Every finding on record at Hillebrand Nursing and Rehabilitation Center

Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least eight consecutive hours a day seven days a week. This had the potential to affect all of the residents residing in the facility. The facility census was 98 residents.Findings include: Review of the facility staffing schedules revealed on 03/22/26 the census was 96 residents and there was no RN on the schedule for this date. Interview on 03/26/26 at 1:04 P.M. with the Director of Nursing (DON) verified there was no RN working during the 24 hours on the date of 03/22/26. The DON verified there needed to be an RN working eight hours of each day. Interview on 03/26/26 at 1:30 P.M. with the Administrator verified there was no RN working on 03/22/26 and an RN was required to work eight hours of each day.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents experienced a dignified dining experience. This affected one (Resident #104) of three residents reviewed for dignity. The facility census was 98 residents. Findings include:Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Observations of the afternoon meal in the dining room on 03/23/26 at 12:00 P.M. revealed Resident #104 was seated at a table with other residents. Certified Nursing Assistant (CNA) #329 brought Resident #104's tray to the table and stood over the resident and began feeding the resident large bites. Resident #104 pushed CNA #329's hand away. CNA #329 did not provide the resident with the opportunity to feed herself, and the CNA remained standing over the resident during the entire meal continuing to put large bites of food into the resident's mouth. Interview on 03/23/26 at 12:30 P.M. with Licensed Practical Nurse (LPN)#104) confirmed CNA #329 should have sat down next to Resident #104 at eye level and should have assisted as the resident fed herself. Review of the facility policy titled Mealtimes undated revealed meals should foster resident independence and improve their quality of life.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident call lights were accessible to the resident. This affected one (Resident #86) of three residents reviewed for accidents and hazards. The facility census was 98 residents. Findings include: Review of the medical record for Resident #86 revealed an admission date of 07/22/23 with diagnoses including vascular dementia, respiratory failure, and dysphagia. Review of the care plan for Resident #86 dated 12/10/25 revealed the resident was at risk for falls related to deconditioning, and gait and balance problems. Interventions including the following: provide a safe environment, ensure the call light was working, ensure the call light was within reach. Review of the Minimum Data Set (MDS) for Resident #86 dated 03/04/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Observation on 03/23/26 at 12:21 P.M. of Resident #86 revealed the resident was sitting up in a wheelchair beside his bed and was yelling out for help. The resident's call light was wrapped around the bed rail out of the resident's reach, and the resident was unable to get to the call light independently. Interview on 03/23/26 at 12:21 P.M. of Resident #86 confirmed he needed assistance and could not reach or get to his call light. Observation on 03/23/26 at 12:24 PM revealed Certified Nurse Assistant (CNA) #329 entered Resident #86's after being notified and assisted the resident and then exited the room. CNA #329 did not place the resident's call light in reach. Interview on 03/23/26 at 12:26 P.M. with CNA #329 confirmed Resident #86 was able to use his call light to summon assistance, but the call light was out of the resident's reach, and the resident was unable to get to it. CNA #329 confirmed staff should always ensure resident call lights are in reach before leaving the resident's room. Review of the facility policy titled Resident Call System dated 11/01/25 revealed each resident when not in direct observation of staff would have the call light readily accessible. Purposeful removal or displacement of the call light by staff members was prohibited.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advance directives were accurate. This affected two (Residents #1 and #11) of three residents reviewed for advance directives. The facility census was 98 residents. Findings include: 1.Review of the medical record for Resident #1 revealed an admission date of 10/11/24 with diagnoses including unspecified bacterial pneumonia, acute pulmonary edema, and Parkinsonism unspecified.Review of the physician's orders for Resident #1 revealed an order dated 12/11/25 for the resident to be a full code. