eating as much as she can. During an interview on 03/11/26 at 10:50 A.M., Physician #215 denied Resident #39's weight fluctuations were attributed to excess fluid. Physician #215 confirmed the orders for prednisone and Lasix have not changed since her initial admission to the facility. Review of the facility's policy titled Weights dated 05/03/22 revealed reweights should be completed when the resident gains or loses five pounds, if they weigh 100 pounds or greater. The threshold for significant unplanned and undesired weight loss is based on the following criteria: a 5.0% weight loss over one month is significant. The RD or designee is responsible for the weight management program, including compliance with weight goals, tracking and trending, nutritional assessments, interventions, care plans, and follow-up.

Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident who was at risk for falling and had a history of falls. This affected one (Resident #17) of five residents reviewed for falls. The facility census was 121 residents. Findings include: Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included displaced fracture of base of next of right femur, a history of falling, vascular dementia, Parkinson's disease, and malignant neoplasm of bronchus or lung. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had moderate cognitive impairment. Resident #17 was assessed as having lower extremity impairment on one side, being dependent on staff for toileting hygiene, mobility and transfers, and having two or more falls since admission without an injury. Review of the care plan dated 02/18/26 revealed Resident #17 was at risk for falls due to decreased mobility, needing assistance from staff, impaired decision making, dementia and Parkinson's disease. Interventions included a fall mat to bedside when in bed (dated 03/01/26), have the bed to the wall and to have bolsters to the bed when Resident #17 was in bed. The nursing progress note dated 03/03/26 revealed on 03/02/26, therapy notified nursing staff that Resident #17 reported that he had fallen over night and got himself back up. Upon assessment, resident's right lower extremity was noted to be rotated inward. The immediate intervention made was to have a fall mat to Resident #17's bedside. Secondary interventions made were to have his bed against the wall and bolsters added to the bed. Review of Resident #17's physician orders dated 03/09/26 revealed Resident #17 was to have his bed to the wall and to fall mat to beside when occupied, and bolsters to his bed, all with the effective date of 03/04/26. An observation of Resident #17 on 03/09/26 on 8:15 A.M. revealed Resident #17 was lying in bed, his bed was centered in the middle of the room and there was not a fall mat at the bedside. An observation of Resident #17 on 03/09/26 at 12:04 P.M. revealed Resident #17 was lying in bed, his bed was centered in the middle of the room and there was not a fall mat at the bedside.An observation of Resident #17 on 03/10/26 at 11:00 A.M. revealed Resident #17's bed was positioned against the wall and he had a fall mat in place next to his bedside. Resident #17 was in the bed and there were no bolsters present in Resident #17's bed. An interview with Licensed Practical Nurse (LPN) #15 on 03/10/26 at 11:02 A.M. revealed Resident #17's bed was newly against the wall and has a new fall mat at his bedside. LPN #15 confirmed the fall mat was not at his bedside and his bed was not against the wall on the morning of 03/09/26. LPLN #15 revealed that at some point on 03/09/26, management moved Resident #15's bed against the wall and placed a fall mat in his room. LPN #15 confirmed there were no bolsters present on Resident #17's bed. Review of the facility policy titled Fall Management Guidelines, revised on 02/03/26, revealed the interdisciplinary team will review the resident's care plan and interventions to ensure that the interventions are appropriate. The interventions will be reviewed and revised as indicated.

Based on observations, record review, policy review, and staff interviews, the facility failed to ensure a resident was seen routinely for podiatry services. This affected one (Resident #97) of one resident reviewed for foot care. The facility census was 121.Findings include:Review of the medical record for Resident #97 revealed an admission date of 04/10/23 with diagnoses including dementia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had severe cognitive impairment and required supervision with personal hygiene and showering. Review of the care plan revealed Resident #97 had an activities of daily living (ADL) self-care deficit related to dementia, cognition impairment, and communication deficit. Intervention dated 12/18/25 included bathing/showering, check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Additionally, Resident #97 had a care plan for ancillary services for resident's needs such as dental, podiatry, optometry, audiology, and psychological. An intervention dated 07/24/23 was to coordinate with social services for scheduling of resident need to see in house specialty physicians.Review of the podiatry notes for Resident #97 dated 07/16/25 revealed right and left foot toenails were elongated, discolored, mycotic (a fungal infection that affects your toenails), thick, yellow, subungual debris (crusty debris under the nail formed by the fungus on the toenail bed), and thickness of three millimeters (mm). Additionally, Resident #97's toenails on the right and left foot were debrided (the removal of damaged or infected tissue from the nail bed and surrounding areas) and reduced in length and thickness to one mm. The recommendation from the podiatry to be seen was indicated as medically necessary but no sooner than 60 days.Review of the podiatry list for residents to be seen on 08/29/25, 09/15/25, 0/16/25, 10/03/25, 11/25/25, 01/23/26, 01/26/26, and 01/27/26 revealed Resident #97 was not on the lists to be seen by the podiatrist any of the above dates.There were no podiatry notes for September 2025, October 2025, November 2025, December 2025, January 2026, or February 2026 for Resident #97 and no progress notes which indicated podiatry services were offered and declined.Review of the signed consent undated for Resident #97 revealed consent was signed for the facility to provide outside services for Resident #97 for podiatry.Review of the progress note created by Licensed Practical Nurse (LPN) # 16 dated 02/24/26 which was a late entry placed in Resident #97's chart on 03/10/26 revealed the right toenail fell off during the dressing change and all parties were notified.The progress note created by the Director of Nursing (DON) dated 02/24/26 as a late entry placed in Resident #97's chart on 03/10/26 revealed interdisciplinary team reviewed the incident dated 02/23/26. The facility staff noted the resident's right great toe was loose from her nailbed. Nursing notified. Resident assessed for further injury, no further new skin alterations noted. Resident denies pain to area, displays no non-verbal indication of pain. Area cleansed and dressed. Facility wound nurse notified for continuity of care throughout wound healing. Appropriate parties notified.The progress note dated 02/25/26 revealed there was a new skin concern to the right dorsum first digit (Hallux) and the toenail was partially off. There were signs and symptoms of infection which included erythema/edema and temperature was increased. The wound site was painful and aching. Medicate prior dressing change. The wound measured 0.9 centimeters (cm) in length and 1.4 cm in width and no depth. There was light exudate and was purulent. There was indication of pus, typically thick, yellow, green, tan or brown, and had a faint odor. Non-pitting edema extends less than four cm around wound. Cleanse with normal saline, apply triple antibiotic ointment (TAO) daily. Resident's toenail was partially removed from nailbed. Review of a physician order for Resident #97 dated 02/25/26 to 03/04/26 revealed to cleanse the right great toe's toenail with normal saline pat dry apply TAO and cover with dry dressing every day shift for monitoring.The provider note dated 03/01/26 revealed Resident #97 was started on Amoxicillin-potassium clavulanate (Augmentin) (antibiotic) 875-125 milligrams (mg) two times a day for seven days for the right great toe infection.The physician order for Resident #97 dated 3/05/26 to 03/12/26 revealed the wound treatment changed for right great toe to apply skin prep to right great toe every day shift for wound care.Interview on 03/10/26 at 2:33 P.M. with LPN #16 stated Resident #97's right toenail was very long. LPN #16 stated Resident #97's right toenail kept getting caught in the thromboembolic deterrent (TED) hose and then it was infected underneath. LPN #16 stated the toenail came off in the bandage when she was doing a treatment. LPN #16 stated the provider came and assessed the right toe when the toenail came off and changed the treatment to skin prep and open to air.Observation on 03/11/26 at 1:38 P.M. revealed Resident #97 was sitting in a recliner in her room. Resident #97's right foot toenails were yellow, thick and extended over skin, the second toenail was broken in half. Resident #97's left foot toenails were thick, yellow, and extended past skin. LPN #16 stated Resident #97's toenails were too long, yellow, and thick. LPN #16 verified the second toenail on Resident #97's right foot was broken in half. Resident #97's left big toenail had a slight redness to the inside of toe. When LPN #16 pushed Resident #97's left great toenail, Resident #97 flinched and said it hurt. There was a brown substance under the nail of Resident #97's left great toenail which LPN #16 verified at the time of the observation.Interview on 03/11/26 at 10:23 A.M. with Social Services #73 revealed the facility used an outside provider for specialty services such as podiatry. Social Services #73 stated the facility had consent for services signed from each resident in the building and when a new resident is admitted to the facility, then the new resident was offered the consents and services. Social Services #73 stated there was a running list for residents who were seen every three months, and the residents were automatically seen every two to three months. Social Services #73 stated if a resident was seen in July 2025, then they would be seen in October 2025. Social Services #73 stated unless a resident refuses on the day of service, then they will be seen every three months. Social Services #73 stated the podiatrist was in the facility usually every two months, because there were so many residents who need to be seen. Social Services #73 stated the podiatrist reports to social services (herself) and the DON on the day of the service and then podiatry reports were sent to the facility for each resident seen that day which was uploaded to the individua resident's electronic medical record. Social Services #73 could not provide a reason why Resident #97 was not seen by podiatry.Interview on 03/12/2026 at 12:58 P.M. with the DON stated all residents in the facility were seen by ancillary services every two to three months. The DON could not provide a reason why Resident #97 was seen by podiatry.Review of the facility policy titled Ancillary-Additional Services and Fees dated 02/14/13 revealed it is the center's policy to provide additional services where appropriate and upon request to our residents/patients that can be billed to their insurance policy or paid privately.

Based on observations, medical record review, policy review, and resident and staff interviews, the facility failed to ensure a resident's orthotic (external wearable medical device) was in place according to physician orders. This affected one (Resident #55) of one resident reviewed for orthotics. The facility census was 121.Findings include:Review of the medical record for Resident #55 revealed an admission date of 03/12/25. Diagnoses included wedge compression fracture of first lumbar vertebra, concussion without loss of consciousness, disorder of bone density and structure, Parkinson's disease, and anxiety disorder.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment, required moderate assistance from staff for showering and upper body dressing. Resident #55 had no rejection of care during the review period.Review of the care plan revealed Resident #55 was at risk for falls related to decreased mobility, use of assistive devices, assist of staff, status post recent hospital admit due to a fall and found with closed head trauma without acute intracranial abnormality, acute lumber one fracture non-operative management (NOM) and use of thoraco-lumbo-sacral orthosis (TLSO) (a brace that provides support from mid to the lower portion of the spine. This brace is most commonly used to provide support and stabilization of the spine after a back injury and/or surgery.) with an intervention dated 01/08/26 splint wear: TLSO brace as needed for comfort.Review of the physician order dated 01/07/26 revealed the lumbar sacral brace to be worn at all times when sitting or standing. May only be removed while sleeping. Every shift do not remove to shower.Observation and interview on 03/09/26 at 8:29 A.M. revealed Resident #55 was sitting in a recliner with part of the back brace lying in his lap. Licensed Practical Nurse (LPN) #16 stated Resident #55's TLSO brace was not on correctly and she corrected it at the time of the observation.Interview on 03/10/26 at 2:21 P.M. with Certified Nursing Assistant (CNA) #525 stated when Resident #55 gets up in the morning, the CNA puts the TLSO brace on him.Review of the Treatment Administration Record (TAR) revealed the TLSO brace had been checked as being put on Resident #55 for 03/11/26 for the 7:00 A.M. shift.Observation on 03/11/26 at 10:36 A.M. revealed Resident #55 was in his room, sitting in a recliner with the footrest up and his legs on the footrest with no TLSO brace on. The TLSO brace was sitting on top of the trash can by his recliner. Interview on 03/11/26 at 10:36 A.M. with Resident #55 stated he did not take off the back brace and that no one had put it on him today.Interview on 03/11/2026 at 10:43 A.M. with Unit Manager #76 verified Resident #55's back brace was on top of his trash can. Unit Manager #76 stated it should be on Resident #55. Unit Manager #76 stated the Director of Therapy was just asking her who was going to put Resident #55's back brace on him. Review of the facility policy titled Activities of Daily Living (ADL) revised date of 12/07/23 revealed the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

