Every finding on record at Heather Knoll Retirement Village

Based on record review, interview, review of AccuWeather forecast and facility policy review, the facility failed to ensure Resident #61 did not exit the facility without staff knowledge, failed to complete a full investigation and health assessment after Resident #61 exited the facility without a coat in 18 degrees Fahrenheit (F) temperatures, and failed to notify Resident #61's responsible party of the incident. This affected one (Resident #61) of three residents reviewed for safety.Findings included:Review of the medical record noted Resident #61 was admitted on [DATE]. Diagnoses included unspecified dementia, anxiety disorder and repeated falls.Review of the plan of care dated 09/22/25 noted Resident #61 had general weakness and was at risk of decline in ambulation. The plan of care was updated on 01/28/26 stating Resident #61 had potential for falls/injury due to weakness, balance deficit, psychotropic medications, dementia, and orthostatic hypotension. No plan of care was created indicating Resident #61 was at risk for elopement.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/25/25, revealed Resident #61 had intact cognition. The resident required partial assistance for bed mobility, transfers, and ambulation.Review of the nursing progress notes dated 01/18/26 at 12:59 P.M. noted Resident #61 was observed outside the facility by Certified Occupational Therapy Assistant (COTA) #205. No other documentation was provided, indicating the resident was found outside the facility without staff.Review of the AccuWeather forecast for [NAME], Ohio for 01/18/26 revealed a high temperature of 18 degrees F and a low temperature of 11 degrees F.Interview on 01/29/26 at 8:28 A.M., Certified Nurse Assistant (CNA) #203 stated she provided care for Resident #61, and he should not be outside by himself. CNA #203 stated she was not aware of Resident #61 leaving the facility without staff or family.Interview on 01/29/26 at 9:23 A.M., Unit Manager #204 stated she was not aware of Resident #61 leaving the facility and verified that Resident #61 should not be outside without staff or family.Interview on 01/29/26 at 9:55 A.M., Resident #61 stated he went out to the parking lot to see his car. Resident #61 stated it was dumb to go outside without a coat because it was cold outside. Resident #61 stated a therapy staff member observed him in the lot, put him in her car and drove him back to the entrance of the facility.Interview on 01/29/26 at 10:03 A.M., COTA #205 stated she observed Resident #61 outside in the parking lot which was approximately 20 feet from the building and 50 feet from the door. Resident #61 was assumed to exit the facility. Resident #61 was wearing street clothes, but no hat, coat or gloves. COTA #205 stated Resident #61 stated he was outside because he wanted to get some fresh air.Interview on 01/29/26 at 10:30 A.M., the Administrator, the Director of Nursing, (DON) and the Quality Assurance Nurse #206 stated no investigation was completed because Resident #61 had a BIMS (Brief Interview for Mental Status) of 15 which indicated the resident had intact cognition. The Administrator stated he spoke with Resident #61 who stated he was outside looking for something but was not specific.Interview on 01/29/26 at 11:26 A.M., Licensed Practical Nurse (LPN) #207 stated she administered Resident #61's medications before he left to wait on his sister for lunch. LPN #207 stated she observed Resident #61 being wheeled back to the unit by COTA #205 stating he was found outside. LPN #207 could not verify the door Resident #61 used or how long he was outside. LPN #207 stated she spoke to Resident #61 briefly explaining that he needed to sign out next time and make sure he was wearing appropriate clothing for the weather. LPN #207 stated Resident #61 stated he did not realize it was that cold outside. LPN #207 stated no assessments were completed or documented, that she called the DON who said Resident #61 had a BIMS of 15 so nothing else needed to be done. LPN #207 stated the doors that she assumed Resident #61 exited through automatically lock so Resident #61 would not be able to return inside.Interview on 01/29/26 at 12:59 P.M., Nurse Practitioner #208 stated someone called her to tell her Resident #61 was observed outside the facility, but Resident #61 was dressed appropriately and no significant changes were noted. NP #208 stated she spoke with Resident #61 on 01/22/26 but did not ask about the incident on 01/18/26.Interview on 01/29/26 at 1:10 P.M., the family of Resident #61 stated she received a call a couple weeks ago from staff stating they caught Resident #61 trying to leave the facility. The family stated she received calls in the past stating Resident #61 was looking for the door but never left the facility. The family stated Resident #61 had short-term memory dementia with sundowning episodes. The family was not aware Resident #61 was observed outside without the facility without staff and not wearing a coat.This deficiency represents non-compliance investigated under Complaint Number 2723679.

Based on record review and interview, the facility failed to ensure Resident #1's medical record was accurate and complete. This finding affected one (Resident #1) of three resident records reviewed for accurate documentation. The facility census was 110.Findings include:Review of Resident #1's medical record revealed the resident was admitted on [DATE] and discharged on 06/02/25 with diagnoses including chronic diastolic congestive heart failure, anxiety disorder and syncope and collapse.Review of Resident #1's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was always incontinent of bowel and bladder and was not on a toileting program.Review of Resident #1's Emergency Department Encounter note dated 06/02/25 revealed the resident presented to the emergency department with a chief complaint of altered mental status. The emergency medical squad (EMS) reported that the nursing facility called because she was not acting like herself and they found her to be unresponsive when the family arrived. The husband stated that he visited the nursing home on [DATE] and the resident was acting confused and told the staff, but she had not been evaluated at that time.Interview on 08/15/25 at 12:11 P.M. with Licensed Practical Nurse (LPN) #810 revealed she vaguely remembered Resident #1's husband reporting concerns about confusion and she had assessed the resident on that date. LPN #810 confirmed she did not document the assessment of the resident at that time but did not identify a change in the resident's condition.An additional interview on 08/15/25 at 3:03 P.M. with LPN #810 confirmed she remembered Resident #1's husband coming to her on 06/01/25 around lunchtime with concerns that the resident had a decline. LPN #810 confirmed she assessed the resident and did not find any changes in condition but neglected to document the assessment in the resident's medical record.This deficiency is an incidental finding discovered during the course of the complaint investigation.

Based on observations, interviews, record review and policy review, the facility failed to provide meaningful activities of interest. This affected one resident #(#89) of one resident reviewed for activities. The facility census was 107. Findings include: Review of the medical record for Resident #89 revealed an admitted [DATE]. Diagnosis included heart failure, abnormal posture, and dependence on wheelchair. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #89 had intact cognition. Under the area of activity preferences, when asked how important it was to him to keep up with the news, he responded it was somewhat important. When asked how important it was to him to do things with a group of people, and how important it is to do his favorite activities, he responded it was very important. Review of the Activity assessment dated [DATE] revealed when not in activities, Resident #89 liked to talk with other residents and staff. His preferred setting for activities was his room, day room, and indoors. Review of the activities log from 02/18/25 through 03/05/25 revealed Resident #89 was only offered coloring page and word search daily and he watched television. He was given communion on 02/20/25 and received mail on 03/04/25. There were no other activities documented for Resident #89. Review of the record of one-on-one activities for Resident #89 from 01/01/25 through 03/05/25 revealed one-on-one activities were only provided on 01/15, 01/20, 01/21, 01/22 and 01/24. There were no one-on-one activities recorded for February 2025 or for March 2025 to-date (through 03/05/25). Interview on 03/03/25 at 10:36 A.M. with Resident #89 revealed he stayed in his room most of the time and watched television. When asked if he attended activities or if the facility provided activities for him, he stated No, I would like that. Interview on 03/05/25 at 12:47 P.M. with Certified Nursing Assistants (CNA) #412, #397, and #422 stated Resident #89 does not attend group activities. The CNAs reported Resident #89 watched television all the time. CNA #412, #397 and #422 verified Resident #89 had not received any one-on-one activity visits throughout the day, as far as they know. The CNAs reported Resident #89 is not routinely offered any other activity throughout the day. Interview on 03/05/25 at 3:10 P.M. with Activities Director #353 stated residents that are unable to attend activities outside of their rooms or don't want to participate in group activities will be provided one-on-one visits in their room. Activities Director #353 verified there was no documentation of Resident #89 having a 1:1 visit since January. Activities Director #353 stated Resident #89 was given the daily Chronicle, which had a coloring page and word puzzle he could complete but did not know if he liked coloring or word puzzles. Review of the facility policy Activity Programs Policy, dated 08/2021 revealed resident who are unable and/or willing to participate in group programs shall receive one on one (1:1) programming based on their interest, abilities, and likes.