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 12/16/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of a paper form in Resident #1's chart undated revealed the resident's code status was do not resuscitate comfort care-arrest (DNRCC-A). Interview on 03/24/26 at 2:29 P.M. with Licensed Practical Nurse (LPN) #114 verified the physician's order in the electronic health record was for Resident #1 to be a full code and there was a signed DNRCC-A form in the paper chart, and it was unclear which code status was correct. 2. Review of the medical record for Resident #11 revealed an admission date of 06/28/25 with diagnoses including hypertensive heart disease, chronic kidney disease, and cerebral infarction Review of the physician orders for Resident #11 in the electronic health record revealed an order dated 06/28/25 for a code status of DNRCC - Arrest. Review of the MDS assessment for Resident #11 dated 12/30/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the paper chart for Resident #11 revealed it contained a paper code dated 06/10/25 for DNRCC-A and an undated form for DNRCC. Interview on 03/24/26 at 2:21 P.M. with LPN #114 verified the physician order in the electronic health record was for Resident #11 to be a DNRCC-A and there were two paper forms in the chart, one for DNRCC-A and another for DNRCC. LPN #114 confirmed it was unclear which code status was correct. Review of the facility policy titled Advance Care Planning revised 04/28/25 revealed the charge nurse or designee would notify the physician of advance directives so that appropriate orders could be documented in the resident's medical record and plan of care.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of staff witness statements, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from verbal/emotional abuse. This affected one (Resident #104) of three residents reviewed for abuse. The facility census was 98 residents.Findings include:Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the facility SRI initiated 03/23/26 and completed 03/27/26 revealed the facility's investigation determined Certified Nursing Assistant (CNA) #329 had verbally/emotionally abused Resident #104. CNA #329 was terminated from employment as a result of the abuse. Review of the SRI included review of a signed witness statement per CNA #329 dated 03/23/26 which revealed the aide acknowledged she was feeding Resident #104 and when the resident spilled her drink, the aide sighed, took her gloves off, and pointed at the resident. Review of the SRI included review of a signed witness statement per LPN #920 dated 03/23/26 which revealed the Surveyor reported to LPN #920 that CNA #329 was standing over and feeding Resident #104 and the aide had taken off her gloves, thrown them on the table, and the aide pointed her finger in the resident's face. LPN #920 then sent CNA #329 out of the dining room and took over feeding Resident #104. Review of the SRI included review of a signed witness statement per LPN #108 undated revealed she was doing rounds in the facility with the Medical Director (MD) when another state Surveyor approached the MD and indicated an aide had yelled at a resident for spilling her drink. LPN #108 observed CNA #329 sitting at the desk after LPN #920 had told the aide to leave the dining room. Observations of the afternoon meal in the dining room on 03/23/26 at 12:20 P.M. revealed Certified Nursing Assistant (CNA) #329 was wearing medical gloves and was standing over Resident #104 feeding the resident large bites. Resident #104 repeatedly pushed CNA #329's hand away and the aide responded by pushing the resident's hands down. Resident #104 picked up a glass of juice, and when CNA attempted to remove the juice from the resident's hand, the juice spilled onto the table. CNA #329 then grimaced with anger, sighed loudly, tore her gloves off, threw the gloves onto the table in front of the resident, and then the CNA put her index finger up near the resident's face. Resident #104 hung her head and said nothing. Staff told CNA #329 to leave the dining room, and the aide walked out of the dining room. During an interview on 03/23/26 at 12:21 P.M, Licensed Practical Nurse (LPN) #920 stated she would finish assisting the resident with her meal. LPN #920 told CNA #329 to leave the dining room, but the aide was allowed to remain on the unit. Review of the facility Abuse Policy updated 09/01/25 revealed verbal abuse was defined as any use of oral, written or gestured language that included disparaging and derogatory terms to residents or families. All abuse was to be reported immediately for investigation.