Based on medical record review, staff and resident interviews, observations, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) received adequate and timely bathing and personal hygiene. This affected three (Residents #2, #12 and #151) of nine residents reviewed for ADLs. The facility census was 121.Findings include:1. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE]. Diagnoses included hypotension, diabetes mellitus, pulmonary hypertension, muscle weakness, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition and was dependent on staff for personal hygiene and bathing. Observation and interview with Resident #2 on 03/09/26 at 11:57 A.M. revealed the resident had multiple chin hairs present. Resident #2 stated staff have not offered to shave her chin hairs but said she would take advantage of the service if it was offered. During an interview on 03/10/26 at 11:31 A.M., Certified Nursing Assistant (CNA) #128 verified the presence of facial hair on Resident #2 and stated she would shave the resident that day, following the resident's shower. 2. Record review for Resident #151 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, fracture of the left radius, muscle weakness, osteoarthritis, tremor, and macular degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated 07/1 6/24 revealed Resident #151 had intact cognition and was dependent on staff for bathing and personal hygiene. Interview and observation of Resident #151 on 03/10/26 at 8:55 A.M. revealed her fingernails exceeded the length of the finger by approximately one inch. Resident #151 said the facility refuses to cut her fingernails and has asked the facility to make her an appointment with a manicurist to have her nails cut. Review of the staff bath tasks, assigned to direct care staff, for Resident #151 revealed her nail length should be checked, and trimmed as appropriate. During an interview on 03/10/26 at 11:46 A.M., Unit Manager (UM) #76 stated nail care should be completed at minimum weekly by CNAs and as needed. She said CNAs can trim nails, provided the resident was not diabetic. If the resident was diabetic, it should be completed by a nurse. She did confirm Resident #151's nails were too long and could cause the resident injury to her skin. She also mentioned the resident's family prefers that they be kept much shorter. UM #76 then trimmed the resident's nails. Review of the facility's policy titled Dignity issued 09/21/23 revealed the facility staff will assist residents with groom, including hairstyles, nails and facial hair, per the resident's preferences. 3. Review of the clinical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included encounter for surgical aftercare following surgery on the digestive system, other retroperitoneal abscess, other cirrhosis of liver, and hydronephrosis with ureteral stricture. Review of the five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and required maximum assistance for showering/bathing, upper body dressing, lower body dressing, footwear, rolling left and right, and sitting to lying, and was dependent on staff for lying to sitting, sit to stand, chair to chair transfer, and toilet transfer. Under Preferences for Customary Routine and Activities, the resident indicated it was very important to be able to choose between a bed bath, shower, tub bath, or sponge bath. Review of the task documentation for bathing revealed Resident #12 received bed baths on 02/06/26, 02/10/26, 02/13/26, 02/17/26, 02/20/26, 02/24/26, 02/27/26, 03/03/26, and 03/06/26, with no showers indicated. There was no documentation Resident #12 refused showers. The care plan revealed there was focus of Resident #12 chooses not to agree with plan of care, may be resistive, refuse, or noncompliant with care or treatment as evidenced by refusing non-pharmacological interventions for pain at times, initiated 02/24/26. The intervention to leave and reapproach later if the resident resists or refuses care or treatment. Resident #12's clinical record and progress notes revealed no documentation of refusals related to bathing, hair care, or turning during bathing. During an interview and observation on 03/09/26 at 2:40 P.M., Resident #12 stated they were only giving her bed baths and preferred to have showers. Resident #12's hair appeared disheveled and Resident #12 stated they only use the shower cap and she has not had her hair thoroughly washed since admission. During an interview and observation on 03/10/26 at 2:08 P.M., Certified Nursing Assistant (CNA) #184 stated Resident #12 typically chooses a bed bath. She stated staff use a shampoo cap for hair care during bed baths. CNA #184 confirmed that the back of Resident #12's hair was very matted. CNA #184 stated Resident #12 refuses to turn for care to the back of the head and refuses trimming of the matted hair. CNA #184 stated a thorough wash would be needed to adequately clean the back of the resident's hair. She stated Resident #12 required a mechanical lift and the resident often refuses, but confirmed there was no documentation of refusals for hair care or turning during bathing. During an interview on 03/10/26 at 2:39 P.M., the Director of Nursing (DON) stated CNAs do not write progress notes; however if a resident refuses care, the CNA should notify the nurse and the nurse should document the refusal in the electronic medical record. The DON further stated if a resident refuses specific areas of care during bathing, it was best practice for CNAs to inform nursing so refusals can be documented, and that it was best practice to offer a full hair wash prior to using a shampoo cap. Review of the facility policy titled Dignity (ADL), dated 09/21/23, revealed it was the policy of the facility that each resident would be cared for in a manner that promoted and enhanced his or her sense of well being, level of satisfaction with life, feeling of self worth, and self esteem. The policy further revealed residents would be treated with dignity and respect at all times. The policy indicated the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs beginning with the initial admission and continuing throughout the resident's stay at the facility. The policy further indicated the individual needs and preferences of residents were to be identified through the assessment process and interactions and discussion with staff. The policy also indicated staff were expected to treat residents with dignity and respect while assisting with activities of daily living. Review of the facility policy titled Accommodation of Needs, dated 08/21/23, revealed the facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The policy further revealed the resident's individual needs and preferences would be accommodated to the extent possible and would be evaluated upon admission and reviewed on an ongoing basis. The policy indicated that in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed toward assisting residents in maintaining independence, dignity, and well being to the extent possible and in accordance with the residents' wishes.

Based on observation, interview with phlebotomist (specialized healthcare professional trained to draw blood for tests), and policy review, the facility failed to ensure the resident had privacy during a blood draw. This affected one (Resident #123) of 43 residents reviewed for privacy. The facility census was 121.Findings include:Medical record review revealed Resident #123 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic pain syndrome, and osteoporosis. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #123 had severe cognitive function and utilized a wheelchair for mobility,Observation on 03/09/26 at 9:00 A.M. and 11:00 A.M. revealed Resident #123 was sitting in the television room with three other residents. On 03/09/26 at 9:40 A.M., Phlebotomist #626 performed a blood draw (venipuncture) from the resident's right antecubital region (the anterior surface of the elbow) in the presence of other residents in the television room.Interview with Phlebotomist #626 on 03/09/26 at 9:42 A.M. confirmed she drew blood in Resident #123's antecubital area in the communal area. Phlebotomist #626 indicated the task was performed in the communal area because Resident #123 was initially refusing to participate in the blood draw. Phlebotomist #626 stated it was not typical to perform a blood draw in a public space. Review of the facility's Venipuncture Specimen Collection policy issued 08/07/23 revealed they were to provide privacy during a venipuncture sample collection.

Based on family interview, staff interview, record review, and facility policy review, the facility failed to ensure the resident's bathing preferences were honored. This affected one (Resident #93) of two residents reviewed for choices. The facility census was 121. Findings include:Review of the medical record for Resident #93 revealed an admission date of 12/19/25. Diagnoses included fracture of the upper and lower end of the right fibula, and morbid obesity due to excess calories.Review of the five-day Minimum Data Set (MDS) 3.0 assessment, dated 02/27/26, revealed the Brief Interview for Mental Status (BIMS) was not assessed. Resident #93 had no behaviors during the review period and was dependent on staff for showering or bathing.Review of the bathing task documentation from 12/20/25 to 03/10/26 revealed Resident #93 received two showers on 02/27/26 and 03/06/26. The resident of the documentation indicated he received multiple bed baths and a few dates the resident was not available. There was no documentation Resident #93 refused showers.Review of the Kardex for Resident #93 revealed bed baths were to be provided when a full bath was not tolerated.Review of progress notes for Resident #93 revealed no documentation indicating the resident refused showers that resulted in the resident receiving a bed bath.Interview with Resident #93's daughter on 03/09/26 at 3:25 P.M. revealed she was concerned the resident was not receiving her showers as scheduled and was only receiving bed baths.Interview on 03/10/26 at 2:08 P.M. with Certified Nursing Assistant (CNA) #184 stated the Kardex for Resident #93 indicated to provide bed baths only if a full shower was refused.Interview on 03/10/26 at 2:39 P.M. with Director of Nursing (DON) revealed she stated CNAs do not have the ability to write progress notes. The DON stated if there was a refusal of care, the CNAs would inform the nurse and the nurse should document the refusal in the electronic medical record. If there was a refusal of specific areas during bathing, it was best practice to inform nursing of any refusal of care. The DON confirmed there were no refusals documented in the electronic medical record regarding showers for Resident #93.Interview on 03/11/26 at 9:19 A.M. with CNA #153 stated Resident #93 preferred showers and the family also preferred showers. CNA #153 stated Resident #93 looked forward to showering but the resident was a Hoyer lift transfer and mainly received bed baths instead of showers due to the transfer with staff.Review of the facility policy titled Dignity (ADL), dated 09/21/23, revealed it was the policy of the facility that each resident would be cared for in a manner that promoted and enhanced his or her sense of well being, level of satisfaction with life, feeling of self worth, and self esteem. The residents would be treated with dignity and respect at all times. The facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs beginning with the initial admission and continuing throughout the resident's stay at the facility. The individual needs and preferences of residents were to be identified through the assessment process and interactions and discussion with staff. Staff were expected to treat residents with dignity and respect while assisting with activities of daily living.Review of the facility policy titled Accommodation of Needs, dated 08/21/23, revealed the facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences would be accommodated to the extent possible and would be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed toward assisting residents in maintaining independence, dignity, and well being to the extent possible and in accordance with the residents' wishes.

Based on observation, record review, resident, family and staff interviews, and policy review, the facility failed to provide a bed and mattress at an appropriate length for Resident #5, the facility failed to ensure Resident #64's hospital bed worked appropriately, and failed to ensure the call light was within reach for Resident #55. This affected three (Residents #5, #55, and #64) of 10 residents reviewed for activities of daily living. The facility census was 121. Findings include:1. Review of the medical record for Resident #64 revealed an admission date of 02/24/26. Diagnoses included fracture of the first and second lumbar vertebra, malignant neoplasm of liver and intrahepatic bile duct. The five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #64 was cognitively intact, required moderate assistance for rolling left and right and sit to lying, and maximum assistance from lying to sitting. Resident #64 experienced frequent pain and shortness of breath when lying flat. Review of the plan of care for Resident #64, initiated 02/24/26, revealed a focus of risk for alteration in skin integrity related to decreased mobility and recent hospitalization following a fall with spinal fusion surgery and laminectomies. Interventions included the use of a pressure redistributing device on the bed, initiated 02/26/26, along with additional care including heel suspension or protection devices and a turning and repositioning program. Interview with Resident #64 on 03/09/26 at 9:28 A.M. stated his bed was too long for the bed frame and he continuously slid down in the bed. Observation and interview on 03/10/26 at 10:44 A.M. revealed the bed was positioned on the frame appropriately. The foot of the bed was angled downward. During this observation, Resident #64 stated the foot of the bed would not raise up. Interview with Resident #64's daughter on 03/10/26 at 10:44 A.M. revealed when the resident initially arrived at the facility, an aide lowered the bed to attempt to fix the angled foot issue of the bed. Resident #64 would sometimes hit the buttons on the bed to lower his feet and he was not sure when he was doing it, and confirmed the angled foot of the bed had been an ongoing concern since his admission. The daughter stated Registered Nurse (RN) #51 initially attempted to fix the bed by completely lowering it and raising it back up. Observation and interview on 03/10/26 at 11:11 A.M. with RN #51 confirmed the foot of Resident #64's bed was not raising to a flat position. During this observation, Resident #64's daughter confirmed with the nurse that this had been an initial concern when the resident first arrived at the facility. Resident #64 stated the bed was not going completely flat and he felt like he was sliding out of the bed and had to pull himself back up to prevent sliding downward. Observation on 03/12/26 at 11:19 A.M. revealed the foot portion of Resident #64's bed was still tilting downward. Maintenance staff had placed a foot board at the bottom of the bed to prevent the resident from sliding further down in the bed. Observation and interview on 03/12/26 at 11:32 A.M. revealed Maintenance Director #28, raised the foot of the bed and it appeared level. Maintenance Director #28 stated he was not aware of any issues with the bed other than the concern reported by Resident #64 today. Review of the facility policy titled Equipment and Assistive Devices dated 10/18/23 revealed device conditions should be maintained according to manufacturers instructions. Defective or worn equipment or devices should be discarded or repaired. 2. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unilateral primary osteoarthritis right hip, type two diabetes mellitus with foot ulcer, pain in right hip, acute osteomyelitis right ankle and foot, peripheral vascular angioplasty status, peripheral vascular disease, pressure ulcer of right heel stage IV, and venous insufficiency (chronic). Resident #5 was 77 inches tall. Observation of Resident #5 on 03/09/26 at 6:50 A.M. revealed Resident #5's mattress was 8.5 inches shorter than the bed frame with the gap between the mattress and the bed frame filled with pillows. Resident #5's heels were resting on the pillows between the mattress and the bed frame. The bottom of Resident #5's feet were resting against a pillow placed against the foot board of the bed. Interview with Resident #5 on 03/9/26 at 6:50 A.M. reported the bed and mattress were too short for him, but a longer bed and mattress have not been provided. Resident #5 reported he was six feet five inches tall, but the bed was made for someone much shorter. Resident #5 revealed the bottom of his feet rest on the foot board so he places a pillow on the foot board to prevent pain from touching. Interview with Assistant Director of Nursing (ADON) #121 on 03/10/26 at 12:11 P.M. revealed Resident #5 has had his current bed frame and mattress since his most recent readmission to the facility on [DATE]. ADON #121 revealed maintenance staff extended the length of the bed and placed pillows in the gap because the mattress was too short to reach the end of the bed frame. ADON #121 confirmed the bed and mattress were too short to accommodate Resident #5's height. Interview with Maintenance #28 on 03/10/26 at 1:12 P.M. revealed Resident #5 requested a longer bed after being readmitted to the facility on [DATE]. Maintenance #28 revealed that a longer bed and mattress were not available from the Durable Medical Equipment (DME) provider. Maintenance #28 installed a bed extender and filled the gap between the foot board and the mattress with pillows. Interview with the Director of Nursing (DON) on 03/10/26 at 3:20 P.M. revealed Resident #5's mattress measured 72 inches and the bed measured 82 inches with the bed extender in place. Interview with the DME Provider #620 on 03/12/26 at 10:19 A.M. revealed longest bed frame was 84 inches and longest air mattress was 84 inches. Review of the policy titled Equipment and Assistive Devices issued 10/18/23 revealed the equipment or assistive device is used according to its intended purpose and to the resident's size and weight. 3. Review of the medical record for Resident #55 revealed an admission date of 03/12/25. Diagnoses included wedge compression fracture of first lumbar vertebra, fall, nondisplaced fracture of distal phalanx of right little finger, abnormalities of gait and mobility, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment, and required moderate assistance from staff for toileting hygiene, showering, and upper and lower body dressing. Review of the care plan for Resident #55 revealed Resident #55 was at risk for falls related to decreased mobility, use of assistive devices, assist of staff, status post recent hospital admit due to a fall and found with closed head trauma without acute intracranial abnormality, acute lumber one fracture non-operative management (NOM) and use of thoraco-lumbo-sacral orthosis (TLSO) (a brace that provides support from mid to the lower portion of the spine. This brace is most commonly used to provide support and stabilization of the spine after a back injury and/or surgery.) with an intervention dated 03/20/25 of call light within reach. Observation on 03/09/26 at 8:29 A.M. revealed in Resident #55's room, the call light was attached to his bed rail and Resident #55 was in the recliner which was one to two feet from the bed. Licensed Practical Nurse (LPN) #16 verified the call light was attached to Resident #55's bed and out of his reach at the time of the observation. Interview on 03/09/26 at 8:29 A.M. with LPN #16 stated Resident #55 knows how to use his call light and usually when Resident #55 needs something, he calls out and staff go and help him. Interview of 03/10/26 at 2:21 P.M. with Certified Nursing Assistant (CNA) #525 stated Resident #55 does use his call light sometimes. Review of the facility policy titled Call Light Accessibility and Timely Response dated 08/16/23 revealed the purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The guidance section of facility policy Call Light Accessibility and Timely Response dated 08/16/23 stated staff will ensure the call light is plugged in, functioning, within reach of residents, and secured, as needed.