Based on observation, interview, record review, review of facility policy and review of manufacturers instructions, the facility failed to ensure Resident #108 received proper treatment and care planned interventions to prevent the development of redness and moisture associated skin damage to his buttocks, scrotum, and penis. In addition the facility failed to ensure Resident #20 had appropriate incontinence care. This affected two residents (Resident's #20 and #108) out of four reviewed for incontinence care. The facility census was 107. Findings include: Review of Resident #108's medical record revealed an admitted [DATE] and diagnoses included dementia, unspecified severity, with other behavioral disturbance, hypertensive heart disease with heart failure, and post traumatic stress disorder. Resident #108 resided at the facility for eight days and was discharged on [DATE]. Review of Resident #108's care plan dated 09/10/24 included Resident #108 had an ADL (activity of daily living) self-care deficit. ADL's would be completed per Resident #108's needs and Resident #108 would achieve maximum functional mobility. Interventions included to check and change Resident #108 every two hours. Review of Resident #108's progress notes dated 09/10/24 at 4:17 P.M. included Resident #108's Braden Scale for Predicting Pressure Sore Risk revealed he was low risk. Review of Resident #108's Admission assessment dated [DATE] included Resident #108 was admitted for a respite stay. Resident #108's skin was intact. Review of Resident #108's aide charting in the electronic record from 09/15/24 through 10/15/24 revealed on 09/16/24 Resident #108's disposable undergarment was changed at 11:34 A.M. for urinary incontinence and at 3:01 P.M. for bowel incontinence. There was no further evidence on 09/16/24 that Resident #108 was checked and his disposable undergarment was changed for urinary or bowel incontinence. On 09/17/24, Resident #108's disposable undergarment was changed at 12:24 A.M. and 11:26 A.M. for urinary incontinence and at 11:28 A.M. for bowel incontinence. There was no further evidence on 09/17/24 that Resident #108 was checked and his disposable undergarment changed for urinary or bowel incontinence. On 09/18/24 Resident #108's disposable undergarment was changed at 6:59 A.M. for urinary incontinence and bowel incontinence. There was no further evidence on 09/18/24 that Resident #108's disposable undergarment was checked and his disposable undergarment changed for urinary or bowel incontinence. Review of Resident #108's physician orders dated 09/16/24 revealed orders for sacral area, cleanse with normal saline, apply foam dressing three times a week and as needed. Check placement every shift, every night shift very Tuesday, Thursday, and Saturday for discoloration. Review of Resident #108's Stasis, Surgical, other Wound Track dated 09/17/24 at 10:30 A.M. included Resident #108's right buttock had a new area of MASD (moisture associated skin damage) acquired on 09/16/24. Measurements were length 5.0 cm, width 5.0 cm, depth 0.1 cm. Description of the wound was MASD with inflamed skin and scattered areas within the measurement. Blanching skin noted to wound bed and peri wound. There was a scant amount of serosanguineous drainage noted. Resident #108's physician, CNP (Certified Nurse Practitioner) and family were notified and new MASD area treatment ordered and in place. Review of Resident #108's Weekly Skin Check dated 09/18/24 at 1:21 P.M. included Resident #108 had a new area of MASD to the buttocks, scrotum, and tip of penis. Review of Resident #108's physician orders dated 09/18/24 at 12:45 P.M. revealed right buttock, cleanse with normal saline, apply EPC (extra protective cream) and cover with foam dressing, every night shift, every Tuesday, Thursday and Saturday and as needed for discoloration. Review of Resident #108's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #108 was unable to complete the Brief Interview for Mental Status. Resident #108 was dependent for toileting and personal hygiene, eating, bathing, and dressing. Resident #108 was dependent for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand and chair, bed-to-chair transfer, and toilet transfer. Resident #108 was always incontinent of urine and bowel. Interview on 10/15/24 at 12:19 P.M. with Family Member (FM) #200 revealed when Resident #108 was admitted to the facility his body was perfectly clear, and when he left the facility his sores were pretty bad on his backside, penis and testicles. FM #200 stated she felt like Resident #108 received terrible care at the facility and with the amount of wounds on his areas she felt like there was no way the wounds would have developed if he was attended to properly. FM #200 stated she went to an out of state funeral and kept calling the facility to talk to Resident #200 and no one answered the phone. FM #200 stated finally the facility phone was answered and she was able to talk to Resident #108. FM #200 indicated Resident #108 told her something dangerous was going on and someone needed to know about it. Resident #108 said his navel was burning and something was sticking out of his [expletive]hole. FM #200 stated she could not remember the nurse's name, asked her what was going on, and the nurse said she did not know but would check. The nurse checked Resident #108's disposable undergarment and said his diaper was twisted, and later sent me a voice mail which stated he had two sores on his bottom. FM #200 stated she called the nurse and was told the sores were the size of a pencil eraser, FM #200 asked if the sores were skin tears or wounds, and the nurse clarified Resident #108 had two wounds on his buttocks. FM #200 stated she went to the facility as soon as she was back in town to check on Resident #108 and found his disposable undergarment was soaked with urine and feces, his penis and testicles had sores all over them, and she was extremely upset, broke down and started crying. FM #200 stated she stayed in the room while facility staff cleaned Resident #108 and noted he had two dime sized sores on his buttocks, and there were no dressings covering the sores. FM #200 stated she asked the man who ran the facility how he would feel if he saw his parent in that condition and the man said he would be livid if he saw his parent in that condition. FM #200 stated Resident #108 used a female urinal at home, she sent it to the facility with a detailed letter about his care, but it was never used and was still in the bag she sent it to the facility in. The facility could not locate the letter with instructions regarding Resident #108's care. FM #200 stated she wanted Resident #108 sent home immediately and the facility arranged the transportation. Interview on 10/15/24 at 1:13 P.M. with Licensed Practical Nurse/Wound Nurse (LPN/WN) #201 revealed she tracked wounds weekly, measured wounds, documented healing and deterioration of wounds, and did skin assessments on all resident wounds. LPN/WN #201 stated Resident #108 was admitted to the facility for a respite stay, and skin breakdown was discovered the day he was discharged . LPN/WN #201 stated Resident #108 had moisture dermatitis on his buttocks, scrotum and penis and she documented the areas in his electronic record. When asked LPN/WN #201 stated MASD could be caused from sweat, wound drainage, but exposure to moisture was generally from incontinence, and any extended exposure to moisture would cause MASD. LPN/WN #201 stated she did not know how often Resident #108 received incontinence care, and would make the assumption he was not getting incontinence care promptly because he developed redness and MASD. LPN/WN #201 indicated Resident #108 was not admitted with redness or skin breakdown to his buttocks, scrotum, testicles, and penis. LPN/WN #201 confirmed she talked to the family about Resident #108's redness and skin breakdown, and the family was upset. Interview on 10/16/24 at 8:44 A.M. with State tested Nursing Assistant (STNA) #202 revealed she usually worked on the hospice and respite nursing unit. STNA #202 stated she worked on 09/14/24, it was a Saturday, and was assigned to care for Resident #108. STNA #202 indicated when she provided incontinence care she noted redness on Resident #108's testicles, penis and back side, put barrier cream on the areas and told a nurse. STNA #108 stated she could not remember which nurse she told. STNA #108 stated Resident #108 did not have redness or sores to his testicles, penis or buttocks when he was first admitted . Review of the facility policy titled Incontinence Care Protocol reviewed 03/2022 included it was the policy of the facility to outline appropriate management for all residents with incontinence, to prevent the loss of skin integrity. Assess and monitor skin with each incontinent episode. 2. Review of Resident #20's Quarterly MDS 3.0 assessment dated [DATE] included Resident #20 was admitted to the facility on [DATE] and had severe cognitive impairment. Resident #20 had diagnoses including diabetes mellitus, CVA (cerebrovascular accident), and aphasia. Resident #20 required substantial to maximal assistance with toileting hygiene and bathing, and was always incontinent of urine and bowel. Observation on 10/15/24 at 3:47 P.M. of STNA's #209 and #212 revealed they entered Resident #20's room to provide incontinence care. STNA #209 and #212 provided Resident #20's incontinence care, and removed one disposable incontinence liner soiled with urine and feces when they were providing care. When they were finished STNA's #209 and #212 put two clean incontinence liners on Resident #20. When asked why two incontinence liners were used STNA #212 confirmed two incontinence liners were used and stated so her bed won't get soaked, and one liner did not keep the bed from getting wet. STNA #209 stated mesh panties were not used often because it was hard to situate the liners inside the panties. Review of the incontinence liners manufacturers instructions included two incontinence liners should not be worn at the same time, and you should not wear more than one liner at a time. Wearing multiple pads could cause hard edges that could damage skin and be uncomfortable. Using more than one pad did not provide extra absorbency. Leakage from the first product would overflow into the second product, causing both products to leak more quickly. The first product would leak onto the second and both would become less absorbent. Wearing more than one pad was considered bad practice. Review of the facility policy titled Incontinence Care Protocol revised 03/2022 included it was the policy of the facility to outline the appropriate management for all residents with incontinence, to prevent loss of skin integrity. This deficiency represents non-compliance investigated under Complaint Number OH00158178.