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the state agency in a timely manner. This affected one (Resident #21) of three residents reviewed for abuse. The facility also failed to report allegations of abuse to the state agency. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 02/10/25 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #21 revealed the resident was cognitively intact. Record review of the facility SRI initiated 03/16/26 revealed an allegation of physical abuse in which Resident #21 reported on 03/13/26 that Registered Nurse (RN) #204 allegedly struck her ear with a towel. Interview on 03/25/26 at 4:41 PM with RN # 204 confirmed the alleged incident of abuse occurred on 03/13/26 at approximately 10:30 PM and was reported immediately to the Licensed Practical Nurse (LPN) supervisor #107. RN #204 confirmed that on 03/13/26, Resident #21 reported to LPN Supervisor #107 that RN #204 physically struck Resident #21 with a towel. Interview on 03/26/26 at 10:14 A.M. with the Director of Nursing (DON) confirmed she was first notified of Resident #21's allegation of abuse per RN #204 on 03/16/26. The DON confirmed staff were expected to report allegations of abuse immediately to their direct supervisor, and the supervisor was expected to escalate the allegation to the DON or Administrator immediately. The DON confirmed the allegation of abuse was made on 03/13/26, but the incident was not reported to her until 03/16/26 which is why the SRI was not initiated until 03/16/26. 2. Review of medical record for Resident #10 revealed an admission date of 06/16/25 with diagnoses including osteomyelitis of right ankle and foot, diabetes mellitus type two, and morbid obesity. Review of the MDS assessment for Resident #10 revealed the resident was cognitively intact and used a wheelchair for mobility. Review of the facility SRIs for October 2025 revealed there were no SRIs filed regarding Resident #10. During an interview on 03/25/26 at 6:59 A.M., the DON stated someone, she couldn't remember who, had reported to her that sometime in October 2025, she couldn't remember the date, Resident #10 alleged Certified Nursing Assistant (CNA) #351 had called Resident #10 a baby. The DON reported CNA #351 was removed from Resident #10's care but not from resident care while administration did an internal investigation. The DON confirmed CNA #351 received a disciplinary write-up related to the allegation of verbal abuse per Resident #10, but the facility had not filed an SRI. Review of the facility policy titled Reporting Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Property, dated 11/16/16, revised 06/01/25, revealed all suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. The policy further revealed allegations of abuse are to be reported immediately to the nursing supervisor, Director of Nursing, and Administrator.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of staff witness statements, observation, staff interviews, and review of the facility policy, the facility failed to prevent possible further abuse by not removing staff from the facility during the investigation. This affected three (Residents #104, #21, and #10) of three residents reviewed for abuse. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the facility SRI initiated 03/23/26 and completed 03/27/26 revealed the facility's investigation determined Certified Nursing Assistant (CNA) #329 had verbally/emotionally abused Resident #104. CNA #329 was terminated from employment as a result of the abuse. Review of the SRI included review of signed witness statement per CNA #329 dated 03/23/26 which revealed the aide acknowledged she was feeding Resident #104 and when the resident spilled her drink, the aide sighed, took her gloves off, and pointed at the resident. Review of the SRI included review of a signed witness statement per LPN #920 dated 03/23/26 which revealed the Surveyor reported to LPN #104 that CNA #329 was standing over and feeding Resident #104 and the aide had taken off her gloves, thrown them on the table, and the aide pointed her finger in the resident's face. LPN #920 then sent CNA #329 out of the dining room and took over feeding Resident #104. Review of the SRI included review of a signed witness statement per LPN #108 undated revealed she was doing rounds in the facility with the Medical Director when a state Surveyor approached the MD and indicated an aide had yelled at a resident for spilling her drink. LPN #108 observed CNA #329 sitting at the desk after LPN #104 had told the aide to leave the dining