Based on observation, resident and staff interview, resident representative interview, medical record review, and policy review, the facility failed to provide a dignified experience when alternate communication methods were not utilized to promote and enhance a resident's quality of life. This affected one (#220) of one residents reviewed for dignity. The census was 111.Findings include:Review of Resident #220's medical record revealed an admission date of 12/29/22 with diagnoses including but not limited to Alzheimer's disease, pancreatitis, type two diabetes mellitus, hypotension, depression, gastro-esophageal reflux disease, and anxiety disorder.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #220 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Resident #220 required moderate assistance with showering, putting on and off footwear, and personal hygiene. Review of Resident #220's care plan dated 08/01/25 revealed Resident #220 was alert and able to make her needs known. Resident #220 spoke Russian and staff were encouraged to use a translation application (app) on their phones to communicate. Additionally, Resident #220's care plan had a focus on communication which revealed Resident #220 had impaired communication as evidenced by a language barrier and had bilateral hearing loss. As Resident #220's dementia progresses, she was speaking Russian more often. Additionally, the goal was Resident #220 would be able to make basic needs known and not be resistant to staff assistance. Furthermore, the interventions for Resident #220 included to assess for the need to use a communication board/book with pictures with Russian language, involve family in translating/communicating as necessary, use simple questions or commands, and ask open-ended questions and give Resident #220 time to respond.Observation on 12/02/25 at 9:15 A.M. revealed no communication board in Resident #220's room.Observation on 12/02/25 at 9:10 A.M. revealed Certified Nurse Aide (CNA) #280 took Resident #220's tray into her room and set it on the bedside tray. CNA #280 was observed to not speak to Resident #220.Observation on 12/02/25 at 9:11 A.M. revealed Resident #220 did not pull out her phone and use the translator app.Observation on 12/0/25 at 9:11 A.M. revealed Unit Manager (UM) #595 speaking loudly from the dining area on unit A and said, She can't hear you, in regard to Resident #220. Interview with UM #595 stated the staff use a translator app on their personal phones to communicate with Resident #220. UM #595 was unable to pull up the app on her phone and called Resident #220's daughter so Resident #220 could communicate.Interview on 12/02/25 at 9:15 A.M. with Resident #220 stated, If my comments are important, then the communication with staff isn't good. Resident #220 stated she had to use hand gestures to try to make her needs known and some of the staff are not very responsive. Additionally, Resident #220 stated, It is hard to communicate specific needs like this morning, my throat was hurting, and my nose was running and I asked for medicine, but they didn't bring it. Resident #220 revealed she was supposed to have medication before her meals, but sometimes they bring it with the meal which causes the medication to not work, and she refuses and they document she refused the medication. Furthermore, Resident #220 stated, If something isn't done right or there is a refusal of services for me, then I get very upset and it causes me a lot of stress. I feel like the communication is a struggle on a daily basis.Interview on 12/02/25 at 9:15 A.M. with Resident #220's daughter stated she had told management and staff several times to use the translator app and communicate with Resident #220, but still communication was a problem. Furthermore, Resident #220's daughter stated the staff were not assisting Resident #220 with care because of communication issues.Interview on 12/02/25 at 9:30 A.M. with Licensed Practical Nurse (LPN) #185 stated Resident #220 spoke a little English. LPN #185 stated the staff use a translator app on the phone and if that does not work, then they call Resident #220's daughter to communicate with Resident #220.Interview on 12/02/25 at 11:18 A.M. with UM #595 stated all the CNAs and nurses have the translator app on their personal phones and use it to communicate with Resident #220. Furthermore, UM #595 stated the translator access number posted in Resident #220's room was for an on-site translator which can take some time getting to the facility which was why she called Resident #220's daughter to translate that morning.Interview on 12/02/25 at 11:27 A.M. with CNA #280 stated she did not have the translator app on her phone and stated she used hand gestures and simple English phrases to communicate with Resident #220.Interview on 12/2/25 at 11:29 A.M. with LPN #185 who stated she did not have the translator app on her phone. Additionally, LPN #185 stated she takes medication to Resident #220 three times a day and stated she only uses the translator app if her simple hand gestures are not effective at communication. Furthermore, LPN #185 verified Resident #220 had medication which should be taken 30 minutes before meals and stated that if the medications are given to Resident #220 with her meals, then Resident #220 refused to take them.Interview on 12/02/25 at 11:58 A.M. with the Administrator stated the staff communicate with Resident #220 through her daughter and Resident #220's daughter comes to the facility whenever they ask her to.Interview on 12/02/25 at 12:57 P.M. with the Director of Nursing (DON) stated Resident #220 uses her own phone and texts on the translator app, then hands the phone to the staff. Additionally, the DON stated the interpreter line in Resident #220's room was only verbally via the phone and since Resident #220 was hard of hearing, then the staff use the translator app or call Resident #220's daughter to translate.Review of the facility policy titled, Communication Barriers, dated 03/10/25, revealed it is the policy of the facility to take reasonable steps to ensure that residents with communication barriers have access and equal opportunity to participate in meaningful conversations about their medical care, services, treatment, and activities in the facility. Additionally, the facility policy revealed the facility will provide communication assistance by utilizing communication aids, which may include but is not limited to a communication boards, dry erase boards, paper and pen or pencil, magnifying glass, large print, braille, assistive technology or translation applications, staff interpreter, and contracted third party interpreters or translators with no cost to the resident being served. Furthermore, the policy revealed family members or friends will not be used as interpreters unless specifically requested by the resident and only after the resident has been offered an interpreter at no charge to them.This deficiency was issued relative to incidental findings that were discovered during the complaint investigation.

Based on medical record review, hospital documentation review, review of an incident report, review of staff training documentation, staff interview, and policy review, the facility failed to ensure residents were administered antibiotic medications and insulin as ordered and within scheduled time frames which resulted in significant medication errors. This affected two (#299 and #45) of six residents reviewed for medication administration. The census was 111.Findings include: 1. Review of the medical record for Resident #299 revealed an admission date of 09/12/25 with diagnoses including pseudomonas as the cause of diseases, gastrointestinal hemorrhage, acute pyelonephritis, and presence of urogenital implants. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #299 was cognitively intact, required setup or clean-up assistance with eating, and was taking an antibiotic and intravenous (IV) medication.Review of a hospital hard script copy dated 09/08/25 and signed by a physician revealed Resident #299 had an order for the antibiotic cefepime four (4) grams intravenous (IV) daily as a continuous 24-hour infusion through 09/18/25.Review of Resident #299's hospital after visit summary dated 09/12/25, for a hospital stay between 09/02/25 and 09/12/25, revealed a medication order to start cefepime 4 grams IV continuous 24-hour infusion through 09/18/25, with the dose to be given every shift.Review of Resident #299's physician order dated 09/12/25 at 11:47 P.M., created by Licensed Practical Nurse (LPN) #720, revealed cefepime hydrogen chloride IV solution reconstituted, two (2) grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of an incident report dated 09/12/25 revealed Resident #299 was ordered continuous IV infusion, but it was entered as twice a day and every shift without directions to run as continuous infusion. Antibiotics were administered each shift instead of continuously. Education was provided to prevent recurrence.Review of Resident #299's physician order dated 09/13/25 revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of Resident #299's medication administration record (MAR) revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day was administered on 09/13/25 at 9:00 A.M. and 9:00 P.M., on 09/14/25 at 9:00 A.M. and 9:00 P.M., and on 09/15/25 at 9:00 A.M.Review of a physician visit document dated 09/14/25 revealed the plan for Resident #299 showed infectious disease was following and recommended continuous IV cefepime. Follow-up with infectious disease was scheduled for 09/16/25 due to a left renal abscess.Review of Resident #299's physician order dated 09/15/25, completed by Unit Manager (UM) #295, revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of the MAR revealed on 09/15/25 at 9:00 P.M. and on 09/16/25 at 9:00 A.M., Resident #299 received 2 doses of the antibiotic scheduled for two times a day.Review of Resident #299's physician order dated 09/16/25 revealed an appointment was scheduled with infectious disease.Review of Resident #299's infectious disease note dated 09/16/25 revealed the resident's daughter reported antibiotics were not being given as a continuous infusion as ordered. The physician contacted the extended care facility and staff were unclear why the antibiotics were entered incorrectly and signed by the physician. The plan revealed the culture was positive for a multiple drug-resistant organism (MDRO) due to pseudomonas. Cefepime was supposed to be a continuous infusion. The discharge prescription was written that way, but the facility incorrectly ordered 2 grams, 2 times per day.Review of Resident #299's progress note dated 09/16/25 at 2:43 P.M. revealed the resident returned from the appointment with new orders.Review of Resident #299's progress note dated 09/16/25 at 7:03 P.M. revealed the Power of Attorney (POA) was in the facility and was made aware that new IV antibiotic orders were in place and the pharmacy would deliver the medication.Review of Resident #299's physician order dated 09/17/25 through 09/26/25 revealed an order for cefepime hydrogen chloride 4 grams IV for a kidney infection until 09/26/25 as a continuous infusion over 24 hours.Review of Resident #299's MAR revealed cefepime hydrogen chloride 4 grams IV for kidney infection until 09/26/25 as a continuous infusion over 24 hours. The first administration was on 09/17/25 at 9:00 A.M. Interview on 12/01/25 at 2:45 P.M. with the Director of Nursing (DON) and the Administrator confirmed a medication error occurred for Resident #299 when the antibiotic (cefepime) was not administered as continuous and was only a short infusion. The error was identified on 09/16/25 after a new order was received from infectious disease. The DON and the Administrator stated education was completed with all licensed nursing staff. The DON confirmed admitting nurses are responsible for entering orders and a second nurse completed a verification.Interview on 12/02/25 at 10:35 A.M. with UM #140 revealed the admitting nurse was responsible for entering physician orders and a second nurse was to verify to make sure the orders were correct.Interview on 12/02/25 at 10:58 A.M. with UM #295 confirmed Resident #299 was in her assigned hallway. UM #295 denied involvement in the incorrect antibiotic order and denied completing the second medication check.Interview on 12/02/25 at 11:10 A.M. with Licensed Practical Nurse (LPN) #720 confirmed she admitted Resident #299 to the facility and remembered calling the physician office to confirm the antibiotic order. LPN #720 stated prior to the telephone call, she was not aware of any medication errors involving Resident #299. LPN #720 denied receiving education following the incident with Resident #299's antibiotic.Interview on 12/02/25 at 1:17 P.M. with Registered Nurse (RN) #830 could not recall specifics about Resident #299's antibiotic order and denied hearing of any errors. RN #830 confirmed she did not receive any education after the incident involving Resident #299's medication error.Review of an education/training sign-in document dated November 2025 for education on the medication error policy revealed the training covered proper entry of medications in the facility electronic medical record system (Point Click Care) for IV and oral medications. Further review revealed LPN #720 and RN #830 were not listed as attending the training.Interview on 12/02/25 at 1:18 P.M. with the DON confirmed both RN #830 and LPN #720 were not listed as attending the education completed for the medication error involving Resident #299.Review of a medication error policy, dated 08/23/23, revealed a medication error was a failure to follow physician orders, manufacturer specifications, or accepted professional standards. When a resident receives a new medication, the order is evaluated to ensure the dose, route, duration, and monitoring align with clinical practice, guidelines, or manufacturer specifications.2. Review of the medical record for Resident #45 revealed an admission date of 09/09/25 with diagnoses including type two diabetes mellitus, hypertension, cardiomegaly, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and chronic kidney disease. Review of an admission MDS assessment dated [DATE] revealed Resident #45 was cognitively intact and received insulin.Review of Resident #45's physician orders revealed an order dated 09/10/25 for the resident to receive insulin lispro per sliding scale subcutaneously before meals for diabetes mellitus. Review of the MAR for November 2025 revealed Resident #45's sliding scale insulin orders were scheduled to be given daily at 7:30 A.M., 11:30 A.M., and 4:30 P.M. Further review revealed the resident received insulin late on 22 occasions during the month. The late administrations occurred on the following dates and times: on 11/01/25, a dose due at 7:30 A.M. was given at 8:54 A.M. On 11/05/25, a dose due at 11:30 A.M. was administered at 1:06 P.M. On 11/06/25, a dose due at 7:30 A.M. was given at 10:35 A.M. On 11/07/25, a dose due at 7:30 A.M. was administered at 8:40 A.M. On 11/08/25, a dose due at 7:30 A.M. was given at 9:20 A.M. On 11/10/25, a dose due at 7:30 A.M. was administered at 10:33 A.M. On 11/12/25, a dose due at 7:30 A.M. was given at 10:28 A.M. On 11/14/25, a dose due at 7:30 A.M. was given at 8:54 A.M. On 11/15/25, a dose due at 7:30 A.M. was given at 8:57 A.M. and another dose due at 4:30 P.M. was administered at 6:23 P.M. On 11/16/25, a dose due at 7:30 A.M. was given at 9:02 A.M. On 11/19/25, a dose due at 7:30 A.M. was administered at 11:27 A.M. On 11/20/25, a dose due at 7:30 A.M. was given at 10:19 A.M. On 11/21/25, a dose due at 7:30 A.M. was given at 8:54 A.M. and another dose due at 4:30 P.M. was administered at 6:24 P.M. On 11/22/25, a dose due at 7:30 A.M. was given at 9:18 A.M. On 11/23/25, a dose due at 7:30 A.M. was given at 9:32 A.M. and another dose due at 11:30 A.M. was administered at 1:19 P.M. On 11/26/25, a dose due at 7:30 A.M. was given at 10:46 A.M. On 11/29/25, a dose due at 7:30 A.M. was administered at 9:29 A.M. On 11/30/25, a dose due at 7:30 A.M. was given at 9:26 A.M.Interview on 12/02/25 at 9:14 A.M. with LPN #25 confirmed the late insulin administrations for Resident #45 noted on the November 2025 MAR as listed above. LPN #25 acknowledged administering some of the doses, but denied giving them late. She stated insulin was a priority medication and was never missed or delayed, and explained they have an hour before and after the scheduled time to give. LPN #25 explained the discrepancies may have been due to delayed documentation, as she previously charted after completing all medication passes rather than in real time. LPN #25 confirmed nursing staff recently received education pertaining to documenting medications in real time. Interview on 12/02/25 at 10:35 A.M. with UM #140 revealed she was not aware of concerns related to late medication administration; however, she confirmed there were timing issues noted on Resident #45's November 2025 MAR. UN #140 stated it appeared to be a documentation issue and nursing staff should be signing off insulin administration in real time, which did not occur for Resident #45 on the above dates and times.Interview on 12/02/25 at 11:35 A.M. with the DON confirmed medications should be documented in real time.Review of the medication administration policy, dated 08/07/23, revealed medications administered are documented following administration. Medications can be administered within a two hour time frame (one hour before to one hour after the time prescribed by the physician). Medications specifically ordered AC (ante cibum; before meals) or PC (post cibum; after meals) must be administered as such or will be considered a medication error.This deficiency represents non-compliance investigated under Master Complaint Number 2639073 and Complaint Number 2620502.