Based on observation, interview, record review, and review of the facility policy the facility failed to follow Resident #66's physician orders and care planned interventions to ensure the resident was free from significant medication error. This affected one resident out of five reviewed for medication administration. The facility census was 107. Findings include: Review of Resident #66's medical record revealed an admitted [DATE] and a re-entry date of 10/02/24. Diagnoses included osteomyelitis of vertebra, thoracic region, hypertensive heart disease with heart failure, methicillin susceptible staphylococcus aureus infection (MSSA) as the cause of diseases classified elsewhere, and aftercare following explanation of knee joint prosthesis. Review of Resident #66's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 was dependent for toileting and lower body dressing. Resident #66 was frequently incontinent of urine and bowel. Review of Resident #66's hospital discharge instructions for a hospital stay from 09/26/24 through 10/02/24 included on 09/26/24 Resident #66 had an Incision and Drainage and left knee revision. Resident #66's physician orders written by Infectious Disease Physician (IDP) #205 included Oxacillin IV (intravenous), 2 Gm (gram) every four hours until 11/07/24. Further review revealed Keflex 500 mg by mouth four times a day from 11/08/24 through 12/06/24. Resident #66 had a left knee PJI (prosthetic joint infection, MSSA). Review of Resident #66's hospital discharge instructions for a hospital stay from 09/26/24 through 10/02/24 revealed Resident #66 received Oxacillin 2 Gm (2000 mg) per 50 ml intravenous solution every four hours and the next dose was due on 10/02/24 at 3:00 P.M. Review of Resident #66's care plan dated 10/02/24 included Resident #66 had a MSSA infection. Resident #66 would be free of signs and symptoms of infection with no complications. Interventions included to administer medications as ordered and monitor for side effects and effectiveness and adverse reactions. Review of Resident #66's Admission Assessment progress notes dated 10/02/24 at 2:00 P.M. included Resident #66 was alert and oriented times three (time, place, person). Resident #66's left upper arm single lumen PICC (peripherally inserted central catheter) dressing was clean, dry and intact. Admitting diagnosis was Incision and Drainage, left knee revision. Resident #66 was currently being treated with antibiotics for sepsis of left knee, back. Resident #66 was incontinent of urine and bowel. Review of Resident #66's physician orders dated 10/02/24 at 2:00 P.M. revealed orders for Oxacillin Sodium Injection Solution Reconstituted 2 Gm, use 2000 mg intravenously every four hours for sepsis in left knee, back, Oxacillin 2 Gm per 50 ml in left upper arm PICC single lumen. Review of Resident #66's progress notes dated 10/02/24 at 5:03 P.M. and written by Registered Nurse (RN) #203 revealed Oxacillin Sodium Injection Solution Reconstituted 2 Gm (gram), use 2000 mg intravenously every four hours for sepsis in left knee, back, Oxacillin 2 Gm per 50 milliliters (ml), in left upper arm PICC single lumen. Waiting for pharmacy delivery, in house Certified Nurse Practitioner (CNP) #204 aware. Review of Resident #66's progress notes dated 10/02/24 at 5:03 P.M. through 10/03/24 at 1:44 P.M. did not reveal orders or instructions from CNP #204 regarding the delay of delivery of Oxacillin from the pharmacy. Further review did not reveal Infectious Disease Physician (IDP) #205 was notified IV (intravenous) Oxacillin was unavailable, and there was no evidence of instructions, orders regarding the Oxacillin being unavailable. Review of Resident #66's pharmacy email dated 10/02/24 at 5:51 P.M. revealed Oxacillin 2 Gm per 100 ml of normal saline was not sent. Oxacillin 2 Gm per 100 ml of normal saline was ordered for tomorrow (10/03/24), RN #203 was informed Oxacillin would not be delivered to the pharmacy until 10/03/24 and would most likely not arrive to the facility until 10/04/24. RN #203 would check with CNP #204 to see if the facility wanted to switch or wait for the medication. Review of Resident #66's progress notes dated 10/03/24 at 9:26 A.M. included Oxacillin 2 Gm per 50 ml, use 2000 mg intravenously every four hours for sepsis was not available. CNP #204 was updated. Review of Resident #66's pharmacy email dated 10/03/24 at 10:13 A.M. revealed no order was received from the facility regarding Resident #66's antibiotic Oxacillin. Further review revealed Resident #66 was receiving Oxacillin and Keflex at the hospital and both were prescribed by ID (Infectious Disease). Resident #66 was prescribed Keflex by mouth, please clarify dosing as well as keeping with Oxacillin. Review of Resident #66's progress notes dated 10/03/24 at 1:44 P.M. revealed CNP #204 was updated that IV (intravenous) antibiotics (Oxacillin) were not available. Attempted to update Infectious Disease Physician (IDP) #205, left voicemail. Review of Resident #66's pharmacy email dated 10/03/24 at 1:54 P.M. revealed order for Keflex, four times a day from 11/08/24 through 12/06/24. Nurse would call back regarding Oxacillin. Review of Resident #66's progress notes dated 10/03/24 at 1:55 P.M. included IDP #205 was updated regarding Resident #66's IV antibiotics not being available. New orders to start Keflex 500 mg four times a day until Oxacillin was available to give, then discontinue the Keflex and restart on originally scheduled date. Review of Resident #66's physician orders dated 10/03/24 at 2:18 P.M. revealed Keflex oral capsule 500 mg, give one capsule by mouth four times a day for MSSA. Review of Resident #66's Medication Administration Record (MAR) dated 10/03/24 at 4:00 P.M. revealed Resident #66 received a Keflex 500 mg capsule by mouth, and would receive it four times a day for MSSA. Review of Resident #66's pharmacy email dated 10/03/24 at 4:35 P.M. included the physician would like to continue Oxacillin when it arrived and would start Keflex 500 mg four times a day until Oxacillin arrived, and then Keflex would start back on original date of 11/08/24 and Keflex was sent to the facility on [DATE]. Review of Resident #66's pharmacy email dated 10/04/24 at 3:59 P.M. revealed med arrived (Oxacillin) and was sent to the facility on [DATE]'s evening run. Review of Resident #66's MAR revealed Oxacillin 2 Gm per 50 ml, use 2000 mg intravenously every four hours for sepsis in left knee, back was administered on 10/05/24 at 8:00 A.M. (although pharmacy documented it was sent on the 10/04/24 evening run to the facility). Observation on 10/16/24 at 8:05 A.M. of Resident #66 revealed she was lying in bed, and an IV pole was noted next to her bed. Resident #66 stated she recently had a staph infection in her left knee, had the same type of staph infection in her back in 01/2024, and needed to have surgeries to get rid of the staph infection in January and October. Resident #66 stated she was on IV antibiotics for six weeks, then she would be on oral antibiotics. Resident #66 stated she wanted to do everything she could to make sure the infection did not come back. Interview on 10/16/24 at 11:34 A.M. of the Director of Nursing (DON) revealed the facility had a medication starter system, but it did not include an Oxacillin starter kit. The DON stated the facility had two pharmacy runs (deliveries) per day, one in the morning, and one in the afternoon, and she did not know what times the deliveries were completed. The DON revealed the facility received notification from the pharmacy stating Oxacillin was not available because they had to compound the drug. The DON indicated CNP #204 was aware the facility was waiting on the Oxacillin. The DON stated the pharmacy was two hours away and medications including antibiotics and Oxacillin were not drop shipped unless they were urgent. Interview on 10/16/24 at 2:32 P.M. of CNP #204 revealed Resident #66 was extremely immunocompromised. Resident #66 recently had a MSSA infection in her left knee prosthesis, and earlier this year she had a MSSA spine infection. Resident #66 received Oxacillin to treat the spine staph infection, the staph infection in her left knee was the same and IDP #205 wanted to use Oxacillin because it was known infection would be a problem. CNP #204 stated when antibiotics including Oxacillin were ordered they should be started as soon as possible. CNP #204 indicated the facility did not always have the ordered antibiotics in the starter kit and had to wait for pharmacy to deliver them. CNP #204 stated she was texted on 10/02/24 at 5:51 P.M. by RN #203 and notified Resident #66's Oxacillin would not arrive to the facility until 10/05/24. CNP #204 stated on 10/02/24 at 5:51 P.M. she told RN #203 to call IDP #205 to inform him Resident #66's Oxacillin was not available. CNP #204 indicated IDP #205 ordered the Oxacillin and he needed to be contacted to see if he wanted Resident #66 to receive another antibiotic until the Oxacillin arrived to the facility. CNP #204 stated it was sometimes hard to contact the Infectious Disease Physician in the evening. Interview on 10/16/24 at 3:09 P.M. of Registered Nurse/Restorative Nurse (RNR) #206 revealed when Resident #66 was readmitted to the facility on [DATE] her Oxacillin was not available from the pharmacy. RNR #206 indicated on 10/03/24 she talked to CNP #204 and was told to contact IDP #205 about Resident #66's Oxacillin not being available. RNR #206 stated she called IDP #205 on 10/03/24 at 1:44 P.M., this was the first time she tried to contact IDP #205, updated him on the missed doses of Oxacillin, and IDP #205 extended out the amount of missed doses of Oxacillin so Resident #66 received the correct amount. RNR #206 indicated IDP #205 started Resident #66 on Keflex 500 mg by mouth until the Oxacillin arrived to the facility. Interview on 10/16/24 at 4:10 P.M. of the DON, the Administrator, and Regional Quality Assurance (RQA) #207 revealed RQA #207 stated IDP #205 was unable to be contacted until the next day (10/03/24), but confirmed there was no evidence the facility tried to contact IDP #205 in Resident #66's medical record including progress notes from 10/02/24 at 5:51 P.M. through 10/03/24 at 1:44 P.M. Review of the facility policy titled Medication Administration Policy reviewed 03/2022 included it was the policy of the facility to ensure medications were administered in a safe and sanitary manner. The EMAR (electronic Medication Administration Record) would be utilized to reference current orders to which medications were due for administration. Licensed nurses would ensure the 6 medication rights were followed, the right resident, right drug, right dose, right time, right route and right documentation. This deficiency represents non-compliance investigated under Complaint Number OH00158178.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #65's incontinence care was provided in a sanitary manner and staff donned appropriate PPE for Resident #66 who required enhanced barrier precautions when entering the room to provide incontinence care. This affected one resident (Resident #65) of four residents reviewed for incontinence care and one resident (Resident #66) of one resident observed for enhanced barrier precautions. Findings include: 1. Review of Resident #65's medical record revealed and admitted [DATE] and diagnoses included cerebral infarction due to embolism of right middle cerebral artery, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, and major depressive disorder. Review of Resident #65's care plan dated 04/25/19 included Resident #65 had the potential for impaired skin integrity, UTI (urinary tract infection) and impaired dignity related to incontinence. Resident 365's skin integrity would be maintained. Interventions included apply protective cream after each incontinent episode. Review of Resident #65's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was dependent for toileting hygiene, bathing and lower body dressing. Resident #65 required substantial to maximal assistance to roll left and right. Resident #65 was always incontinent of urine and bowel. Observation on 10/15/24 at 4:24 P.M. of State tested Nursing Assistant (STNA) #211 revealed she entered Resident #65's room to provide incontinence care. Resident #65 stated she was on the bedpan, tried to remove it herself, and messed it up. Observation of STNA #211 revealed she did not prepare plastic bags prior to Resident #65's incontinence care for soiled linens and disposable undergarments. Observation of Resident #65 and her sheets revealed there was feces on the sheets and on Resident #65's buttocks. STNA #211 proceeded to provide incontinence care and and as she provided care she placed the feces soiled wash cloths, soiled sheet and soiled disposable undergarment at the end of the bed in a pile. There was no barrier under the pile of soiled linens and disposable undergarment that protected the clean bed linens from feces contamination. When STNA #211 was finished with Resident #65's incontinence care she lifted the pile of soiled linens and disposable undergarment and moved it to Resident #65's wheelchair and placed the soiled pile onto a blanket on the wheelchair. There was no protective barrier between the soiled pile and the blanket. STNA #211 found plastic bags in Resident #65's room and separated the soiled linens from the disposable undergarment, and put them in separate plastic bags, and placed the bags on the floor. STNA #211 then picked up the feces contaminated blanket that was under the soiled pile of linens and disposable undergarment and used it to cover Resident #65. STNA #211 confirmed she placed the soiled linens and disposable undergarment at the foot of Resident #65's bed and on her wheelchair without using a protective barrier underneath the soiled items. STNA #211 confirmed she covered Resident #65 with the feces contaminated blanket which was under the soiled items on her wheelchair. STNA #211 stated she forgot to prepare plastic bags ahead of time. Review of the facility policy titled Incontinence Care Protocol reviewed 03/2022 included it was the policy of the facility to outline appropriate management for all residents with incontinence, to prevent the loss of skin integrity. 2. Review of Resident #66's medical record revealed an admitted [DATE] and a re-entry date of 10/02/24. Diagnoses included osteomyelitis of vertebra, thoracic region, hypertensive heart disease with heart failure, methicillin susceptible staphylococcus aureus infection (MSSA) as the cause of diseases classified elsewhere, and aftercare following explanation of knee joint prosthesis. Review of Resident #66's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 was dependent for toileting and lower body dressing. Resident #66 was frequently incontinent of urine and bowel. Review of Resident #66's care plan dated 10/02/24 included Resident #66 had a MSSA infection. Resident #66 would be free of signs and symptoms of infection with no complications. Interventions included to administer medications as ordered and monitor for side effects and effectiveness and adverse reactions. Resident #66 had a need for Enhanced Barrier Precautions (EBP) related to surgical incision, IV (intravenous). Resident #66 would have minimized risk of MDRO (multidrug-resistant organisms) infections. Interventions included to don appropriate PPE (personal protective equipment) prior to providing high-contact resident care activities such as providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use; EBP related to surgical incision, IV. Resident #66 had the potential for impaired skin integrity, UTI (urinary tract infection) related to incontinence. Resident #66's skin integrity would be maintained. Interventions included apply protective cream after each incontinent episode. Review of Resident #66's physician orders dated 10/03/24 revealed Enhanced Barrier Precautions related to surgical incision, IV (intravenous), every shift. Observation on 10/16/24 at 8:05 A.M. of Resident #66's room revealed an Enhanced Barrier Precaution sign was posted to the right of the doorway to her room. The sign included providers and staff must wear gloves and a gown for the following high-contact resident care activities, dressing, bathing, showering, transferring, bathing, showering, providing hygiene, changing briefs, changing linens, device care, wound care. Observation on 10/16/24 at 8:05 A.M. of State tested Nursing Assistant's (STNA)'s #208 and #209 revealed they entered Resident #66's room to provide incontinence care, donned gloves but did not don a gown. Resident #66 stated she was last changed at 5:00 A.M. Observation revealed STNA's #208 and #209 provided incontinence care and during the care their clothing brushed against Resident #66's gown and bed linens. Further observation revealed Resident #66 had an undated dressing on her coccyx area. Resident #66 stated it was not changed on a regular schedule, she just let the staff know when it bunched up and was uncomfortable, then the dressing was changed. After surveyor intervention Licensed Practical Nurse (LPN) #210 stated he would check Resident #66's physician orders, then would come in her room. LPN #210 entered Resident #66's room but did not don a gown before entering her room or during his evaluation of her coccyx dressing. LPN #210's clothing brushed Resident #66's bed linens as he leaned over to check her coccyx dressing, and removed the dressing. Observation of Resident #66's coccyx revealed it was red, but there were no open areas. LPN #210 confirmed there was no date written on the dressing indicating when it was changed, but stated he checked with Resident #66's physician and the physician said the dressing could be discontinued. Interviews on 10/16/24 at 8:15 A.M. of STNA's #208 and #209 confirmed they did not wear a gown when providing Resident #66's incontinence care, and confirmed there was a sign to the right of the doorway to Resident #66's room stating they should wear a gown and gloves when providing high contact resident care activities. Interview on 10/16/24 at 10:17 A.M. of LPN #210 confirmed there was a sign posted to the right of Resident #66's doorway to her room stating to wear a gown and gloves for high contact resident care activities, and he did not don a gown when he checked Resident #66's coccyx dressing and removed the dressing. Review of the CDC (The Centers for Disease Control and Prevention) Enhanced Barrier Precautions in Skilled Nursing Facilities dated 04/05/22 included providers and staff must wear gloves and a gown for the following high-contact resident care activities, dressing, bathing, showering, transferring, bathing, showering, providing hygiene, changing briefs, changing linens, device care, wound care. This deficiency represents non-compliance investigated under Complaint Number OH00158178.