room. Observations of the afternoon meal in the dining room on 03/23/26 at 12:20 P.M. revealed Certified Nursing Assistant (CNA) #329 was wearing medical gloves and was standing over Resident #104 feeding the resident large bites. Resident #104 repeatedly pushed CNA #329's hand away and the aide responded by pushing the resident's hands down. Resident #104 picked up a glass of juice, and when CNA attempted to remove the juice from the resident's hand, the juice spilled onto the table. CNA #329 then grimaced with anger, sighed loudly, tore her gloves off, threw the gloves onto the table in front of the resident, and then the CNA put her index finger up near the resident's face. Resident #104 hung her head and said nothing. Staff told CNA #329 to leave the dining room, and the aide walked out of the dining room. During an interview on 03/23/26 at 12:21 P.M, Licensed Practical Nurse (LPN) #920 stated she would finish assisting the resident with her meal. LPN #920 told CNA #329 to leave the dining room, but the aide was allowed to remain on the unit. Interview on 03/26/26 at 10:14 AM with the Director of Nursing (DON) confirmed staff members accused of abuse should not be permitted to remain in the facility while an abuse investigation was pending. 2.Review of the medical record for Resident #21 revealed an admission date of 02/10/25 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the MDS assessment for Resident #21 revealed the resident was cognitively intact. Record review of the facility SRI initiated 03/16/26 revealed an allegation of physical abuse in which Resident #21 reported on 03/13/26 that Registered Nurse (RN) #204 allegedly struck her ear with a towel. Review of the facility staffing schedule dated 03/13/26 through 03/15/26 revealed RN #204 continued to be assigned to work during the time period following the allegation. Interview on 03/25/26 at 4:41 P.M. with RN # 204 confirmed the alleged incident of abuse occurred on 03/13/26 at approximately 10:30 PM and was reported immediately to the Licensed Practical Nurse (LPN) supervisor #107. RN #204 confirmed that on 03/13/26, Resident #21 reported to LPN Supervisor #107 that RN #204 had physically struck Resident #21 with a towel. Interview on 03/26/26 at 10:14 A.M. with the Director of Nursing (DON) confirmed she was first notified of Resident #21's allegation of abuse per RN #204 on 03/16/26. The DON confirmed staff were expected to report allegations of abuse immediately to their direct supervisor, and the supervisor was expected to escalate the allegation to the DON or Administrator immediately. The DON confirmed the allegation of abuse was made on 03/13/26, but the SRI was not initiated until 03/16/26 and RN #204 continued to work in the facility from 03/13/26 to 03/16/26. 3. Review of medical record for Resident #10 revealed an admission date of 06/16/25 with diagnoses including osteomyelitis of right ankle and foot, diabetes mellitus type two, and morbid obesity. Review of the MDS assessment for Resident #10 revealed the resident was cognitively intact and used a wheelchair for mobility. Review of the facility SRIs for October 2025 revealed there were no SRIs filed regarding Resident #10. During an interview on 03/25/26 at 6:59 A.M., the DON stated someone, she couldn't remember who, had reported to her that sometime in October 2025, she couldn't remember the date, Resident #10 alleged Certified Nursing Assistant (CNA) #351 had called Resident #10 a baby. The DON reported CNA #351 was removed from Resident #10's care but not from resident care while administration did an internal investigation. The DON confirmed CNA #351 received a disciplinary write-up related to the allegation of verbal abuse per Resident #10. Interview on 3/26/26 at 9:15 A.M. with the DON confirmed she was unable to locate the facility's internal investigation of verbal abuse per CNA #351 towards Resident #10 sometime in October 2025 nor did the aide's personnel file contain a disciplinary write-up related to the abuse allegation per Resident #10 against CNA. Review of the facility policy titled Reporting Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Property, 06/01/25, revealed all suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. The policy further revealed allegations of abuse are to be reported immediately to the nursing supervisor, Director of Nursing, and Administrator. Review of the facility Abuse Policy updated 09/01/25 revealed all allegations of abuse were to be reported immediately for investigation. If staff are accused of abuse they should be removed from the facility during the investigation.