Based on observation, staff interview, and record review the facility failed to ensure that the medication error rate was less than five percent. The facility medication error rate was 6.89 percent (%) based on 29 medication opportunities and two medication errors. This affected one (Resident #56) of three residents reviewed for medication administration. The facility census was 113 residents. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnoses including cerebrovascular disease, hypertension, benign neoplasm of colon, peripheral vascular disease, and type two diabetes mellitus. Review of the physician's orders for Resident #56 revealed an order dated 11/11/24 for Aspirin 81 milligrams (mg.) chewable, give 1 tablet by mouth one time a day and an order dated 02/11/25 for Senna-S 8.6-50 mg., give one tablet by mouth twice daily. Observation of medication administration 02/25/25 at 8:45 A.M. for Resident #56 per Licensed Practical Nurse (LPN) #18 revealed the nurse administered a Senna 8.6 mg tablet and an enteric coated Aspirin tablet 81 mg. crushed in applesauce. Interview on 02/25/25 at 8:58 A.M. with LPN #18 confirmed that Aspirin was ordered in chewable form for Resident #56 and was administered in enteric coated form which was contraindicated to be crushed. LPN #18 further confirmed Resident #56 had an order for Senna-S 8.6-50 mg., but the nurse administered Senna 8.6 mg. which omitted the 50 milligram Docusate dose as ordered by the physician. Interview on 02/25/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed the physician was notified of the medication errors for Resident #56 which included administration of enteric coated Aspirin in a crushed form and administration of Senna 8.6 mg tablet instead of Senna 8.6-50mg tablet. Review of a summary sheet written by the Cleveland Clinic titled Aspirin Enteric-Coated Capsules or Tablets dated 2025 revealed enteric coated Aspirin should be swallowed whole. Patients are advised not to crush, chew, or cut enteric coated Aspirin, because doing so can increase stomach distress. Review of the facility policy titled Medication Administration dated 08/07/23 revealed the facility would safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs. Medications should not be crushed when clinically contraindicated. This deficiency represents noncompliance investigated under Complaint Number OH00162882.

Based on medical record review, resident representative interview, staff interview, hospice staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to investigate allegations of staff to resident physical abuse. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents. Finding Include: Review of the medical record for Resident #77 revealed an admitted [DATE] with diagnoses including moderate dementia with behavioral disturbance, anxiety disorder, acquired absence of kidney, and atherosclerotic heart disease. Review of the (Minimum Data Set) MDS assessment for Resident #77 dated 02/13/25 revealed the resident had severe cognitive impairment. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including Lewy body disease, anxiety disorder, macular degeneration, and depression. Interview on 02/25/25 at 12:23 P.M. with Resident #77's representative confirmed that on 02/11/25 two staff members came in Resident #77's room to provide incontinence care. One staff held Resident #77 down by the wrists, while the other staff flipped Resident #77 back and forth to remove the soiled clothing which caused the resident to scream out in pain. Resident #77's representative confirmed she reported the incident involving Resident #77 during a care conference on 02/19/25 with the Director of Nursing (DON), Unit Manager (UM) #54, and the hospice nurse, Registered Nurse (RN) #178. Resident #77's representative further confirmed she also reported an allegation of staff to resident abuse towards Resident #78 on 02/11/25 in which the representative allegedly witnessed two staff members drag the resident by her arms down the hallway while the resident screamed. Interview on 02/26/25 at 12:44 P.M. with the hospice nurse, RN #178 confirmed Resident #77's representative reported during a care conference on 02/19/25 that recently a staff member had held Resident #77 down by her wrists while another staff member provided incontinence care to Resident #77. RN #178 further confirmed Resident #77's representative also reported during the care conference on 02/19/25 that on 02/11/25 two staff members had dragged Resident #78 down the hallway by the resident's arms. Interview on 02/26/25 at 3:08 P.M. with UM #54 confirmed Resident #77's representative reported during the resident's care conference on 02/19/25 that on 02/11/25 she witnessed one staff member hold Resident #77 down by the wrists while the other staff member flipped Resident #77 back and forth to remove the soiled clothing which caused the resident to scream out in pain. UM #54 confirmed that the DON was present when the incident was reported at the care conference and the incident was not reported to the Administrator. UM #54 further confirmed Resident #77's representative also reported during care conference on 02/19/25 that on 02/11/25 she witnessed two staff members dragging Resident #78 down the hallway by the resident's arms. UM #54 confirmed the DON was present at the care conference and neither of the allegations of abuse reported by Resident #77's representative were investigated. Interview on 02/26/25 at 3:09 P.M. with the DON confirmed the DON was present for a care conference held for SR #77 on 02/19/25, but the DON denied being notified of abuse allegations regarding Residents #77 and #78 and confirmed the facility had not investigated allegations of staff to resident abuse towards Residents #77 and #78 Review of the SRIs dated 02/19/25 through 02/26/25 revealed there were no SRIs initiated related to Resident #77's representative allegation of physical staff to resident abuse towards Resident #77 and no SRIs or investigation initiated regarding Resident #77's representative's allegation of staff to resident abuse towards Resident #78. Review of the facility policy titled Abuse dated 05/24/23 revealed the facility would investigate allegations of abuse and take the necessary actions as a result of the investigation. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm during and after the investigation, including the immediate removal of the resident from contact with the alleged abuser. This deficiency represents noncompliance investigated under Complaint Number OH00162859 and Complaint Number OH00162858.

Based on medical record review, staff interview, family interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported to Ohio Department of Health (ODH) in a timely manner. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents. Findings include: 1. Review of the medical record for Resident #77 revealed an admitted [DATE] with diagnoses including moderate dementia with behavioral disturbance, anxiety disorder, acquired absence of kidney, and atherosclerotic heart disease. Review of the (Minimum Data Set) MDS assessment for Resident #77 dated 02/13/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #77 dated 01/29/25 timed at 7:23 P.M. per by Licensed Practical Nurse (LPN) #101 revealed the nurse heard a scream from a resident's room and upon arrival found an altercation had taken place between Resident #77 and Resident #78 with both residents sustaining bruises and scratches as a result of the altercation. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including Lewy body disease, anxiety disorder, macular degeneration, and depression. Review of a progress note for Resident #78 dated 01/29/25 timed at 7:23 P.M. per LPN #101 revealed that the nurse heard a scream in a resident's room, and upon arrival found an altercation had taken place between Resident #77 and Resident #78 with both residents sustaining bruising and a scratches as a result of the altercation. Interview on 02/24/25 at 11:29 A.M. with LPN #101 confirmed Resident #77 got into a fight with Resident #78 in Resident #78's room at the end of the shift on 01/29/25. LPN #101 confirmed Resident #78 was found on the floor with a black eye to the right face and some scratches, and Resident #77 had facial bruising and a scratch, and was found sitting on the bed. LPN #101 confirmed she reported the incident to the oncoming nurse who was supposed to report it to the Administrator. LPN #101 confirmed she did not report the potential resident-to-resident physical abuse to the Administrator. Review of the Self-Reported Incident (SRI) dated 01/30/25 timed at 12:31 P.M. revealed the facility initiated an investigation of physical abuse between Residents #77 and #78. Further review revealed the facility did not initiate the SRI involving potential resident- to-resident abuse until approximately five hours after the incident occurred. Resident #77 sustained a scratch to her left jaw and bruising to her left forearm and bruising under her left eye and Resident #78 sustained a hematoma to her left temple as result of the resident-to-resident altercation. 2. Interview on 02/25/25 at 12:23 P.M. with Resident #77's representative confirmed that on 02/11/25 two staff members came in Resident #77's room to provide incontinence care. One staff held Resident #77 down by the wrists, while the other staff flipped Resident #77 back and forth to remove the soiled clothing which caused the resident to scream out in pain. Resident #77's representative confirmed she reported the incident involving Resident #77 during a care conference on 02/19/25 with the Director of Nursing (DON), Unit Manager (UM) #54, and the hospice nurse, Registered Nurse (RN) #178. Resident #77's representative further confirmed she also reported an allegation of staff to resident abuse towards Resident #78 on 02/11/25 in which the representative allegedly witnessed two staff members drag the resident by her arms down the hallway while the resident screamed. Interview on 02/26/25 at 12:44 P.M. with the hospice nurse, RN #178 confirmed Resident #77's representative reported during a care conference on 02/19/25 that recently a staff member had held Resident #77 down by her wrists while another staff member provided incontinence care to Resident #77. RN #178 further confirmed Resident #77's representative also reported during the care conference on 02/19/25 that on 02/11/25 two staff members had dragged Resident #78 down the hallway by the resident's arms. Interview on 02/26/25 at 3:08 P.M. with UM #54 confirmed Resident #77's representative reported during the resident's care conference on 02/19/25 that on 02/11/25 she witnessed one staff member hold Resident #77 down by the wrists while the other staff member flipped Resident #77 back and forth to remove the soiled clothing which caused the resident to scream out in pain. UM #54 confirmed that the DON was present when the incident was reported at the care conference and the incident was not reported to the Administrator. UM #54 further confirmed Resident #77's representative also reported during care conference on 02/19/25 that on 02/11/25 she witnessed two staff members dragging Resident #78 down the hallway by the resident's arms. UM #54 confirmed the DON was present at the care conference and neither of the allegations of abuse reported by Resident #77's representative were investigated. Interview on 02/26/25 at 3:09 P.M. with the DON confirmed the DON was present for a care conference held for SR #77 on 02/19/25, but the DON denied being notified of abuse allegations regarding Residents #77 and #78 and confirmed the facility had not investigated allegations of staff to resident abuse towards Residents #77 and #78 Review of the SRIs dated 02/19/25 through 02/26/25 revealed there were no SRIs initiated related to Resident #77's representative allegation of physical staff to resident abuse towards Resident #77 and no SRIs or investigation initiated regarding Resident #77's representative's allegation of staff to resident abuse towards Resident #78. Review of the SRIs dated 02/19/25 through 02/26/25 revealed there were no SRIs initiated related to Resident #77's representative allegation of physical staff to resident abuse towards Residents #77 and #78. Review of the facility policy titled Abuse dated 05/24/23 revealed abuse included willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The facility should educate staff on identifying abuse and possible indicators of abuse. All allegations of abuse must be immediately reported to the facility administration. The facility would report any allegations of abuse to the state survey agency in accordance with state law. This deficiency represents noncompliance investigated under Complaint Number OH00162859 and Complaint Number OH00162858.

Based on staff interviews and review of daily staffing postings the facility failed to identify a licensed charge nurse in the facility for all tours of duty. Findings include: Review of the daily staffing postings for June 2024 and July 2024 revealed there is no designated charge nurse for the 7:00 A.M. - 7:00 P. M. shift on weekends (Saturday and Sunday) or any observed holidays (i.e. Memorial Day and the 4th of July). The sheets simply say see on call list at front desk. Interview on 07/11/24 at 7:20 A.M. with the Director of Nursing (DON) confirmed the nightshift supervisor is the charge nurse from 7:00 P.M. to 7:00 A.M. The DON confirmed the day shift charge nurse Monday through Friday is the unit manager. The DON stated on weekends and holidays the on-call manager is the day shift charge nurse and is available by phone. There is always a manager on duty scheduled and always a nurse on-call. The posting at the nurse's stations and front desk always lets them know who to call. Interview on 07/11/24 at 10:05 A.M. with state tested nursing assistant (STNA) #133 revealed if there was a concern that the nurse on the unit was not addressing resident concerns raised by STNA #133 she would simply call or text the unit manager. When asked if she knew who the charge nurse was or how to reach the charge nurse with concerns, STNA #133 indicated there is a list of who is on-call at the desk, but she would still simply text or call the unit manager with concerns. Interview on 07/11/24 at 10:30 A.M. with the DON revealed there is no job description for a charge nurse. The DON indicated all nurses are in charge of their units so any nurse can be considered a charge nurse.