Based on observation, record review and interview, the facility failed to ensure appropriate [CONDITION(S)] care was completed for Resident #2. This affected one (Resident #2) of one resident reviewed for [CONDITION(S)] care. Findings include: Review of Resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/28/22 at 11:58 A.M. with Registered Nurse (RN) #847 and Licensed Practical Nurse (LPN) Infection Preventionist #835 revealed RN #847 washed her hands, opened the packages of sterile suctioning equipment, put on a pair of sterile gloves, picked up the sterile suction catheter and attached it to one end of the plastic connector tubing which LPN Infection Preventionist #835 was holding. The other end of the connector tubing was connected to a suction machine sitting on Resident #2's bedside stand. RN #847 turned to suction the resident while holding the sterile suction catheter with connector tubing and the suction catheter dislodged from the connector tubing. The connector tubing fell to the floor and LPN Infection Preventionist #835 picked up the connector tubing and handed the tubing to RN #847. RN #847 reattached the sterile suction catheter to the contaminated connector tubing and proceeded to suction Resident #2's [CONDITION(S)]. An interview on 09/28/22 at 12:05 P.M. with LPN Infection Preventionist #835 confirmed improper technique was used during Resident #2's [CONDITION(S)] care. Review of the [CONDITION(S)] Care policy revised 05/20 indicated the purpose of the [CONDITION(S)] care was to ensure airway patency by keeping the [CONDITION(S)] tube free of blood clots after insertion and free of [MEDICATION(S)] buildup as well as to maintain mucous membrane and skin integrity while helping to prevent infection.

Based on record review, interviews and review of the facility abuse policy, and review of facility self-reported incidents (SRIs) the facility failed to ensure Resident #30, Resident #34, #70 and Resident #103 were free from abuse. This affected three of five residents reviewed for staff treatment/abuse and one additional resident. The facility census was 102. Findings include: 1. Review of the medical record for Resident #103 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current plan of care dated 08/16/21 revealed Resident #103 had an Activities of Daily Living (ADL)/self-care deficit related to her [CONDITION(S)] accident, cognitive impairment, and weakness. Interventions included to transfer Resident #103 with two staff and indicated she was full weight bearing. Review of the Admission Minimum Data Set 3.0 (MDS) assessment, dated 08/20/21, revealed Resident #103 had moderately impaired cognition. She required extensive assistance of two staff for bed mobility, transfers, ambulation and one staff member for eating. The resident was always incontinent of bowel and bladder. Review of the nursing progress note dated 10/11/21 at 8:00 P.M. revealed Resident #103 sustained a skin tear to the back of her left hand during a transfer from the wheelchair to the shower bench. The note indicated her hand bumped the shower wall while she was holding onto the shower rail. The physician, Director of Nursing (DON) and Resident #103's daughter were notified. The nurse indicated five Steri-Strips, strips of adhesive tape placed across an incision or cut, to pull the edges of a wound together for improved healing. The wound tracking from 10/12/21 revealed Resident #103's skin tear measured 3.5 centimeters (cm) by 0.1 cm by 0.1 cm. This incident was discussed with the interdisciplinary team and they implemented two staff members to be with Resident #103 for transfers. Review of the nurse progress notes dated 10/17/21 at 10:45 A.M. revealed Resident #103 was transferring into the wheelchair and her left leg turned into the attached footrest causing a skin tear on her left outer shin area. The nurse note indicated the skin tear was cleansed with normal saline the wound edges were fairly approximated and Steri-Strips were applied. Resident #103 was noted to have increased swelling in her left hand and forearm and she said her arm was numb. Her left arm was flaccid (hanging loosely or limp). There was no facial droop noted and she was able to move her left leg. The physician was notified and an order was received to transport her to the emergency room for evaluation. Resident #103's daughter was notified of the skin tear, her status, and order to transport her to the hospital. Review of the Weekly Skin Check dated 10/17/21 revealed Resident #103 sustained a skin tear to her left outer shin area in a V shape, measuring 15 cm long by 10 cm wide. Resident #103 was readmitted to the nursing facility from the hospital on 10/19/21. Review of the Weekly Skin Check dated 10/19/21 revealed Resident #103 had 14 Steri-Strips applied to the large skin tear on her outer left shin area and it was covered with a thick absorbent dressing and wrapped with a Kerlix gauze wrap. Review of the Brief Interview of Mental Status assessment dated [DATE] revealed Resident #103 was alert, oriented and had intact cognition. Review of the facility SRI dated 10/20/21 revealed Resident #103 alleged STNA #140 was rough with her and hurt her leg. The DON and Administrator were notified, and an investigation was initiated. STNA #140 was suspended immediately. Resident #103's interview revealed STNA #140 was assisting her with care on 10/17/21 and he was getting her up too fast and was not allowing her the time she needed to balance herself and feel ready before trying to transfer her into the wheelchair. She stated STNA #140 pushed her quickly into the wheelchair and she cut her leg on the wheelchair. The nurse was notified of the injury and treatment was completed. This investigation revealed STNA #140 was interviewed and confirmed Resident #103 sustained a skin tear on her leg when he assisted her to transfer to the wheelchair. STNA #140 said Resident #103 was weak, not stable and started to fall so he quickly guided her to the wheelchair. STNA #140 stated he was trying to prevent a fall, so he guided her to the chair quickly and her leg scraped the side and she got a skin tear. The facility did not substantiate this allegation of physical abuse. Resident #103 stated she did not care for STNA #140 and preferred he longer provided care for her. Review of the signed, handwritten witness statement from Licensed Practical Nurse (LPN) #117 dated 10/20/21 revealed the family had come in to visit and Resident #103 told them she had been mistreated by STNA #140. She stated he had been rough with her. LPN #117 indicated she had been working the day of 10/17/2, but Resident #103 had not reported abuse to her as Resident #103 had to be sent to the hospital for a possible [CONDITION(S)] accident (stroke) and was admitted to the hospital for a urinary tract infection. Review of the unsigned, handwritten statement for Resident #103 dated 10/20/21 revealed STNA #140 was rough with her when he stood her up. He did not give her time to get up and balance and he pushed her into the chair. Resident #103 was agreeable to have STNA #140 removed from provision of her care. Review of the unsigned, witness statement recorded for STNA #140 dated 10/22/21 revealed STNA #140 was interviewed on the day he was in-service for customer service and abuse. STNA #140 reported he stood Resident #103 up at bedside on 10/17/21 and she became weak and limp. STNA #140 said he quickly placed the resident in the wheelchair to prevent a fall resulting in a skin tear to her calf from the wheelchair brake. The employee stated he reported the incident to LPN #117. Review of the undated, written and signed statement from STNA #140, revealed the incident happened when he transferring Resident #103 up at the bedside to pull up her pants. STNA #140 said he had the wheelchair in front Resident #103 and he was standing on her left side, which was her weak side, to get her pants up. He said she dropped her weight on her legs and her left lower leg struck the wheelchair leg rest attachment causing a skin tear. STNA #140 said he transferred the resident back to her bed and immediately notified the charge nurse. Resident #103 was discharged to another facility on 10/22/21. Interview on 11/03/21 at 12:00 P.M. with STNA #140 confirmed he was transferring Resident #103 by himself from the bed to the wheelchair and her legs gave out and she fell into the wheelchair. STNA #140 said Resident #103 hit her leg on the leg rest causing a skin tear. STNA #140 said he usually transferred/walked Resident #103 to the by himself. He indicated he was aware threw were a few residents who did not want him to provide care to them, but he was not going to speculate as to why they did not want him to care for them because he could not see inside their heads. He stated he was not assigned a specific unit he would just have another staff member provide care for those residents. STNA #140 verified he filled out an incident report and was counseled on using the proper amount of assistance/staff for resident transfers. Interview on 11/03/21 at 12:12 P.M. with the DON verified Resident #103 was to be a two-person transfer and STNA #140 had transferred her inappropriately. The DON indicated they have a couple residents who are care planned to have just female care givers. She indicated she had one other resident who did not want STNA #140 to provide care for her, that was Resident #30. She verified at this time Resident #103 was to be a two-person transfer and STNA #140 had transferred her inappropriately. She said they counseled STNA #140 on customer service and explained to him his behavior could eventually lead to an abuse allegation. Interview on 11/03/21 at 2:50 P.M. the DON indicated it was during the summer when her and the previous Administrator had gone down and spoke to Resident #70. Resident #70 indicated STNA #140 was rough with her and she did not like how he had turned her. Resident #70 stated she did not like how STNA #140 had turned her because he hurt her hip. The DON stated the had done a skin assessment with no issues. She stated she was not aware STNA #140 had grabbed the arm of Resident #70 and bruised it. Review of the SRI's submitted since the facility's last annual survey on 09/12/19, they submitted four SRI's involving STNA #140 as the specified perpetrator. These were SRI # 0, # 5, # 4 and # 5 and the facility found them all to be unsubstantiated. Interview on 11/03/21 at 2:55 P.M. with the Administrator indicated she was not aware STNA #140 was involved in previous SRI's at the facility. Interview on 11/03/21 at 3:40 P.M. the DON indicated STNA #140 was terminated this day due to poor customer service. Review of the undated facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate abuse, neglect, exploitation of it's residents or the misappropriation of resident property and would investigate all alleged violations. This policy indicated facility staff should immediately report all such allegations to the Administrator and to the appropriate State Department of Health. In cases where a crime was suspected, staff should also report to local law enforcement in accordance with the facility's crime reporting policy. Residents, interested family members, or other persons may contact any member of the administration or the facility's nursing staff at any time with concerns. Abuse was defined as the willful (meaning the individual acted deliberately) infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Neglect is the failure of the facility and it's employees to provide goods and services to residents necessary to avoid physical harm, pain, mental anguish, or emotional distress. The section of this policy related to facility prevention and identification procedures included identification of patterns and trends that may constitute abuse to determine the direction of their investigation. The investigation section indicated the facility would include a review of the alleged staff's employment records. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, toileting and two staff assist for dressing and personal hygiene. Interview on 11/03/21 at 12:30 P.M. with Resident #30 indicated STNA #140 had grabbed her arm when trying to turn her over in bed and bruised her arm. She stated STNA #140 hurt her hip also. Resident #30 stated STNA #140 did not like to be told what to do and if you told him he was doing something wrong he would get mad and start yelling at you. Resident #30 said she told the head of nursing and they decided to not allow him to take care of her anymore. Interview on 11/03/21 at 2:30 P.M. with LPN #110 verified Resident #30 did not want STNA #140 taking care of her because he had been too rough with her during care. Interview on 11/03/21 at 2:50 P.M. the Director of Nursing (DON) verified it was during the summer when her and previous administrator had gone down and spoke to Resident #30. The resident had indicated STNA #140 was rough with her and she did not like how he had turned her. She stated they asked the Resident if it was abuse or a customer service issues, and the Resident stated she just did not like how STNA #140 had turned her because he hurt her hip. The DON stated the had done a skin assessment with no issues. She stated she was not aware STNA #140 had grabbed the arm of Resident #30 and bruised it. Review of the SRI's submitted since the facility's last annual survey on 09/12/19, they submitted four SRI's involving STNA #140 as the specified perpetrator. These were SRI # 0, # 5, # 4 and # 5 and the facility found them all to be unsubstantiated. Interview on 11/03/21 at 2:55 P.M. with the Administrator indicated she was not aware STNA #140 was involved in previous SRI's at the facility. Interview on 11/03/21 at 3:40 P.M. the DON indicated STNA #140 was terminated due to poor customer service. Review of the undated facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate abuse, neglect, exploitation of it's residents or the misappropriation of resident property and would investigate all alleged violations. This policy indicated facility staff should immediately report all such allegations to the Administrator and to the appropriate State Department of Health. In cases where a crime was suspected, staff should also report to local law enforcement in accordance with the facility's crime reporting policy. Residents, interested family members, or other persons may contact any member of the administration or the facility's nursing staff at any time with concerns. Abuse was defined as the willful (meaning the individual acted deliberately) infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Neglect is the failure of the facility and it's employees to provide goods and services to residents necessary to avoid physical harm, pain, mental anguish, or emotional distress. The section of this policy related to facility prevention and identification procedures included identification of patterns and trends that may constitute abuse to determine the direction of their investigation. The investigation section indicated the facility would include a review of the alleged staff's employment records. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #34 was alert, oriented, intact cognition and required extensive staff assistance for bed mobility, transfers, and toilet use. Interview on 11/03/21 at 10:10 A.M. with Ombudsman #300 indicated she had visited the facility on 10/29/21 and spoke to residents in response to a call she received. Ombudsman #300 stated three residents, including Resident #34, indicated they did not want STNA #140 taking care of them because he was too rough. Interview on 11/03/21 at 10:40 A.M. with Resident #34 indicated she did not want STNA #140 taking care of her because he was too rough. She stated when he rolls her over, he does it too hard and it hurts. She stated she has told him he was too rough, but he continues to do it. She stated about a month and half ago he hurt her shoulder and she told the nurse but could not remember the nurse's name. Resident #34 said he says very mean and inappropriate things. Resident #34 said when he was washing her roommate up, he was making fun of her belly rolls and was telling her she was fat. Resident #34 said it's bad enough they must have someone take care of them, but to have them make fun of them was awful. Resident #34 stated they should not have to put up with this kind of care. She said she did not feel safe with him taking care of her and was scared of him. Resident #34 said she had told the staff and STNA #140 was not allowed to take care of her and her roommate anymore. Interview on 11/03/21 at 2:30 P.M. with LPN #110 verified Resident #34 did not want STNA #140 taking care of her and her roommate because they both reported he had been too rough with them during care. Review of the SRI's submitted since the facility's last annual survey on 09/12/19, they submitted four SRI's involving STNA #140 as the specified perpetrator. These were SRI # 0, # 5, # 4 and # 5 and the facility found them all to be unsubstantiated. Interview on 11/03/21 at 2:55 P.M. with the Administrator indicated she was not aware STNA #140 was involved in previous previous SRI's at the facility. Interview on 11/03/21 at 3:40 P.M. the DON indicated STNA #140 was terminated this day due to poor customer service. Review of the undated facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate abuse, neglect, exploitation of it's residents or the misappropriation of resident property and would investigate all alleged violations. This policy indicated facility staff should immediately report all such allegations to the Administrator and to the appropriate State Department of Health. In cases where a crime was suspected, staff should also report to local law enforcement in accordance with the facility's crime reporting policy. Residents, interested family members, or other persons may contact any member of the administration or the facility's nursing staff at any time with concerns. Abuse was defined as the willful (meaning the individual acted deliberately) infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Neglect is the failure of the facility and it's employees to provide goods and services to residents necessary to avoid physical harm, pain, mental anguish, or emotional distress. The section of this policy related to facility prevention and identification procedures included identification of patterns and trends that may constitute abuse to determine the direction of their investigation. The investigation section indicated the facility would include a review of the alleged staff's employment records. 4. Interview on 11/03/21 at 10:10 A.M. with Ombudsman #300 indicated she had visited the facility on 10/29/21 and spoke to residents in response to a call she received. Ombudsman #300 stated three residents including Resident #70, indicated they did not want STNA #140 taking care of them because he was too rough. Interview on 11/03/21 at 2:50 P.M. with the DON indicated it was during the summer when her and the previous Administrator had gone down and spoken to Resident #70. Resident #70 indicated STNA #140 was rough with her and she did not like how he had turned her and he hurt her hip. The DON stated they had done a skin assessment with no issues. The DON indicates she was not aware STNA #140 had grabbed and bruised Resident #70's arm. and bruised it. Review of the SRI's submitted since the facility's last annual survey on 09/12/19, revealed four SRI's involving STNA #140 as the specified perpetrator. These were SRI # 0, # 5, # 4 and # 5 and the facility found them all to be unsubstantiated. Interview on 11/03/21 at 2:55 P.M. with the Administrator indicated she was not aware STNA #140 was involved in previous SRI's at the facility. Interview on 11/03/21 at 3:40 P.M. the DON indicated STNA #140 was terminated this day due to poor customer service. Review of the undated facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate abuse, neglect, exploitation of it's residents or the misappropriation of resident property and would investigate all alleged violations. This policy indicated facility staff should immediately report all such allegations to the Administrator and to the appropriate State Department of Health. In cases where a crime was suspected, staff should also report to local law enforcement in accordance with the facility's crime reporting policy. Residents, interested family members, or other persons may contact any member of the administration or the facility's nursing staff at any time with concerns. Abuse was defined as the willful (meaning the individual acted deliberately) infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Neglect is the failure of the facility and it's employees to provide goods and services to residents necessary to avoid physical harm, pain, mental anguish, or emotional distress. The section of this policy related to facility prevention and identification procedures included identification of patterns and trends that may constitute abuse to determine the direction of their investigation. The investigation section indicated the facility would include a review of the alleged staff's employment records. This deficiency substantiates Master Complaint Number OH 112, Complaint Number OH 110 and Complaint Number OH 007.