Based on medical record review, observation, staff, resident and family interview, review of the drug control sheet, and policy and procedure review, the facility failed to ensure pain was addressed, treated, and monitored appropriately after reports of pain for Residents #28 and #44, and failed to ensure pain medication was available and administered as ordered for Residents #18 and #25. Actual Harm occurred when Resident #28 experienced pain during incontinence care rated on a numeric pain scale as a nine out of 10 (zero being no pain and 10 being the worst pain), the State tested Nurse Assistant (STNA) continued to provide the care without addressing or reporting the pain. Actual Harm also occurred when Resident #44 experience pain rated on a numeric pain scale as an eight out of 10, and upon follow-up the resident continued to complain of eight out of 10 pain and no new pain interventions were completed until approximately four hours after the pain follow-up. This affected four residents (#18, #25, #28, and #44) out of four residents reviewed for pain management. The census was 84. Findings Include: 1. Review of the medical record for Resident #44 revealed an admitted [DATE] and 11/23/22 with diagnoses of malignant neoplasm of the bladder, diabetes type two, liver cirrhosis, muscle weakness, need for assistance with personal care, hydronephrosis with renal and urethral calculous obstruction, pain in left hip, metabolic encephalopathy, and chronic kidney disease stage four. Review of the five day minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and he required extensive one staff assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. It documented he had a surgical wound. Review of the care plan dated 12/29/22 revealed Resident #44 was at risk for pain related to chronic pain, pain evaluations, malignant neoplasm of the bladder, diabetes, and liver cirrhosis with interventions to attempt to eliminate and/or reduce causative factors of pain, administer pain medication as ordered and monitor effectiveness, and observe for non-verbal pain. Prior to 12/19/22, there was no pain specific care plan for Resident #44. Review of Resident #44's pain assessment dated [DATE] revealed he has frequent pain daily at an intensity of 7/10, he can complain of pain vocally, and the resident had as needed pain medication ordered. Review of Resident #44's physician orders for December 2022 revealed orders for Oxycodone five mg with instructions to give 15 mg every four hours as needed for pain (initiated 12/16/22). Review of the Medication Administration Record (MAR) revealed on 12/21/22 at 10:01 A.M. the Oxycodone was administered for a pain rating of eight out of 10. Upon reassessment, the medication was ineffective and at 4:22 P.M. the Oxycodone was administered again for a pain rating eight out of 10. Upon reassessment, the medication was effective. Review of the nurses notes dated 12/21/22 at 10:01 A.M. revealed Resident #44 was in eight out of 10 pain to his left hip so Oxycodone 15 mg was administered. at 12:34 P.M. the residents pain was reassessed and it was documented that the pain medication was ineffective and he was still at an eight out of 10 on the pain scale. At 4:22 P.M. the Oxycodone 15 mg was administered again for eight out of 10 pain to his left hip. At 6:10 P.M. the residents pain was reassessed and it was documented the resident also received an ice pack and the interventions were effective. Interview on 12/21/22 at 4:08 P.M. with Licensed Practical Nurse (LPN) #140 stated Resident #44 had his left hip replaced before he arrived at the facility and he had previously fallen on it and it causes him a lot of pain. She also stated they have completed X-Rays on the hip and there is nothing that is compromised. They try repositioning which is normally effective. LPN #140 revealed she reassessed Resident #44's pain in the early afternoon, after his first dose of the Oxycodone, and he was still experiencing an eight out of 10 pain to his left hip. She stated she notified the physician and they ordered lab work. She stated she offered him Tylenol but he refused it and there were no further pain relieving interventions completed. The LPN #140 stated Resident #44 was able to have another as needed Oxycodone at 2:00 P.M., but she was busy and never administered it. She stated she would go administer it right now if he was still in pain. Observation and interview on 12/21/22 at 4:15 P.M. with Resident #44 revealed he was in eight out of 10 pain for his left hip, he stated the pain is constant and a thumping pain and it hurts so bad at times that he gets tearful. He stated after pain pills the pain does normally mellow out but he felt an ice pack would help. The resident was lying in bed and would readjust himself often, during readjustments his face would grimace. Review of the facility policy and procedure titled Pain Management Program Policy, dated 11/12/14 revealed its the facilities policy to manage and recognize residents pain in order to assist residents to attain and/or maintain their highest practicable level of well-being and to prevent or manage pain, to the extent possible. 42728 2. Medical record review revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, shortness of breath, chronic kidney disease, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition and required extensive assistance from two staff members for bed mobility, transfers, and toilet use. Review of the active care plans for Resident #28 revealed no care plans addressed actual or potential pain. Review of the active physician order dated 11/21/22 revealed an order to monitor pain level every shift for pain management. Further review of the active physician orders revealed no medication ordered to treat pain. Review of the Treatment Administration Record (TAR) for 11/21/22 through 12/27/22 revealed the resident pain level was documented as zero every shift, indicating the resident had no pain. Review of the nurses progress notes dated from 12/20/22 through 12/27/22 revealed no documentation of Resident #28 experiencing pain or notification to the physician or hospice staff of pain being experienced by the resident. Observation on 12/21/22 at 10:55 A.M. revealed State tested Nursing Assistant (STNA) #226 was providing incontinence care to Resident #28. The residents groin, inner thighs, peri-area, and buttocks were observed severely excoriated and deep red in color. While cleansing the residents peri-area and groin, the resident began yelling That hurts while grimacing and tensing up. Resident #28 asked STNA #226 why it was hurting and STNA #226 told Resident #28 it always hurt like this when we cleaned you because you are raw. STNA #226 then proceeded to clean the remainder of the residents groin, inner thighs, peri-area, and buttocks while the resident continued to grimace and voice complaints of pain which the resident verbally rated as a nine out of 10 pain rating. Interview with the LPN #222 on 12/21/22 at 2:10 P.M., revealed there had been no reports from staff of Resident #28 experiencing pain during the shift. LPN #222 stated the resident usually responded well to the administration of Tylenol for pain, then verified the resident had no active orders for Tylenol to be administered for pain. Telephone interview with the Hospice Registered Nurse (HRN) #700 on 12/21/22 at 2:45 P.M., revealed she had believed Resident #28 had Tylenol ordered every six hours as needed for pain and would follow up with the facility. 43064 3. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, unspecified mood disorder, pain in right wrist, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the physician's orders for Resident #25 revealed an order dated 12/13/22 for Lidocaine Patch five percent applied to the lower back topically one time a day for pain and removed per the schedule. Additional orders dated 12/07/22 for Tramadol HCL 50 milligrams (mg) one tablet by mouth every eight hours for pain and orders dated 11/29/22 for Tramadol HCL 50 mg one tablet by mouth every six hours as needed for pain. Review of Resident #25's progress note dated 12/08/22 revealed Lidocaine Patch five percent was on order. Review of Resident #25's progress notes dated 12/13/22, 12/18/22, 12/19/22 revealed Lidocaine Patch five percent was indicated as having an order administration note, however nothing was indicated. Review of Resident #25's progress note dated 12/12/22 at 3:13 P.M. revealed Tramadol HCL tablet 50 mg was not available, and a script was called to hospice. Review of Resident #25's progress note dated 12/13/22 at 6:05 A.M. revealed the Tramadol HCL tablet 50 mg was not available and they were waiting on the pharmacy medication drop, the 10:18 A.M. progress note revealed no order administration notes for Tramadol, and the 4:10 P.M. progress note revealed Tramadol was not available, a new script was sent and awaiting authorization. Review of Resident #25's progress notes dated 12/14/22 at 4:53 A.M. and 12/15/22 at 8:10 A.M. and 3:24 P.M. revealed Tramadol HCL Tablet 50 mg was not available. Review of Resident #25's progress note dated 12/16/22 at 6:47 A.M. revealed hospice was contacted about getting a new script for Tramadol 50 mg. Review of Resident #25's progress note dated 12/16/22 at 10:51 A.M. and 3:20 P.M. and 12/17/22 at 12:46 A.M. and 9:05 A.M. revealed Tramadol HCL Tablet 50 mg was on order. Review of Resident #25's Medication Administration Record (MAR) for December 2022 revealed the Lidocaine Patch five percent was not administered on 12/08/22, 12/13/22, 12/18/22 and 12/19/22 and the MAR indicated there were order administration notes. Review of Resident #25's Medication Administration Record (MAR) for December 2022 revealed for Tramadol HCL Tablet 50 mg every eight hours on 12/12/22, 12/15/22, and 12/16/22 at 12:00 A.M. and on 12/14/22 at 8:00 A.M. and 4:00 P.M. there was no administration documentation. Additionally, on 12/12/22 at 4:00 P.M., on 12/13/22 at all administration times, on 12/14/22 at 12:00 A.M., on 12/15/22 at 8:00 A.M. and 4:00 P.M., and on 12/17/22 at 12:00 A.M. and 8:00 A.M. Tramadol was not administered, and the MAR indicated there were order administration notes. On 12/16/22 at 8:00 A.M. and 4:00 P.M. the MAR indicated the medication was on hold and to see nurse's notes. Review of the controlled substance record for Tramadol HCL tablet 50 mg revealed Resident #25 was out of Tramadol beginning on her 4:00 P.M. dose on 12/12/22 until her 4:00 P.M. dose on 12/17/22. Additional review revealed Resident #25 was not given her 12/20/22 4:00 P.M. dose of Tramadol despite it being indicated on the MAR. Interview on 12/21/22 at 2:21 P.M., and 4:29 P.M., and on 12/27/22 at 10:50 A.M., with the Director of Nursing (DON) revealed the Lidocaine patches were on back order, she did not know why the order was not placed on hold. The DON verified Resident #25 was out of Tramadol from her 12/12/22 to 12/17/22, she believed there was a problem with how hospice wrote the script, she additionally said Tramadol was not administered as ordered on 12/19/22. The DON verified there was no documentation to indicate the physician was aware Resident #25 was out of either pain medications. 33023 4. Medical record review revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of laryngeal cartilage, chronic pain syndrome, pulmonary embolism, acute embolism and thrombosis, and alcohol abuse. Review of the quarterly MDS assessment dated [DATE] revealed Resident #18 was was alert to name only and unable to make his needs known. Review of current physician orders revealed Resident #18 was ordered Buprenorphrine patch 20 micrograms (mcg) per hour transdermal once a week for cancer related pain. The Medication was due on 12/10/22 per the Medication Administration Records, however, the medication was not available to apply on 12/10/22 date as it had not been received from the pharmacy. Review of the Controlled Drug Receipt revealed the medication was dispensed and delivered on 12/11/22. The patch was not applied until 12/14/22 per LPN #162, which was reflected on the nursing note on the same date. Review of the Nursing note from 12/14/22 revealed LPN #162 documented the pain patch placed today on the left upper arm due to it not being placed on Monday 12/12/22 when it was received from the Pharmacy. Interview with the LPN #162 on 12/20/22 at 10:55 A.M., verified that the patch was not placed after it was received from the pharmacy on 12/11/22. She verified she was off work when the patch came in, and when she returned on 12/14/22, she noticed it had not been administered while she was off work. Then verified she had placed the patch on Resident #18, and signed it off on the Controlled Medication Report. This deficiency represent non-compliance found in Complaint Number OH00135966.