Based on record review, interview, and review of the investigation, the facility failed to ensure Resident #103 was transferred safely with the appropriate number of staff, resulting in a large skin tear to her left leg. This affected one of three residents reviewed for safe transfers. Including finding: Review of the medical record for Resident #103 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)] disease, chronic obstructive pulmonary disease, protein-calorie malnutrition, urinary tract infections, [CONDITION(S)], pleural effusion, diabetes, cerebral infarction (stroke) with left [CONDITION(S)] (paralysis on one side of the body), [CONDITION(S)], [CONDITION(S)], low back pain, and [CONDITION(S)]. Review of the current plan of care dated 08/16/21 revealed Resident #103 had an Activities of Daily Living (ADL)/self-care deficit related to her [CONDITION(S)] accident, cognitive impairment, and weakness. Interventions included to transfer Resident #103 with two staff and indicated she was full weight bearing. Review of the Admission Minimum Data Set 3.0 (MDS) assessment, dated 08/20/21, revealed Resident #103 had moderately impaired cognition. She required extensive assistance of two staff for bed mobility, transfers, ambulation and one staff member for eating. The resident was always incontinent of bowel and bladder. Review of the nursing progress note dated 10/11/21 at 8:00 P.M. revealed Resident #103 sustained a skin tear to the back of her left hand during a transfer from the wheelchair to the shower bench. The note indicated her hand bumped the shower wall while she was holding onto the shower rail. The physician, Director of Nursing (DON) and Resident #103's daughter were notified. The nurse indicated five Steri-Strips, strips of adhesive tape placed across an incision or cut, to pull the edges of a wound together for improved healing. The wound tracking from 10/12/21 revealed Resident #103's skin tear measured 3.5 centimeters (cm) by 0.1 cm by 0.1 cm. This incident was discussed with the interdisciplinary team and they implemented two staff members to be with Resident #103 for transfers. Review of the nurse progress notes dated 10/17/21 at 10:45 A.M. revealed Resident #103 was transferring into the wheelchair and her left leg turned into the attached footrest causing a skin tear on her left outer shin area. The nurse note indicated the skin tear was cleansed with normal saline the wound edges were fairly approximated and Steri-Strips were applied. Resident #103 was noted to have increased swelling in her left hand and forearm and she said her arm was numb. Her left arm was flaccid (hanging loosely or limp). There was no facial droop noted and she was able to move her left leg. The physician was notified and an order was received to transport her to the emergency room for evaluation. Resident #103's daughter was notified of the skin tear, her status, and order to transport her to the hospital. Review of the Weekly Skin Check dated 10/17/21 revealed Resident #103 sustained a skin tear to her left outer shin area in a V shape, measuring 15 cm long by 10 cm wide. Resident #103 was readmitted to the nursing facility from the hospital on 10/19/21. Review of the Weekly Skin Check dated 10/19/21 revealed Resident #103 had 14 Steri-Strips applied to the large skin tear on her outer left shin area and it was covered with a thick absorbent dressing and wrapped with a Kerlix gauze wrap. Review of the Brief Interview of Mental Status assessment dated [DATE] revealed Resident #103 was alert, oriented and had intact cognition. Review of the facility Self-Reported Incident dated 10/20/21 revealed Resident #103 alleged STNA #140 was rough with her and hurt her leg. The DON and Administrator were notified, and an investigation was initiated. STNA #140 was suspended immediately. Resident #103's interview revealed STNA #140 was assisting her with care on 10/17/21 and he was getting her up too fast and was not allowing her the time she needed to balance herself and feel ready before trying to transfer her into the wheelchair. She stated STNA #140 pushed her quickly into the wheelchair and she cut her leg on the wheelchair. The nurse was notified of the injury and treatment was completed. This investigation revealed STNA #140 was interviewed and confirmed Resident #103 sustained a skin tear on her leg when he assisted her to transfer to the wheelchair. STNA #140 said Resident #103 was weak, not stable and started to fall so he quickly guided her to the wheelchair. STNA #140 stated he was trying to prevent a fall, so he guided her to the chair quickly and her leg scraped the side and she got a skin tear. The facility did not substantiate this allegation of physical abuse. Resident #103 stated she did not care for STNA #140 and removing him from her care was preferred. Review of the unsigned, handwritten statement for Resident #103 dated 10/20/21 revealed STNA #140 was rough with her when he stood her up. He did not give her time to get up and balance and then he pushed her into the chair. Resident #103 was agreeable to have STNA #140 removed from her care. Review of the unsigned, witness statement for STNA #140 dated 10/22/21 revealed STNA #140 was interviewed on the day of his in-service for customer service and abuse. STNA #140 reported he stood Resident #103 up at bedside and she became weak and limp on 10/17/21. STNA #140 said he quickly placed the resident in the wheelchair to prevent a fall resulting in a skin tear to calf from the wheelchair break. The employee stated he reported the change to LPN #117. Review of the undated, signed, handwritten statement from STNA #140 revealed the incident happened when transferring Resident #103 up at the bedside to pull up her pants. STNA #140 said he had the wheelchair in front Resident #103 and he was standing on her left side, which was her weak side, to get her pants up. He said she dropped her weight on her legs and her left lower leg struck the wheelchair leg rest attachment causing a skin tear. STNA #140 said he transferred the resident back to her bed and immediately notified the charge nurse. Resident #103 was discharged to another facility on 10/22/21. Interview on 11/03/21 at 12:00 P.M. with STNA #140 indicated he was transferring Resident #103 by himself from the bed to the wheelchair and her legs gave out. Then Resident #103 fell into the wheelchair, hitting her leg on the wheelchair footrest, causing a skin tear. He indicated he usually transferred and walked Resident #103 to the bathroom by himself. He stated he finds out information about the resident care needs from the Kardex but sometimes they were not updated for a couple days. He stated they were given printed copies daily to use for provision of care. STNA #140 verified he was counseled on using the proper amount of assistance with transfers since Resident #103 was supposed to have two staff for all transfers. Interview on 11/03/21 at 12:12 P.M. with the DON verified Resident #103 was to be a two-person transfer and STNA #140 had transferred her inappropriately. This deficiency substantiates Complaint Number OH 007.

Based on observation, record review and interview the facility failed to implement appropriate infection control practices during incontinence care for Resident #37. This affected one of three residents reviewed for incontinence. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of current care dated 07/18/18 revealed Resident #37 had a potential for impaired skin integrity, urinary tract infection and impaired dignity related to incontinence. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #37 had moderately impaired cognition, required extensive assistance of two staff members for bed mobility and personal hygiene, extensive assistance of one staff for dressing, and required total assistance of one staff member for toilet use. Resident #37 was always incontinent of bladder and bowel. Observation on 10/28/21 at 11:15 A.M. of provision of incontinence care for Resident #37 was conducted with State tested Nursing Assistant (STNA) #114. STNA #114 was observed to wash and rinse Resident #37 from the back, near the rectal area to the front, where the vagina and urethra (opening where urine passes from the body) are located. This could transfer bacteria from the rectum to the front and increase the risk for associated infections. Interview on 10/28/21 at 11:30 A.M. STNA #114 verified she had performed incontinence care incorrectly by washing the resident from the rectal area to the vagina/urethra area. She verified she should have washed from front to back. Review of the facility policy titled, Incontinence Care Protocol, dated 11/13, revealed the appropriate management for all residents who were incontinent included for staff to cleanse the perineal area from front to back using body wash, perineal cleaner or soap and rinse with water after each incontinence episode.

Based on observation, record review, and interview, the facility failed to provide full visual privacy during the provision of wound care for two (Resident #7 and Resident #51) of two sampled residents observed during the provision of wound care. Findings include: 1. The Admission Record documented Resident #7 had been admitted to the facility on [DATE]. The wound assessment, dated 09/10/19, found in the Assessment section of the electronic clinical record (EHR), documented the resident had a stage IV wound to the sacrum. On 09/10/19 at 2:40 P.M., Licensed Practical Nurse (LPN) #47, the facility's wound nurse, was observed as he performed wound care for Resident #7. After he washed his hands and donned gloves, LPN #47 proceeded to expose the resident from the waist down to perform the wound treatment. The window blinds were pulled up and the lower two feet of the window had no covering, allowing exposure of the resident to anyone who would have walked by on the sidewalk in the garden area outside. On 09/10/19 at 3:30 P.M., LPN #47 was asked if he had provided full visual privacy for the resident by not closing the window blinds during the wound treatment. He stated, I didn't. 2. The Admission Record documented Resident #51 was admitted to the facility on [DATE]. The wound assessment, dated 09/03/19, found in the Assessment section of the EHR, documented the resident had a healing stage IV wound to the left ischium. On 09/10/19 at 3:01 P.M., LPN #47 was observed as he performed a wound treatment for [REDACTED]. After he washed his hands and donned gloves, LPN #47 proceeded to pull down the resident's pants and incontinent pad, exposing Resident #51's genitals. He then turned the resident onto his right side, facing the window. The window blinds were wide open, exposing the resident to anyone who might have walked by on the sidewalk in the garden outside. LPN #47 did not pull the privacy curtain to protect the resident from view from the hallway. At 3:08 P.M., LPN #47 left the room to retrieve supplies from the treatment cart in the hallway, leaving the door open approximately two to two- and one-half feet, exposing the resident's naked left hip/buttock to anyone who might have walked by in the hallway. At 3:15 P.M., LPN #47 went back to the treatment cart in the hallway to get a supply, allowing the door to open all the way before closing it. This, again, exposed the resident's naked left hip/buttock to anyone who might have walked by in the hallway. The wound treatment lasted approximately 20 minutes, all of which time the resident's genitals were exposed through the open window blinds. On 09/10/19 at 3:29 P.M., the above observation regarding the exposure of Resident #51 during the wound treatment was reviewed with LPN #47. When asked if he had provided full visual privacy by not closing the blinds and by opening the door to the hallway two times to get supplies, exposing the resident to anyone who might have walked by, he stated, No. On 09/10/19 at 3:49 P.M., the above observations regarding the exposures of Resident #7 and Resident #51 during the provision of wound care were reviewed with the Director on Nursing (DON). When asked if it was facility's policy/procedure to provide full visual privacy during the provision of care, including wound care, she stated, I would assume that we would. On 09/11/19 at 1:37 P.M., the DON stated the facility had no policy/procedure for providing privacy during the provision of wound care. When asked if her expectation would be for staff to provide full visual privacy during a wound treatment, she stated, Yes.