Based on medical record review, observation, staff and family interview, review of electronic communication, review of the fall investigations, review of the incident log, review of the education sheet, review of the hospital records, and policy review, the facility failed to ensure fall interventions were in place to prevent falls. This resulted in Actual Harm for Resident #76 when he had a fall, was sent to the hospital and suffered an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the fourth proximal phalanx base (ring finger) as well as an age indeterminate fracture of the fifth metacarpal base (small finger) and a laceration to the head requiring a suture. In addition, the facility failed to ensure fall interventions were implemented, fall investigations were thorough, and the fall root cause analysis was identified. This affected six residents (#05, #25, #38, #44, #62, and #76) out seven residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment. The resident required the extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Resident #76 had one fall with injury. Review of the plan of care dated 11/07/22 and 12/07/22 revealed Resident #76 was at risk for falls and had a safety awareness deficit related to a history of falls. Fall interventions were added as follows: on 09/04/22 send to the emergency room , on 09/10/22 offer snacks or beverages between meals, on 09/15/22 use gripper socks, on 09/16/22 dycem in the wheelchair, on 09/23/22 dycem on the top and the bottom of the cushion in the wheelchair, on 10/04/22 encourage nonskid shoes, on 10/30/22 one-to-one observation and send to the emergency room , on 11/02/22 therapy and physician evaluation, on 11/05/22 one-to-one observation, send to emergency room , scheduled toileting, hipsters, bed in the lowest position, a fall mat, 15-minute checks, and a medication review, on 11/16/22 assisting to the recliner following dinner, on 11/18/22 dycem to the recliner, on 11/22/22 place the resident in the recliner when out of the bed and out of the room with dycem, on 12/03/22 a Velcro cushion to the chair, and a physical therapy evaluation, and on 12/06/22 staff education on safety precautions. Additional interventions included anticipating and meeting needs and evaluate for unsteady gait. Review of Resident #76's physician's orders revealed an order dated 08/20/22 for non-skid footwear when out of bed. An order dated 09/23/22 for dycem to the top and the bottom of the wheelchair cushion when in use. An order dated 11/07/22 for non-skid footwear or grippy socks, offer snacks and beverages between meals, to toilet before and after meals, upon rising, at bedtime, and twice at night, for hipsters on at all times except when doing care, the bed next to the wall, and for a fall mat to the left side of the bed. An order dated 12/03/22 revealed an order for a sheet of dycem to be applied under and over the cushion to prevent sliding. Review of the progress note dated 09/04/22 at 12:26 P.M. revealed Resident #76 was found on the bathroom floor lying on his right arm. Blood was noted on the floor next to his head and his third finger on his right hand was swollen and painful to the touch. Resident #76 was sent to the hospital for evaluation. Review of the fall investigation dated 09/04/22 revealed Resident #76 was found on the bathroom floor with only his socks on. He was not able to state how he had fallen; injuries were noted, and Resident #76 was sent to the hospital. Predisposing factors were that the bathroom recess was slippery and footwear. Review of the emergency room documentation dated 09/04/22 revealed Resident #76 had a laceration of the scalp and a closed fracture of his right hand. The radiographic imaging of his right hand during the visit revealed an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the 4th proximal phalanx base as well as an age indeterminate fracture of the fifth metacarpal base. Resident #76 received one suture to his head laceration. Interview on 12/18/22 at 4:54 P.M. with Resident #76's family revealed he was supposed to have dycem in his wheelchair to prevent falls, but it was not always present. Observation on 12/19/22 from 10:37 A.M. to 12:49 P.M. revealed Resident #76 was in his wheelchair. At 12:49 P.M. State tested Nursing Aide (STNA) #187 assisted Resident #76 to a standing position revealing a pressure reducing cushion in his chair. There was dycem above the cushion, however, there was no dycem present under the cushion. STNA #187 confirmed this observation and reported she thought another resident had the dycem. Interview on 12/20/22 at 10:34 A.M., with STNA #187 revealed Resident #76 required assistance with dressing and undressing including footwear. STNA #187 reported Resident #76 was unable to identify the next step in dressing and undressing. Interview on 12/20/22 at 11:13 A.M., with the Director of Nursing (DON) verified Resident #76 had an intervention of non-skid footwear prior to his 09/04/22 fall that was not in place. Review of the progress note dated 09/15/22 at 10:32 A.M. revealed the nurse was informed by the laundry personnel Resident #76 was on the floor. The resident was found in his room on the floor in front of his wheelchair. Resident #76 did not have on shoes and was wearing only socks. Review of the fall investigation dated 09/15/22 revealed immediate action taken included an assessment revealed a small skin tear to his left elbow, no other concerns were noted. Predisposing factors were identified as improper footwear, gait imbalance, ambulation without assistance, lack of safety awareness, and recent falls. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified Resident #76 had a previous intervention of non-skid footwear which was not in place at the time of his 09/15/22 fall. Review of the progress note dated 10/04/22 at 11:30 A.M. revealed Resident #76 was in his wheelchair in the hallway, he went to stand and fell landing on his left side. He was assessed with no concerns and reported he was bored. Therapy was to evaluate the resident for seating and his shoes were assessed. Resident #76 was noted to have slippers on and not shoes with traction. Review of the fall investigation dated 10/04/22 indicated predisposing factors as poor lighting, improper footwear, impaired memory, gait imbalance, easy agitation, lack of safety awareness, recent falls, poor judgement, and ambulating without assistance. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified Resident #76 had a previous intervention of non-skid footwear which was not in place at the time of his 10/04/22 fall. Review of the progress note dated 10/30/22 at 2:49 P.M. revealed Resident #76 fell in the common area and hit his head, the resident was noted with a cut to his forehead and abrasion to the right upper corner of his top lip. Resident #76 was sent to the hospital. Review of the fall investigation dated 10/30/22 revealed Resident #76 was found on the floor after a loud noise was heard. Resident #76 was last seen in the dining room eating lunch. He was noted with injuries to his face. Predisposing factors included confusion, forgetfulness, gait disturbance, and a history of falls. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified the situation surrounding Resident #76's 10/30/22 fall was not clearly identified or illustrated in the fall investigation, additionally, it was unclear if fall interventions were in place at the time of his fall. The DON was unable to provide additional information regarding the fall. Review of the progress note dated 11/22/22 revealed Resident #76 slid out of his wheelchair at 1:40 A.M. with no injuries. There was no documentation that dycem in his wheelchair was in place. Review of the progress note dated 12/03/22 at 5:00 A.M. revealed Resident #76 was sitting on the floor with the wheelchair behind him. He was assessed with no concerns noted and returned to his wheelchair, dycem to his wheelchair was recommended. Review of the fall investigation dated 12/03/22 revealed dycem to the wheelchair was recommended as well as Velcro to the cushion. Predisposing factors included impaired memory, gait imbalance, incontinence, recent falls, and an overestimation of ability. Neurological checks were initiated A follow-up interview on 12/20/22 at 11:13 A.M., and at 2:22 P.M., with the DON verified dycem should have been in place according to the 09/23/22 physician's order. The DON was unable to find completed neurological checks for the 12/03/22 fall. Review of the progress note dated 12/06/22 at 7:26 P.M. revealed Resident #76 was observed in a neighbor's bathroom on the floor with his wheelchair near the bed while his head faced the toilet. No injuries were noted, and the immediate intervention was staff education on safety precautions. Review of the fall investigation dated 12/06/22 revealed Resident #76 was assessed, and staff were educated. Predisposing factors included confusion, recent falls, ambulating without assistance, and overestimation of ability. A follow-up interview on 12/28/22 at 1:12 P.M., with the DON revealed staff were educated on the 12/06/22 fall because he was in his wheelchair and should have been in the recliner, which was a previous fall intervention. Review of the education sheet dated 12/06/22 revealed two staff were educated on safety precautions related to resident falls. Electronic communication on 12/29/22 at 12:14 P.M., with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individual's needs. 2. Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including Parkinson's disease, unspecified convulsions, dysphagia, liver disease, hypertension, protein-calorie malnutrition, depression, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had severely impaired cognition. The resident required the extensive assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the plan of care dated 12/13/22 revealed Resident #38 was at risk for falls related to history of falls. Fall interventions were added as follows: on 10/05/22 a room evaluation with a wider path made to ensure safety, on 11/01/22 the emergency room , on 11/02/22 was a Spanish visual aide, on 11/14/22 the bed in the lowest position, on 11/18/22 ensuring non-skid footwear when out of bed, on 11/26/22 offer snacks between meals, on 11/28/22 offering morning showers was unsuccessful and changed to 15-minute checks for two days, on 12/10/22 one hour checks for 72 hours, on 12/11/22 dycem above and below the cushion in the wheelchair. Additional interventions included anticipating meeting resident needs, call light in reach, and provide safe environment. Review of Resident #38's physician's orders revealed an order dated 07/02/22 for nonskid footwear when out of bed, an order dated 11/14/22 for the bed in the lowest position, and an order dated 11/18/22 for nonskid footwear when out of the bed. Review of the progress note dated 11/18/22 at 1:30 P.M. revealed Resident #38 was found on the bedroom floor next to the door. Her slippers were half on and half off her feet and her walker was in close range. The resident stated the floor was slippery. A new order to use nonslip socks when out of bed and check placement was added. Review of the fall investigation dated 11/18/22 revealed the predisposing factors were listed as footwear, impaired memory, confusion, gait imbalance, and recent falls. Interview on 12/21/22 at 11:50 A.M., with the DON verified Resident #38 did not have nonskid footwear in place and this was an intervention initiated prior to the fall. Review of the progress note dated 11/26/22 at 4:19 P.M. revealed Resident #38 had just finished eating lunch and was asked to go to the living room with the other residents. Resident #38 refused and began hitting the nurse who stepped away to give her space. The aide spotted the resident wandering around the kitchen area and asked the resident to come with her and the resident refused hitting her as well. The aide proceeded to help another resident to the bathroom, when both staff heard a loud boom. The staff ran to the dining area and noticed the resident laying on the floor next to a chair by the kitchen window. Resident #38 reported she was standing on the chair and fell . Review of the fall investigation dated 11/26/22 revealed the fall investigation additionally reported an injury to the back of the head. Predisposing factors included forgetfulness, gait imbalance, recent falls, ambulating without assistance, and wandering. Review of the progress note dated 11/27/22 revealed Resident #38 had a recent fall and was noted to have a bruise to the forehead. A follow-up interview on 12/21/22 at 11:50 A.M., with the DON revealed she would not have left the resident alone, however, she was unwilling to speak on what the staff should have done. The DON noted the discrepancy between the descriptions of the injury related to the 11/26/22 fall. She reported she believed the problem was related to how the program used for fall investigations works. The DON reported she believed the nurse applied ice to a hematoma but had been unable to get a hold of the nurse to clarify. Review of the fall investigation dated 11/28/22 revealed the nurse heard a loud noise when standing by Resident #38's room. The nurse found the resident lying on her back her head resting on wall and her feet facing the shower. She was assessed and assisted to bed. There were no predisposing factors listed. A follow-up interview on 12/21/22 at 11:50 A.M. with the DON revealed she was unable to find additional information regarding whether fall interventions were in place at the time of the fall and additional details surrounding Resident #38's fall. Review of the progress note dated 12/10/22 at 8:40 A.M. revealed Resident #38 was found by the nurse with an open cut on the forehead and side of head, there was blood on her pillow. Resident #38 was drowsy and emergency services were contacted. Review of the fall investigation dated 12/10/22 revealed Resident #38 revealed a fall intervention was put in place for one hour checks. A follow-up interview on 12/20/22 at 4:37 P.M., with the DON verified there was no information in the 12/10/22 progress note and fall investigation indicating Resident #38 fell . Further interview on 12/21/22 at 11:50 A.M. revealed the nurse who worked on 12/10/22 clarified the fall investigation and she would provide it. Review of the fall investigation dated 12/10/22 provided on 12/21/22 at 4:29 P.M. revealed a clarification had been made indicating blood was noted on the resident floor in front of the bathroom door. The Resident had been observed one hour prior by an STNA when she was resting quietly in her bed without injury. Review of the progress note dated 12/11/22 at 7:40 P.M. revealed the aide found Resident #38 on the floor by the wall after hearing a bang. The aide asked the resident to sit after noticing she was unstable and the resident refused. Review of the fall investigation dated 12/11/22 at 7:40 P.M. revealed Resident #38 was found on the floor by the wall after hearing a bang. The aide had asked the resident to sit after noticing she was unstable and the resident refused. The resident was sent to the emergency room for evaluation due to injury to the back of the head. No predisposing factors were indicated. A follow-up interview on 12/20/22 at 4:37 P.M., and 12/21/22 at 11:50 A.M., the DON verified the fall investigation had not explained the details of the fall including where it occurred and if fall interventions were in place at the time of the fall. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individual's needs. 3. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, mood disorder, pain in right wrist, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the plan of care dated 11/28/22 revealed Resident #25 was at risk for falls. Fall interventions were added as follows: on 05/12/22 staff assistance getting into bed, on 05/13/22 send to the emergency room , on 09/13/22 encourage use of the walker, on 09/18/22 send to the emergency room , on 11/25/22 send to the emergency room and dycem in the wheelchair, and on 11/26/22 change the wheelchair seat. Additional interventions included anticipating and meeting resident needs, assisting with toilet needs, bed in the lowest position, ensuring appropriate footwear, and reviewing past falls to attempt to determine cause. Review of the progress note dated 11/23/22 revealed the nurse was approached by Resident #25's daughter with a concern that she was reporting extreme back pain with movement. The daughter stated she was informed by a staff member that her mother had fallen a few days ago. Review of the medical record revealed no additional information related to a fall prior to 11/23/22. Review of the incident log through August 2022 revealed no incidents for Resident #25 in the days leading up to 11/23/22. Interview on 12/21/22 at 2:21 P.M., with the Director of Nursing (DON) verified there was no documentation related to Resident #25's fall and no fall interventions. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individuals needs. 4. Observation on 12/18/22 at 10:05 A.M., 11:35 A.M., 1:23 P.M. and 2:58 P.M. revealed Resident #05's bed was not in the lowest position. This was verified by STNA #187 on 12/18/22 at 1:23 P.M. who reported she did not know this was an intervention for Resident #05. Review of the medical record for Resident #05 revealed an admitted [DATE] with diagnoses including dementia, repeated falls, anxiety disorder, cognitive communication deficit, and muscle wasting and atrophy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #05 had severely impaired cognition. Review of the plan of care dated 11/14/22 revealed Resident #05 was at risk for falls related to cognitive impairment, confusion, history of repeated falls, poor comprehension, need for assistance, and medication use. Fall interventions were added as follows: on 12/22/21 assistance with transfers, on 11/14/22 bed in the lowest position and two staff for assistance with transfers at all times. Additional interventions included ensuring appropriate footwear, involve responsible party in treatment plan, monitor medication use for side effects, and orient resident to facility and environment. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individuals needs. 38604 5. Review of the medical record for Resident #44 revealed an admitted [DATE] and 11/23/22 with diagnoses including malignant neoplasm of the bladder, diabetes type two, liver cirrhosis, muscle weakness, need for assistance with personal care, unsteadiness on feet, and chronic kidney disease. Review of the five day MDS assessment dated [DATE] revealed Resident #44 had intact cognition and he required extensive one staff assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. Review of Resident #44's care plan dated 10/21/22 revealed the resident was at risk for falls related to deconditioning, requiring assistance with ambulation, required assistance with transfers, total/partial loss of balance while standing, and unsteady gait. Interventions included orthostatic blood pressures for 48 hours on 11/28/22 for possible hypotension, bed in the low position, offer toileting at night and twice through the night, and monitor vital signs as ordered. Review of the fall risk assessments for Resident #44, dated 11/14/22, 11/23/22, and 11/28/22, revealed he was at moderate risk for falls. Review of Resident #44's physician orders for November 2022 revealed order for orthostatic blood pressures of lying, sitting, and standing every shift for two days, initiated on 11/28/22. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2022 revealed only two documented blood pressures, one on 11/29/22 and one on 11/30/22. Review of Resident #44's fall investigations revealed the following: On 11/26/22, the nurse observed the residents call light was on, upon checking on him, the resident was noted kneeling on the floor in front of his chair with no underwear/pants on, he was soiled with feces. Feces was noted on the carpet and in his bathroom on the commode. He stated he had finished going to the bathroom and was trying to put on his underwear when he slipped and fell . The resident stated he crawled on his knees to the chair. A head to toe assessment was completed, a small abrasion was noted to his knees, he complained of pain to knees and legs, range of motion was within normal limits, he denied hitting his head when asked, and he was alert and oriented per his baseline. He was assisted off the floor with three staff assistance to his bed and pericare was provided. As needed pain medication was administered and neurological checks were initiated. A new intervention to offer toileting before bed and twice during the night was initiated. The physician and family were aware. On 11/28/22 the STNA informed the nurse that the resident was down on his knees in his room. The nurse found the resident facing the head of his bed on the left side, trying to use the chair as leverage to get up. The resident was actively trying to get his legs under him so that he had enough strength to pull himself from the floor, using the back of the chair. The resident was unable to do this so the nurse and aide assisted the resident with a gait belt. When the nurse asked the resident what happened, he responded that he was trying to get something off of his bedside table. The resident denied hitting his head or any pain or discomfort. A head to toe skin assessment was completed and noted bilateral abrasions on knees actively bleeding. The bilateral knee abrasions were cleaned and bandages were applied. Neurological checks were initiated and the physician and his family were notified of the fall and abrasions. physician and family notified. Review of the nurses notes dated 11/28/22 at 4:12 P.M. revealed the physician notified the nurse of new orders for orthostatic blood pressures of lying, sitting, and standing every shift for two days. Resident #44 was notified of the new orders. There was no documented evidence of the results of the orthostatic blood pressures in the nurses notes. Interview on 12/20/22 at 12:45 P.M., with the DON verified there were no root cause analysis determinations for the 11/28/22 fall. At 3:50 P.M., the DON verified there was no documentation of what Resident #44's orthostatic blood pressures were. 6. Review of the medical record for Resident #62 revealed an admitted [DATE] and the diagnoses of fractured right femur, severe protein calorie malnutrition, muscle weakness, high blood pressure, malignant neoplasm of right breast, and atrial fibrillation. Review of the Admission MDS assessment dated [DATE] revealed Resident #62 had intact cognition and the resident required extensive two staff assistance for bed mobility, transfers, toilet use and personal hygiene, and supervision for eating. Review of the fall risk assessment for Resident #62 dated 11/07/22 revealed the resident was a high risk for falls. Review of the care plan for Resident #62 dated 10/21/22 revealed the resident was at risk/or potential risk for falls related to history of fall related injury, incontinence, medication use, poor safety awareness, unsteady gait and requires assistance with transfers. Interventions included bed in lowest position when in bed and check the placement every shift. Review of the care plan dated 10/21/22 revealed the resident had an activities of daily living (ADL) self care performance deficit and was at risk for decline in ADL self-performance and associated complications related to impaired balance, limited mobility, limited range of motion, pain, requires assist to perform/complete ADL care, self-performance varies, and weakness with interventions to ensure hands on assistance by staff for bed mobility and transfers. Observation on 12/18/22 at 10:22 A.M. of Resident #62 revealed her bed was elevated and not in the lowest position. Observation and interview on 12/18/22 at 10:48 A.M., with Registered Nurse (RN) #168 verified Resident #62's bed was not in the lowest position, she promptly lowered the bed. Review of the facility policy and procedure titled Accident/Incident-Prevention/Fall Risk, dated 07/31/14 revealed the nursing staff are responsible for assessing a residents fall risk and implementing proactive interventions as well as new interventions should an incident or accident occur.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, observations, staff interviews, review of the facility's documentation of unvaccinated staff members, census, and testing results, review of the facility policies and procedures on contact and droplet/airborne precautions, how to apply N-95 masks, Coronavirus/COVID-19 Preparedness and Response Plan, review of the staff screening for COVID-19 documentation, medical record reviews, and review of an e-mail from the County Public Health Department, and review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker and guidance, the facility failed to implement effective and recommended infection control practices, including a system to ensure all staff and residents were tested for COVID-19 according to CMS guidelines, a system to ensure all staff were self-screening for symptoms of COVID-19 prior to each shift of work, cohorting residents who were positive for COVID-19, and the appropriate use of Personal Protective Equipment (PPE) by staff to prevent the potential spread of COVID-19 within the facility. This resulted in Immediate Jeopardy and potential serious negative health outcomes and/or life-threatening harm when eight residents (Residents #01, #03, #07, #09, #22, #46, #65, and #70) and five staff (Employees #100, #101, #102, #103, and #104) tested positive for COVID-19 without systems in place to ensure all staff and residents were tested according to CMS guidelines and to ensure staff were self-screening for symptoms of COVID-19 prior to working. The facility was also not cohorting the two residents who were positive for COVID-19 away from residents who were negative and were not ensuring staff were using PPE effectively. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 76 residents at potential risk for the likelihood of harm, negative health complications and/or death. The facility census was 76 residents. On 01/06/22 at 3:55 P.M., the Administrator and Director of Nursing (DON)/Infection Control Preventionist (IP) were notified Immediate Jeopardy began on 12/03/21 when the facility failed to have evidence of a system to ensure all staff and residents were tested for COVID-19 according to CMS guidelines, a system to ensure all staff were self-screening for symptoms of COVID-19 prior to each shift of work, cohorting residents who were positive for COVID-19, and the appropriate utilization of PPE by staff. The Immediate Jeopardy was removed on 01/08/21 when the facility implemented the following corrective actions: · On 01/07/22, the DON/IP and Administrator reviewed the facility's policy and procedure on proper usage of PPE, including donning and doffing, and on hand hygiene. No changes were made. · On 01/07/22, the DON/IP and Administrator audited all staff working to ensure masks and PPE were being worn correctly. · On 01/07/22, the DON/IP and Designee began in-servicing all staff on the facility's policy for PPE use, including properly wearing respirator masks (and all masks); proper handwashing; and proper donning and doffing of PPE, particularly upon entering and exiting isolation and quarantine areas. All staff training will be completed by 01/08/22, after which time, staff will not be permitted to work until educated. · Nursing leadership along with designated center department managers will audit staff compliance daily on each shift for compliance with proper PPE procedures, including proper PPE usage/donning/doffing based upon the room/unit's transmission-based precautions status for two weeks and then in accordance with the plan of correction. · On 01/07/22, the Administrator, DON/IP and Corporate Nurse #650 reviewed the current procedure for staff self-screening prior to each shift. The procedure was revised to ensure screening sheets are audited by a nurse manager or department head and placed in the Administrator's office each shift for filing. · On 01/07/22, the Administrator and DON/IP audited all screening forms to ensure that all staff currently working had completed the screening form for COVID-19. · On 01/07/22, the Administrator, DON/IP or designee began in servicing all staff on the facility screening policy, including single point of entry for all staff, how to properly complete screening form, and the need to complete it prior to working. Education of all staff will be completed by 01/08/22, after which time, staff not educated will not be permitted to work until educated. · On 01/07/22, Nurse Managers and Departments Heads were trained by the DON/IP or Administrator on proper auditing of screening forms each shift to ensure all staff in the building have been screened properly before they enter the facility. · On 01/07/22, all COVID-19 positive residents (#01, #03, #07, #09, #22, #46, #65, #70) were cohorted together at the end of unit C. Their doors remain closed with signage and PPE outside of the room. · On 01/07/22, the Administrator and DON/IP or designee began in-servicing all staff on the facility policy for cohorting COVID-19 positive residents, including location of COVID-19 area and protocol for ensuring all COVID-19 positive residents are placed in the area. Education of all staff will be completed prior to their next shift worked. · As of 01/07/22, all 77 residents in the facility had been tested for COVID-19. On 01/09/22, the results of the COVID-19 tests revealed Resident #44 tested positive for COVID-19 and was moved to the COVID-19 unit on 01/09/22. · On 01/07/22, the Administrator conducted an audit of all residents' most recent COVID-19 test results and validated all residents were placed on the correct unit as indicated. · On 01/07/22, the Administrator, DON/IP, and Medical Director #600 reviewed the facility's policy on resident and staff routine and outbreak testing. · On 01/07/22, COVID-19 testing logs were utilized by the DON/IP to include a list of vaccinated staff, unvaccinated staff, date and test results for monitoring who needs testing, whether testing was complete and the results of tests. A roster is being utilized for schedule tracking for vaccinated staff testing and for unvaccinated staff testing. · On 01/07/22, the DON/IP or designee will maintain the COVID-19 testing logs. The DON/IP reviewed the testing log to ensure staff currently working were tested per protocol. · On 01/07/22, an outbreak testing log was utilized by the DON/IP to ensure all exposed residents and staff are being tested in accordance with outbreak testing protocol and the same is documented on the log. · On 01/07/22, the DON/IP reviewed the list of exposed residents to ensure that they were being tested in accordance with outbreak testing protocols. · Starting 01/07/22, the DON/IP will review COVID-19 testing logs weekly to ensure that all staff have tested per requirements. · On 01/07/22, the DON/IP or designee educated eight nurses, 15 State tested Nurse Aides (STNA), and 10 administrative staff on testing schedule and process and to ensure staff do not work unless tested in accordance with the schedule. In-servicing will be completed for staff by 01/08/22. Thereafter, staff will not be permitted to work until they have been educated. · On 01/07/22, Corporate Nurse #650 educated the Administrator and DON/IP on resident and staff testing policy. The Administrator and DON/IP educated all management staff on resident and staff testing policy, to ensure all staff are tested routinely in accordance with the policy. · On 01/07/22, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the DON/IP, Administrator and Medical Director #600 to review the action plan. · Starting on 01/08/22, the Administrator and DON/IP or designee will audit screening forms daily for two weeks and then in accordance with the plan of correction. The Administrator and DON/IP or designee will audit all resident testing results to ensure residents who are COVID-19 positive are cohorted in the COVID-19 isolation area. Audits will be done until current outbreak testing is completed. The Administrator and DON/IP or designee will audit testing results to ensure proper procedures are followed for symptomatic residents and staff, for routine testing and for outbreak investigation, at least two times per week for two weeks and then in accordance with the plan of corrections. The results of all audits and monitoring will be reported to the QAPI Committee weekly. · On 01/10/22, interviews with STNAs #132, #180, and #190, Licensed Practical Nurse (LPN) #185, and Housekeeper #195 revealed they were educated on infection control related to how to don and doff PPE, screening prior to work, COVID-19 testing, and cohorting of residents who are positive for COVID-19. STNA #132, #180, and #190, LPN #185, and Housekeeper #195 were observed wearing their PPE appropriately. No concerns were identified, and staff were knowledgeable regarding the in-service provided by the facility. Although the Immediate Jeopardy was removed on 01/08/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, CMS Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 . We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). 1) Interview with the Director of Nursing on 01/05/22 at 8:30 A.M. revealed the facility had an outbreak of COVID-19 beginning on 12/26/21 that included five staff members and eight residents as follows: On 12/26/21, LPN #100 tested positive; on 12/27/21, STNA #101 and STNA #102 tested positive; on 12/28/21, Resident #01 tested positive; on 01/02/22, Registered Nurse (RN) #103 tested positive; on 01/02/22, Minimum Data Set (MDS) Nurse #104 tested positive; and on 01/03/22, Resident #03 tested positive. On 01/05/21, Residents #09, #22, #46, and #70 tested positive for COVID-19 and on 01/06/21, Residents #07 and #65 tested positive for COVID-19. Review of the facility's list of staff members who were not vaccinated against COVID-19 revealed 27 staff members were not vaccinated which included 14 STNAs (#106, #107, #108, #109, #110, #112, #113, #115, #119, #120, #121, #123, #124, and #126), six LPNs (#111, #114, #117, #118, #128, and #129), one RN (#127), one clinical manager (#122), two dietary aides (#105 and #131), one maintenance supervisor (#116), one cook (#130) and one front desk clerk (#125). Review of the facility's test results revealed the facility provided test results with names of people, no dates, and no results. The names of people did not state if it was a resident or a staff member. There were pages of results, but it did not provide a date nor what resident or staff name the results were for. There was no documentation to show the unvaccinated staff members were being tested routinely per the CMS guidelines. There was no documentation to show that outbreak testing began on 12/26/21 and that all staff and residents were tested per the CMS guidelines. Interview with the Administrator on 01/05/22 at 4:15 P.M. confirmed the facility was in COVID-19 outbreak status due to the positive staff and residents. She stated the facility was testing all staff and residents twice weekly on Tuesday and Friday. However, interviews with the Administrator on 01/05/22 at 4:50 P.M. and on 01/06/22 at 12:00 P.M., revealed the facility had no system in place since 12/03/21 to document and ensure that all staff and residents were being tested per CMS guidelines. Review of the CMS's QSO-20-38-NH-revised Memo, dated 09/10/21, revealed to enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident trigger an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. For level of COVID-19 Community Transmission of high (red), a minimum testing frequency of unvaccinated staff is twice a week. Review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker (https://covid.cdc.gov/covid-data-tracker/#county-view|Ohio| |Risk|community_transmission_level) revealed the COVID-19 Integrated County view, dated on 01/04/22, 12/28/21, 12/20/21, 12/14/21, and 12/07/21, indicated the facility's county community transmission level was color coded red indicating it was at a high level. Review of the facility's policy titled Employee & Resident Testing, last revised on 09/10/21, revealed each nursing home shall require its employees to be tested in accordance with the Ohio Department of Health (ODH) and CMS guidelines. The guidelines included the facility must maintain a complete ongoing list of individual-level employee and resident testing and results must be immediately available in a spreadsheet format. All unvaccinated staff shall be tested at least twice per week. Unvaccinated refers to a person who does not fit the definition of fully vaccinated, including people whose vaccination status is unknown. Regardless of vaccination status, all staff and residents shall be tested upon identification of a single new case of COVID-19 infection in any staff or resident, unless the exposure to COVID-19 was outside of the facility and they did not enter the facility while potentially infectious. Exposed residents and staff should be retested every three to seven days until testing identifies no new cases of COVID-19 for a period of 14 days. The documentation of testing includes the facility must demonstrate compliance with the testing requirements. 2) On 01/05/22, the surveyor requested evidence of screening for COVID-19 prior to working for LPN #118, Cook #130, and Dietary Aide #131 (who were all unvaccinated) since 12/03/21. On 01/05/22 at 4:00 P.M., an interview with Scheduler #132 confirmed LPN #118 had worked at the facility on 12/06/21, 12/09/21, 12/12/21, 12/15/21, 12/16/21, 12/18/21, 12/20/21, 12/23/21, 12/26/21, 12/29/21, 12/30/21, 01/01/22, 01/03/22, and 01/04/22; Cook #130 had worked at the facility on 12/08/21, 12/09/21, 12/10/21, 12/11/21, 12/16/21, 12/17/21, 12/18/21, 12/23/21, 12/24/21, 12/25/21, 12/30/21, 12/31/21, and on 01/01/22; and Dietary Aide #131 had worked at the facility on 12/05/21, 12/06/21, 12/07/21, 12/12/21, 12/13/21, 12/14/21, 12/19/21, 12/20/21, and 12/21/21. Interview with the Administrator on 01/06/22 at 12:00 P.M. verified the facility had no evidence of screening for symptoms of COVID-19 prior to working for LPN #118, Cook #130, or Dietary Aide #131 since 12/03/21. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, dated 09/10/21, revealed the facility should establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so they can be properly managed: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2; 2) symptoms of COVID-19, or; 3) who meets criteria for quarantine or exclusion from work. Review of the facility's Coronavirus/COVID-19 Preparedness and Response Plan, revised 12/16/21, revealed all persons entering the facility shall be screened for signs and symptoms or possible exposure to COVID-19. Screening includes taking the temperature of each person as they arrive at the facility, prior to resident contact, and as they leave the facility. Screening of staff will be at the start and at the end of each shift. 3) Review of the medical record for Resident #01 revealed he was readmitted to the facility 12/31/21. The resident was at the hospital when the positive test results were received on 12/30/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the DON on 01/10/22 at 12:15 P.M. revealed Resident #01 was placed into isolation upon his readmission to the facility on [DATE]. The DON explained the delay in the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #03 revealed he was admitted to the facility 12/13/21. Resident #03 was vaccinated for COVID-19. Review of the nurse's notes on 01/03/22 revealed Resident #03 was given a COVID-19 test which was positive. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 01/05/22 at 9:35 A.M. revealed Resident #03 resided on Unit A. There was a sign on the door indicating the resident was on airborne precautions. Resident #03's room door was open. On 01/05/22 at 10:07 A.M., Resident #03 could be heard coughing in the room. Resident #03 had not been cohorted to a section of the building with residents of similar symptoms/diagnosis. There were residents (#43 and #76) residing in rooms beside Resident #03 on both sides of his room who were not positive for COVID-19 and were not on quarantine protocols. Observations on 01/05/22 at 10:55 A.M. revealed Resident #01 resided on Unit C. There was a sign on the door indicating Resident #01 was on airborne precautions. Resident #01's room door was open, and Resident #01 was in the room. The resident had not been cohorted to a section of the building with residents of similar symptoms/diagnosis. There was a resident (#22) in the room next to his who was not positive for COVID-19 and was not on quarantine protocols. Interview with the Administrator on 01/05/22 at 9:55 A.M. revealed she was aware the facility had residents who were positive for COVID-19, but she did not know who they were or why the facility was not cohorting those residents away from residents who were negative. Interview with the DON on 01/05/22 at 11:40 A.M. revealed she had not spoken to anyone at the Local Health Department (LHD) regarding the resident's positive for COVID-19. She indicated she had been the DON for about six weeks. She stated the previous DON had discussed it with them and was told by the LHD that because the residents were in private rooms, it was ok not to move them away from residents who were negative. She confirmed the residents who were positive for COVID-19 should have their doors closed to prevent respiratory droplets from escaping the room. Review of the facility's e-mail correspondence with the LHD, dated 01/05/22 at 2:45 P.M., revealed the email was from an Infectious Disease Nurse at the County Public Health Department. The e-mail stated she was providing updated COVID-19 facility guidance. In the facility guidance, under Effective Cohorting of Residents, there was information about determining a location of a COVID-19 care unit and physically separating from other rooms. This should be a dedicated floor, unit, or group of rooms at the end of the hall. Review of the facility's census list revealed the facility was noted to have 23 empty rooms. Review of the CDC's guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 09/10/21, revealed under Evaluating and Managing Personnel and Residents, the facility should identify space in the facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection. The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. Review of the facility's Coronavirus/COVID-19 Preparedness and Response Plan, revised 12/16/21, revealed if one or more residents in the facility are diagnosed with COVID-19, follow all directions from the County Public Health Department and the resident ' s physician and if possible, residents with symptoms will be grouped together and staffing assignments will be dedicated to that area. Continue to follow standard, contact, and droplet precautions. Continue these precautions until advised to discontinue by the County Public Health Department. 4. Review of the medical record for Resident #14 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 01/05/22 at 9:22 A.M. revealed STNA #134 exiting Resident #14's room, which had a sign on the door indicating contact precautions. STNA #134 was removing a meal tray from the room. STNA #134 had on an N-95 mask which was below her nose and not covering her nose at all. She was observed to remove her gloves and dispose of them in a container just inside the resident's room. STNA #134 was observed to push a cart with the resident's soiled meal trays down the hall to the unit's servery. STNA #134 was not observed to wash or sanitize her hands after removing the gloves upon exiting Resident #14's room. She also still had her nose exposed above the N-95 mask. Observations on 01/05/22 at 9:45 A.M. revealed STNA #134 was on Unit A with her N-95 mask below her nose and not covering her nose at all. Interview with the DON on 01/05/22 at 12:35 P.M. confirmed Resident #14 was on contact precautions for shingles. She further stated staff were to wash/sanitize their hands after removing gloves and prior to leaving the room of a resident on contact precautions. She further stated staff were to have their noses covered with N-95 masks. Observation on 01/10/22 at 10:05 A.M. revealed the DON was standing at the nursing station on Unit B. The DON was wearing an N-95 mask and both straps to the N-95 mask were around the base of her neck. Continuous observation of the DON revealed she walked from Unit B to Unit C with the N-95 masks straps remaining at the base of her neck. On 01/10/22 at 10:20 A.M., the DON was in a common area talking to the Administrator and Dietary Manager #200 and the DON's N-95 mask straps remained at the base of her neck. Interview with the Administrator on 01/10/22 at 10:22 A.M. verified the DON was improperly wearing her N-95 mask. The Administrator stated the DON educated the staff on how to wear a N-95 mask properly, so the DON knows how to wear one. Interview with the DON on 01/10/22 at 10:25 A.M. verified she was wearing her N-95 mask improperly and knows that one strap needs to go on the crown of her head and the other strap needs to sit at the base of her neck. The DON explained she was wearing a different N-95 mask today because she didn't have time to get another one that properly fits her. She demonstrated when she puts the one strap on her crown of her head, that the strap breaks. The DON verified there were different N-95 masks for the staff to utilize and were available, but the DON preferred to get her own N-95 mask from the supply closet and not from the staff supplies on the units. Review of the CDC guidance on How to Put On (Don) PPE Gear, dated 06/09/20, revealed the respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Both your mouth and nose should be protected. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 09/10/21, revealed in general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals when caring for fully vaccinated individuals moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. Under Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, source control and physical distancing are recommended for everyone in healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Review of the facility's undated instructions for application of an N-95 mask revealed the instructions stated to position the respirator under your chin and the nosepiece on the bridge of your nose. While holding the respirator in position, pull the top headband over your head and rest it at the crown of the back of your head. As you continue to hold the respirator in position, pull the bottom headband over your head and rest it around your upper neck, below your ears. Untwist the straps and optimally position the respirator low on your nose. Using both hands, mold the malleable nosepiece to fit snugly against the nose bridge and face below the eyes. Using a mirror, further check and adjust the edges to provide a good seal around the face. Review of the facility's policy titled Isolation-Categories of Transmission Based Precautions, revised January 2012, revealed Contact Precautions were to be used for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident environment. The policy stated to wear gloves when entering the room. Remove gloves before leaving the room and perform hand hygiene. 5. Interview with STNA #135 on 01/05/22 at 9:56 A.M. revealed Resident #03 was on airborne precautions because he was positive for COVID-19. Observations on 01/05/22 at 10:07 A.M. revealed STNA #135 to apply a gown and gloves. She was already wearing an N-95 mask and face shield. She then entered Resident #03's room to provide care. Resident #03 could be heard coughing during the provision of care. On 01/05/22 at 10:37 A.M., STNA #135 exited Resident #03's room. She had already removed her gown and gloves. She still had on the N-95 mask and face shield. She then, without changing her N-95 mask, cleaning her face shield, or washing her hands, proceeded down the hall to the soiled utility room. After exiting the soiled utility room, she went to a bathroom located behind the nurse's station. She left the door open and was then observed to wash her hands. She was observed to cleanse her face shield while in the bathroom. She confirmed at that time, she did not change her N-95 mask after providing care to Resident #03. She stated this as she was preparing to enter Resident #08's room, who was not positive for COVID-19. Interview with the DON on 01/05/22 at 12:35 P.M. confirmed all staff were to follow the procedures for contact and droplet/airborne precautions provided and should change their N-95 mask after providing care for a resident positive with COVID-19. Review of the sign posted on Resident #03's door revealed the procedure for all staff regarding contact and droplet/airborne precautions revealed when leaving a resident room, staff are to remove gloves and dispose of, perform hand hygiene, remove gown and dispose, perform hand hygiene, remove eye protection, perform hand hygiene after cleaning reusable eye protection, remove mask and dispose of, and perform hand hygiene. This deficiency substantiates Complaint Number OH 475. This is an example of continued non-compliance from the survey dated 12/03/21.