Based on observation, record review, and interview, the facility failed to provide care in a manner to prevent cross contamination for two (Resident #7 and Resident #30) of four sampled residents for whom the provision of care was observed. Findings include: 1. The Admission Record documented Resident #7 had been admitted to the facility on [DATE]. The wound assessment, dated 09/10/19, found in the Assessment section of the electronic health record (EHR), documented the resident had a stage IV wound to the sacrum. On 09/10/19 at 2:40 P.M., Licensed Practical Nurse (LPN) #47, the facility's wound nurse, was observed performing wound care for Resident #7. Upon completion of the wound treatment, LPN #47 repositioned the resident's urine-saturated incontinent brief, rolled the resident onto her back and, without removing his contaminated gloves, proceeded to handle the resident's call light, bed control, and linens and re-applied her pressure-reducing boots. On 09/10/19 at 3:30 P.M., the above observation regarding touching clean items with contaminated gloves was reviewed with LPN #47. He was asked if his failure to remove soiled/contaminated gloves prior to touching clean items in the room was good infection control to prevent cross contamination. He stated, No. On 09/10/19 at 3:49 P.M., the above observation regarding touching clean items with contaminated gloves was reviewed with the Director of Nursing (DON). When asked if touching clean items while wearing soiled gloves was a good infection control practice, the DON stated she agreed it was not good infection control to handle clean items with soiled gloves. On 09/11/19 at 1:37 P.M., the DON stated the facility had no policy/procedure for the performance of wound care. She stated her expectation would be for staff to use proper hand hygiene to prevent cross contamination during the provision of a wound treatment. The facility's Infection Control Policies Transmission-Based Precautions policy, last reviewed 11/2017, documented: Gloves and Hand washing 1) Wear gloves as you would in standard precautions, and during the course of providing direct personal care for a resident. Change gloves after having contact with infective material that may contain high concentrations of microorganisms. 2. Review of Resident #30's Face Sheet located in the resident's paper medical chart indicated Resident #30 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/19, documented the resident had been readmitted from an acute hospital setting. The quarterly resident assessment documented the resident was totally dependent on one person for physical assistance with all personal/hygienic care; had a suprapubic catheter, a [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], was quadriplegic, and was taking an antibiotic medication. Review of Resident #30's annual MDS assessment, with an ARD of 07/03/19, documented the resident was totally dependent on staff for all her care needs; had a suprapubic catheter, a [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], was quadriplegic; and had a urinary tract infection [MEDICAL CONDITION] within the last 30 days. Review of Resident #30's plan of care, revised on 07/17/19, documented a potential for complications related to an indwelling catheter; had bladder spasms, chronic UTI, and had a very malodorous urine. The goal was for Resident #30 to remain free of signs and symptoms (s/s) of UTI's and avoid complications. Interventions included: catheter care per the facility's policy and after each incontinent episode of bowel; assess patency of elimination equipment; observe drainage; assess urine color; observe and record output every shift; urinary assessment as needed; administer medications as ordered; observe for side effects and effectiveness; monitor labs; obtain urine analysis (U/A) and culture and sensitivity (C&S) per medical doctor (MD) if s/s of UTI occur; report results to MD and initiate treatment as ordered. Review of Resident #30's recent lab results revealed on 06/21/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI. On 07/10/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI with a culture of Acinetobacter Baumanni/Haemolyticus, a multidrug-resistant (superbug), emerging pathogen in the healthcare system commonly found on the skin. On 08/02/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI. Lab was reported critical and was positive for Ecoli, a type of bacteria that normally lives in the intestine, and ESBL (extended spectrum beta lactamase) positive, an enzyme that causes some antibiotics not to work for treating bacterial infections (superbug). Observation on 09/09/19 at 2:37 P.M. revealed Resident #30 lying in her bed. Attached on the side of the resident's bed was a catheter bag draining per gravity. The catheter bag was approximately half full of pale-yellow urine with white colored mucus and sediment. On 09/11/19 at 2:20 P.M. State tested Nursing Assistant (STNA) #81 was observed performing suprapubic care for Resident #30. STNA #81 washed her hands, put on disposable gloves, filled two plastic pans with warm water, and placed a washcloth in each pan of warm water. STNA #81 took a bottle of cleansing body soap and squirted the soap out of the bottle onto one washcloth. STNA #81 then took the soapy washcloth and cleaned around Resident #30's suprapubic catheter site. STNA #81 then returned the soapy washcloth back into the pan. Without changing the gloves STNA #81 had just cleaned the catheter site with, STNA #81 took the clean, unused washcloth and wiped the soap off from around the suprapubic catheter site. The catheter bag at that time remained draining per gravity from the side of the resident's bed. The urine was light yellow and slightly cloudy. Following the observation, STNA #81 was asked why she did not change her gloves after cleaning the suprapubic catheter with the soapy washcloth and before cleansing the soap off the catheter site (dirty to clean). STNA #81 replied, I was not taught that way. I understand what you are saying though. During an interview, regarding the suprapubic catheter care performed on Resident #30 by STNA #81 on 09/11/19 at 3:00 P.M., the DON was explained how everything had been set up and then explained how the care had been performed step by step. The DON was then asked if she had noticed anything performed incorrectly by STNA #81. The DON stated, She (STNA #81) didn't change gloves between dirty and clean. On 09/12/19 at 9:15 [NAME]M., LPN #14 who worked on Resident #30's unit was asked if Resident #30 experienced frequent UTI's. She stated, Yes, she does. She was asked who performed the care to Resident #30's suprapubic catheter site. LPN #14 said the assistants did the care every shift. Review of the facility's policy titled, Catheter Care undated, indicated, Policy: It is the policy of (name deleted) that catheter care will be provided as ordered. Protocol: [NAME] Gather soap and water. B. Wash hands, put on gloves. C. Wash around catheter site, monitor for drainage or bleeding from site. D. Remove gloves and wash hands. E. Notify nurse of any abnormal findings. F. Catheter Care to be prepared Q (every) shift and PRN (as needed).

Based on observation and interview, the facility failed to ensure sanitary conditions in the dining room and the kitchen. This affected 40 residents (Resident #48, #16, #41, #44, #42, #2, #73, #77, #17, #43, #94, #22, #6, #13, #21, #34, #69, #55, #5, #88, #90, #58, #38, #64, #18, #28, #74, #7, #27, #1, #59, #15, #76, #41, #78, #57, #29, #32, #63, and #49) who ate in the dining room and 89 residents who received meals from the kitchen (Resident #4 was ordered nothing-by-mouth). The census was 90. Findings include: 1. Observation on 06/25/18 from 11:10 A.M. to 11:54 A.M. during lunch service revealed Dietary Aide (DA) #3 serving beverages to residents while holding the rim of the cups by her fingers and serving soup while putting her thumb on the inside of the soup bowl. DA #4 was also serving beverages to residents while holding the rim of the cups by her fingers after touching the beverage cart handle and holding the beverages against her shirt. State tested Nurse Aide (STNA) #5 was assisting Resident #58 with her meal. STNA #5 picked up a cup of water, with her fingers on the rim, and gave the cup of water to Resident #58. Resident #58 drank the water with her mouth to the rim of the cup. Interview on 06/25/18 at 12:01 P.M. with Registered Dietitian #6 verified cups should not be held by the rim. 2. Observation on 06/26/18 from 4:43 P.M. to 5:23 P.M. in the kitchen revealed Cook #7 placing four serving scoops on the top of a visibly dirty cart. The four serving scoops were going to be used to serve the dinner meal until the surveyor intervened. DA #8 was carrying cups of water and apple juice with her fingers resting on the rim of the cups. Cook #7 grabbed the handle of the refrigerator with her right, gloved hand then touched Resident #51 and Resident #73's turkey and cheese sandwich with the same gloved hand without changing gloves or completing hand hygiene. Interview on 06/26/18 at 6:10 P.M. with Dietary Manager (DM) #2 verified Cook #7 should not have touched the resident's sandwiches after grabbing the handle of the refrigerator and DA #8 should not be carrying cups with fingers on the rim of the cups. DM #2 also verified the cart, that the scoops were placed on, was dirty.

Based on observation, menu review and interview, the facility failed to ensure the menu was followed for nutrition adequacy. This affected 10 residents (Residents #58, #41, #3, #76, #44, #22, #52, #21, #33 and #63) who were ordered a pureed diet. Findings include: Review of the 06/26/18 dinner menu, initialed by Registered Dietitian #9, indicated a #6 scoop (2/3 cup) was to be used to serve the pureed hamburger with bun, a #12 scoop (1/3 cup) was to be used to serve the pureed corn on the cob and pureed pickles was to be served. Mashed potatoes were not on the menu. Observation on 06/26/18 at 5:03 P.M. during tray line service revealed Cook #7 used a #16 scoop (1/4 cup) to serve the pureed hamburgers (without buns) and a #16 scoop to serve the pureed corn. Cook #7 did not serve pureed pickles to Resident #44, Resident #88, and Resident #58. Interview, during the observation, with Cook #7 verified buns were not combined with the pureed hamburgers instead Cook #7 served ½ cup of mashed potatoes. Cook #7 also verified she forgot to serve the pureed pickles to Residents #44, #88 and #58. Interview on 06/26/18 at 6:10 P.M. with Dietary Manager #2 verified Cook #7 used the incorrect serving scoop to serve the pureed hamburgers (without buns) and the pureed corn.

Based on observation, meal ticket review, record review and interview, the facility failed to ensure food preferences were honored for Resident #52. This affected one (Resident #52) of three residents reviewed for food. Findings include: Record review of Resident #52 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 04/08/18 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #52 was moderately-cognitively impaired and was ordered a mechanically-altered diet. Review of the (MONTH) (YEAR) physician orders [REDACTED]. Review of Resident #52's undated lunch meal ticket indicated Resident #52 disliked spinach. Interview on 06/25/18 at 10:58 A.M. with Resident #52's family member indicated Resident #52 had a list of food items Resident #52 disliked; however, the kitchen frequently sent those food items on her meal tray. Observation on 06/27/18 at 11:45 A.M. revealed Resident #52 was in the dining room being assisted with her lunch meal by Speech Language Pathologist (SLP) #1. Resident #52 had a diced grilled cheese sandwich on one plate and had pureed chicken, pureed bread, pureed potatoes and pureed spinach on another plate with portions of the pureed potatoes eaten; the pureed spinach was untouched. Interview on 06/27/18 at 11:48 A.M. with Dietary Manager #2 verified Resident #52 disliked pureed spinach and the cook did not prepare an alternate pureed vegetable to offer Resident #52.

Based on observation, record review and interview the facility failed to position Resident #18's urinary catheter drainage bag to prevent infection. This affected one of one resident (Resident #18) reviewed for indwelling urinary catheter use. Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was alert but forgetful and able to make her needs known. The assessment revealed the resident was totally dependent on two plus staff members for bed mobility, transfers, toilet use, bathing, dressing, eating and personal hygiene. On 06/26/18 at 8:45 A.M., Resident #18 was observed seated in wheelchair in the dayroom during activities. Resident #18's urinary catheter drainage bag was observed on the floor with the urinary catheter tubing tangled in the wheels of the wheelchair. The catheter tubing was observed to have tea-colored urine. The Activities Director approached Resident #18 and attempted to elevate the urinary catheter bag from the floor and untangle the tubing. During an interview with State tested nursing assistant (STNA) #10 on 06/26/18 at 8:50 A.M., she verified that Resident #18's urinary catheter drainage bag was on the floor. STNA #10 attempted to reposition the drainage bag unsuccessfully. STNA conferred with the D-wing nurse and indicated the drainage bag would be changed to a leg bag for better positioning. On 06/27/18 at 3:50 P.M., Resident #18 was observed seated in her wheelchair in the dayroom. Resident #18's urinary catheter drainage bag was observed on the floor with the urinary catheter tubing tangled in the wheels of the Resident's wheelchair. Interview with Licensed Practical Nurse (LPN) #11 on 06/27/17 at 3:55 P.M. verified that the urinary catheter drainage bag was on the floor. Review of the facility's policy titled Long Term Catheter Use/Management dated June, 2014 revealed urinary catheters would be managed according to the catheter care policy. Review of the facility's policy titled Catheters: Long Term Catheter Use dated September, 2013 revealed measures would be used to reduce the risk of urinary tract infection and promote a system resistive to bacterial invasion. Per the policy, the drainage bag and tubing should not touch the floor.

Based on record review and interview, the facility failed to ensure controlled medications were properly accounted for for Resident #1, one of three residents reviewed for medication needs, and had the potential to affect 20 residents who receive controlled medications on an as needed basis. Findings include: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. a. Resident #1 had a current order for Morphine Sulfate, a narcotic pain medication, 5 milligrams (mg)/0.25 milliliters (ml) every four hours as needed for pain. Review of the Controlled Substance Record (CSR) for the month of August 2017 indicated this medication was signed out on 25 occasions, yet the corresponding Medication Administration Record [REDACTED]. b. Resident #1 had a current order for Valium, 2 mg one tablet every eight hours as needed for anxiety. Review of the CSR for the month of August 2017 indicated this medication was signed out on 33 occasions, yet the corresponding MAR for the same month revealed the resident received this controlled medication 12 times, a discrepancy rate of 36%. c. Resident #1 had a current order for Ativan 0.5 mg one tablet every four hours as needed for anxiety or agitation. Review of the CSR for the month of August 2017 indicated this medication was signed out on 21 occasions, yet the corresponding MAR for the same month revealed the resident received this controlled medication nine times, a discrepancy rate of 21%. These findings were confirmed with the Director of Nursing on 08/27/17 at 2:20 P.M.

Based on record review and interview, the facility failed to assess and evaluate Resident #1 and administer only the appropriate controlled medication and/or other pain medication each time. This affected one of three residents reviewed for medication needs. Findings include: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. a. Resident #1 had a current order for [MEDICATION NAME], a narcotic pain medication, 5 milligrams (mg)/0.25 milliliters (ml) every four hours as needed for pain. Review of the Controlled Substance Record (CSR) for the month of August 2017 indicated this medication was signed out on 25 occasions, yet the corresponding Medication Administration Record [REDACTED]. b. Resident #1 had a current order for [MEDICATION NAME], 2 mg one tablet every eight hours as needed for anxiety. Review of the CSR for the month of August 2017 indicated this medication was signed out on 33 occasions, yet the corresponding MAR for the same month revealed the resident received this controlled medication 12 times. c. Resident #1 had a current order for [MEDICATION NAME] 0.5 mg one tablet every four hours as needed for anxiety or agitation. Review of the CSR for the month of August 2017 indicated this medication was signed out on 21 occasions, yet the corresponding MAR for the same month revealed the resident received this controlled medication nine times. The resident was also ordered, and received another pain medication, [MEDICATION NAME] 50 mg every four hours as needed for pain. According to the MAR, Resident #1 received multiple doses of these as needed medications at the same time without an assessment or evaluation if one medication would be effective to address the behaviors and/or pain prior to the delivery of a second medication. [MEDICATION NAME] and [MEDICATION NAME] (both pain relievers) were given at the same time on 08/03/17 and 08/10/17; [MEDICATION NAME] and [MEDICATION NAME] were both administered simultaneously on 08/18/17; [MEDICATION NAME] and [MEDICATION NAME] were both administered at the same time on 08/04/17, 08/09/17, and on three occasions on 08/07/17. These findings were confirmed with the Director of Nursing on 08/27/17 at 2:20 P.M.

Based on record review and interview the facility failed to assist Resident #51 with obtaining a hearing aid in a timely manner. This affected one out of one resident with a missing hearing aid. Findings include: During the annual survey on 04/18/17 at 10:20 A.M. an interview with Resident #51's daughter indicated the facility had not scheduled an appointment with the audiologist or other service to obtain a replacement hearing aid for Resident #51. Resident #51's daughter indicated her mother was very hard of hearing and had lost her right hearing aid during the move from the previous facility to the present facility. Resident #51's daughter stated she had informed the staff at the facility several months ago but was unable to remember the name of the staff member. Resident #51's daughter stated she had not been informed of any attempts to obtain a replacement hearing aid. Resident #51 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #51's Transfer Sheet dated 10/17/16 indicated physician orders [REDACTED]. The physician orders [REDACTED].#51's hearing aid every day and remove at night and store in a container in the bedside drawer. An interview with Resident #51 on 04/18/17 at 4:30 P.M. revealed the facility was aware of her missing hearing aid. Resident #51 stated upon admission she informed the facility of the missing hearing aid and thought it was lost during the transfer from the previous facility to the present facility. Resident #51 stated the facility called the previous facility and asked them to look for the hearing aid. The previous facility was unable to locate the hearing aid. Resident #51 stated she requested the present facility to arrange services to obtain a new hearing aid. Resident #51 stated the facility was aware of her request at the time of her admission to the facility in October, 2016. Resident #51 stated the facility had failed to follow-up with her on the progress for obtaining a new hearing aid. Resident #51 stated she did not attend activities at the facility due to her inability to hear the instructions or what was going on during the activities. An interview with the Licensed Social Worker (LSW) on 04/19/17 at 10:00 A.M. revealed she was aware of Resident #51's missing hearing aid. The LSW stated she had been aware of the missing hearing aid for a couple months and failed to implement the needed actions to assist Resident #51 with obtaining her hearing aid. On 04/20/17 at 11:19 A.M. the LSW stated there was no appointment scheduled with an audiologist or other service to assist Resident #51 with replacing her lost hearing aid.

Based on observation, record review and interview the facility failed to ensure water pitchers were routinely filled and within reach for residents to independently access to maintain adequate hydration. This affected seven residents (Resident #5, #66, #86, #13, #62, #61 and #21) observed during the complaint investigation. The facility census was 95. Findings include: Observation of resident rooms on 03/06/17 from 4:33 P.M. to 5:00 P.M. revealed the following residents without water pitchers or fluids in their rooms out of reach: Resident #5 did not have a water pitcher available to her in her room. Interview with Resident #5's daughter at the time of the observation revealed each time she visits her mother does not have a water pitcher in her room. The resident's daughter indicated she felt her mother would drink more if she had a pitcher full of water. Resident #66's water pitcher was up against the window and out of the resident's reach. Resident #86 did not have a water pitcher in her room. Resident #13 had three glass of fluid on a small shelf on the entrance to her room. Resident #13 did not have a water pitcher and the fluids were approximately 10 feet out of her reach. Resident #62 did not have a water pitcher in her room. Resident #61 did not have a water pitcher in her room. Review of the facility resident council meeting minutes, dated 01/09/17 revealed the council members complained water pitchers were not being filled for residents. Interview with Resident # 21's family member on 03/06/17 at 4:45 P.M. revealed there were times she would come in at different hours and Resident #21 would not have a water pitcher for the entire shift. Resident #21's family member stated her husband did not complain about not having a water pitcher. Interview with the Director of Nursing (DON) on 03/06/17 at 9:30 P.M. revealed water pitchers were picked on night shift and taken to the dietary department. The dietary department would wash the pitchers and staff would filled the pitchers with ice water. The DON verified every resident should have a water pitcher unless on a fluid restriction. Interview with the Administrator on 03/06/17 at 10:00 P.M. revealed she was unaware residents did not have water pitchers as noted above. Review of the facility's undated hydration policy revealed the policy was to ensure residents had access to fluids throughout the day as needed and as requested by the residents unless otherwise ordered or restricted by the physician. Residents would be delivered fluids during all three meals. Resident were provided fluids during medication administration. Fluids were available from the dietary department upon request. Ice water would be passed on all units daily and as needed. This deficiency substantiates Complaint Number OH 772.