Based on observation, medical record review, staff interviews and policy review, the facility failed to ensure Resident #01 received adequate supervision and assistance with bathing to prevent the resident from falling. This resulted in actual harm to Resident #01 when she fell off the bench and on to the floor in the bathroom after a shower sustaining a fracture to nasal bones, scalp hematoma and left [MEDICAL CONDITION] which required stitches. This affected one (Resident #01) of three residents reviewed for falls. The facility census was 92. Findings include: Medical record review for Resident #01 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the fall assessment, dated 08/03/19, revealed Resident #01 was a moderate risk for a fall and had no history of falls. Review of the admission Minimum Data Set (MDS) assessment, dated 08/10/19, revealed she was severely cognitively impaired. The resident required one-person physical assistance for bathing support. Resident #01 was not steady and was only able to stabilize with staff assistance for moving from a seated to standing position, walking, and surface to surface transfer. Review of the baseline care plan, dated 08/03/19, revealed Resident #01 was confused, and she was at risk for falls. The interventions were to evaluate for safety, ambulation devices as necessary, instruction provided on appropriate safety measures, assess cognitive status for ability to ask for assistance, assess footwear for fit, provide and assist to have non-skid shoes/socks when up for transfers/ambulation and the bed in low position. Review of the progress note, dated 08/19/19 at 10:15 [NAME]M. by Licensed Practical Nurse (LPN) #112, revealed State tested Nursing Aide (STNA) #81 yelled for the LPN to come to Resident #01's room and upon entry, the nurse observed the resident sitting on the shower floor, bleeding from the nose and forehead. Blood was cleaned from her face and gauze was placed in the right nostril to stop the bleeding. Steri-strips were placed to the laceration above the left brow. The bleeding continued even after placement of the steri-strips. The resident was assisted to the chair times two staff members. A skin assessment was completed, and she had a bruise to the right knee, and an abrasion to right lateral thigh. Resident #01 was sent to the emergency room (ER) due to the laceration in the forehead and the bleeding. The documentation revealed Resident #01 did not have a loss of consciousness nor an alteration in mental status following the fall at the facility. The resident was supposed to discharge on this date and would go home after the ER visit. Review of the After-Visit Summary from the hospital, dated 08/22/19, revealed Resident #01's imaging showed bilateral nasal bone fractures, left [MEDICAL CONDITION] with stitches and a scalp hematoma. Review of the Interdisciplinary Team (IDT) note, dated 08/23/19 at 6:00 P.M., revealed Resident #01 was noted to have a fall on 08/19/19 at approximately 10:00 [NAME]M. when she was showering to prepare for discharge from the facility. STNA #81 went to grab extra footwear for the resident and when she returned to the bathroom, the STNA called for the nurse due to the resident being on the shower floor with a bloody nose, multiple abrasions and a left [MEDICAL CONDITION]. Observation and an attempted interview with of Resident #01 on 09/10/19 at 10:06 [NAME]M. revealed she was lying in a low bed. Interview with LPN #112 on 09/10/19 at 12:34 P.M. revealed Resident #01 fell on [DATE] while STNA #81 was showering her for a pending discharge from the facility. She stated STNA #81 came to get her and said she had fallen and there was blood. She stated when she entered the bathroom, Resident #01 was sitting on the floor on her bottom and had blood coming from her face. She stated she dried the blood from her face and held a towel on her face and she and the aide got her up to the chair. She stated she called the transport team and they were on the way. She further revealed while holding a towel to Resident #01's face she cleaned her wound and attempted to apply butterfly bandages, but the bandages wouldn't stick. She stated STNA #81 told her Resident #01 was sitting on the bench in her shower connected to the bedroom and she turned around to reach into her dresser, which she left the bathroom door open, and didn't lose sight of the resident and reached to get socks for her and while doing this she fell flat on her face. When asked if she should have been left unattended to reach for socks, she said the resident could follow simple instructions, just not multi-step instructions. She agreed Resident #01 was a one-person assistance for showering. She denied she knew if the STNA said anything to Resident #01 in the shower when she reached for the socks. Interview with STNA #81 on 09/10/19 at 1:20 P.M. revealed Resident #01 fell on [DATE] the day she was supposed to discharge to home. She stated she had showered her in the bathroom and had her sitting on a bench and told her she needed to go to the dresser to get her some non-skid socks and said stay right there, I will be right back in a minute and she said the resident said ok and the aide left the bathroom to the dresser in the bedroom to retrieve the socks. She said she heard the resident say, I want to lay down and the aide said, wait for me and the aide heard her fall and when she entered the bathroom the resident was lying on the floor with blood coming from her head into her eyes. The aide said she had left her in the bathroom before and went out into the bedroom to retrieve something. She stated Resident #01 could follow simple instructions but said she didn't know why she didn't on this day. She stated if a resident with [MEDICAL CONDITION] was severely cognitively impaired but could follow simple instructions, it was permissible to leave the resident unattended to go to the bedroom. Interview with the Director of Nursing (DON) on 09/10/19 at 3:31 P.M. verified STNA #81 should not have left Resident #01 alone in the shower. She stated STNA #81 was showering Resident #01 and went out of the bathroom to the bedroom dresser to get some non-skid socks and when she turned back around Resident #01 had fallen and caused an eyebrow laceration. She stated she talked to STNA #81 and LPN #112 and instructed them to not leave a resident in the bathroom alone even for a second. She stated if they needed something for safety issues such as non-skid socks, to use the call light in the bathroom. She stated these were the only staff educated. Review of the facility policy titled Falls and Fall Risk, Managing, dated 12/01/07, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency substantiates Complaint Number OH 705.