Based on medical record review and staff interview, the facility failed to ensure residents were offered pneumococcal vaccines and failed to ensure resident medical records included documentation of receipt or refusal of the vaccine. This affected two (Residents #4 and #8) of five residents reviewed for infection control. The facility census was 98 residents. Findings include: 1.Review of the medical record for Resident #4 revealed an admission date of 08/24/23 with diagnoses including vascular dementia, malignant neoplasm of bladder, and atrial fibrillation. Review of the immunization record for Resident #4 revealed it did not include documentation of administration of the pneumococcal vaccine, did not include documentation of the resident receiving the vaccine prior to admission to the facility, nor did the record include documentation of resident refusal of the vaccine. 2.Review of the medical record for Resident #8 revealed an admission date of 11/06/22 with diagnoses including end stage renal disease, nonrheumatic aortic stenosis, and diabetes mellitus type two. Review of the immunization record for Resident #8 revealed it did not include documentation of administration of the pneumococcal vaccine, did not include documentation of the resident receiving the vaccine prior to admission to the facility, nor did the record include documentation of resident refusal of the vaccine. Interview on 03/26/26 at 1:32 P.M. with the Director of Nursing (DON) confirmed residents should be offered vaccines and education regarding vaccines during their first care conference at the facility. The DON confirmed there was no documentation in Residents #4 and #8's medical records to indicate if either resident had received the pneumococcal vaccine in the past, had refused the vaccine, or if the vaccine was withheld due to medical contraindications.

Based on medical record review, review of facility fall investigations, resident interview, and staff interview the facility failed to ensure safe resident transfers to prevent falls. This affected one (Resident #4) of three residents reviewed for accidents and hazards. Based on medical record review, observation, and staff interview, the facility failed to follow safe swallowing recommendations during mealtime. This affected one (Resident #104) of three residents reviewed for accident hazards. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #4 revealed an admission date of 06/09/23 with diagnoses including vascular dementia, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #4 revealed the resident was cognitively intact and required the assistance of one staff with transfers. Review of the nurse progress note for Resident #4 dated 03/23/26 at 7:23 A.M. revealed the nurse was called to the resident room because the resident had fallen in the bathroom while a staff person was assisting with transferring the resident from the toilet. Review of the facility investigation for Resident #4's fall on 03/23/26 revealed staff had transferred the resident from the toilet without using a gait belt. Interview on 03/23/26 at 4:45 P.M with Resident #4 confirmed she had fallen in the bathroom earlier in the day while staff were transferring her, and the fall occurred because the staff person had not transferred her correctly. Interview on 03/26/26 at 11:30 A.M. with the Director of Nursing (DON) confirmed the facility policy was to use gait belts with all manual transfers. The DON stated the aide who transferred Resident #4 on 03/23/26 at approximately 7:23 A.M. was Certified Nursing Assistant (CNA) #329 and the aide had not used a gait belt as per policy. Review of the facility policy titled Gait Belts undated revealed staff should always have a gait belt on their person. Gait belts should be used for assisting residents with ambulation and transfers from sitting or standing. 2, Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the physician's orders for Resident #104 dated March 2026 revealed the resident was receiving a mechanical soft diet. The orders specified the resident needed partial feeding assistance such as set up, cueing, sips of fluids between one to two bites, a divided plate, built-up utensils, and was not to use straws. Observation 03/26/26 at 12:45 P.M of the afternoon meal revealed Resident #104 was drinking a soda with the use of a straw. Interview on 03/26/26 at 12:50 P.M with CNA #305 confirmed she was not aware of the resident's requirements for safe swallowing which included the residents were not to drink using a straw. Interview on 03/26/26 at 1:00 P.M with Licensed Practical Nurse (LPN) #920 confirmed Resident #104 had been drinking with a straw, but the resident had a physician's order not to drink with straws due to the resident's requirements for safe swallowing.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents had adaptive utensils at meals as ordered by the physician. This affected one (Resident #104) of 24 residents sampled. The facility census was 98 residents. Findings include: . Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the physician's orders for Resident #104 dated March 2026 revealed the resident received a mechanical soft diet. The orders specified the resident needed partial feeding assistance such as set up, cueing, sips of fluids between one to two bites, divided plate and built-up utensils and no straws. Review of the dietary ticket for Resident #104 dated 03/23/26 for lunch revealed the resident was to receive built-up utensils at meals. Observation of the afternoon meal on 03/23/26 at 12:20 P.M. revealed Certified Nursing Assistant (CNA) #329 was feeding the resident using regular utensils. There were no built-up utensils available on the tray for the resident. Resident #104 reached for the food and attempted to feed herself, but CNA #329 pushed the resident's hands away and continued to feed the resident Interview on 03/23/26 at 12:30 P.M. with CNA#329 confirmed Resident #104 required total assistance with feeding and built-up utensils were not needed. Observation on 03/26/26 at 10:05 A.M. revealed CNA #558 was feeding the resident using regular utensils. CNA #558 left the resident, and then the resident attempted to feed herself some more food using the regular utensils. There were no built-up utensils available on the tray. Resident #104 appeared to have difficulty handling the regular utensils and kept dropping them. Interview on 03/26/26 at 12:45 P.M. with CNA #558 confirmed she was not aware Resident #104 had a physician's order for the use of built-up utensils. CNA #558 also stated Resident #104 was hospice and she was feeding her so the resident wouldn't make a mess.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned proper personal protective equipment (PPE) when providing gastrostomy tube (g-tube) care to residents with physician's orders for enhanced barrier precautions (EBP.) The affected one (Resident #23) of two facility-identified residents with orders for EBP. The facility census was 98 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/18/25 with diagnoses including congestive heart failure, atrial fibrillation, and gastrostomy status (g-tube) status. Review of the physician's orders for Resident #23 revealed an order dated 9/17/25 for EBP due to presence of a g-tube. Observation of g-tube feeding for Resident #23 on 03/25/26 at 10:23 A.M. per Licensed Practical Nurse (LPN) #114 revealed the nurse did not don a gown prior to administration. There was a sign outside Resident #23's door indicating gloves and gowns should be worn while providing care. Interview on 03/25/26 at 10:29 A.M. with LPN #114 confirmed Resident #23 was on EBP due to the presence of a g-tube and staff were supposed to don gowns prior to tube feeding administration. LPN #114 confirmed she had not donned a gown prior to caring for Resident #23. Review of facility policy titled Enhanced Barrier Precautions dated 03/30/24 revealed EBP was indicated for residents with indwelling medical devices even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Review of facility policy titled Documentation for Enteral Feeding revised April 2024 revealed EBP should be followed while managing a feeding tube.

Based on medical record review and staff interviews, the facility failed to ensure resident's medical record contained documentation for completed care and services provided by staff. This affected one (#216) out of three residents reviewed for quality of care. The facility census was 103. Findings included Review of the medical record for Resident #216 revealed an admitted [DATE] and a discharge home on [DATE] with private care givers and hospice. Resident #216 expired in the home on [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia with agitation and anxiety. Review of the discharge Minimum Data Set (MDS) assessment for Resident #216 dated [DATE] was not completed at the time of the survey. Review of the baseline plan of care for Resident #216 dated [DATE] revealed the resident was admitted to nursing facility for a respite due to Alzheimer's disease. Interventions include use of my personal preferences to help develop plans of care and daily routine, manage all activities of daily living (ADL) supports, incontinence, medication and risks. Review of physician orders for Resident #216 revealed an order for a mechanical soft diet with mechanical soft texture and thin consistency, requires feeding assistance, cues, encouragement, send one to two finger foods per meal for diet type dated [DATE]. Review of the electronic health record (EHR) for the certified nursing assistant (CNA) documentation for Resident #216 dated [DATE] to [DATE] revealed two entries for percentage of meal consumed on [DATE]. The documentation contained one meal consumed at fifty percent to seventy five percent and one meal consumed at twenty six percent to fifty percent. The remaining dates during the time frame contained no documentation for percentage consumed. Review of the EHR for the CNA documentation for Resident #216 dated [DATE] to [DATE] titled ability to roll from lying on back to the right and left side five revealed five entries. There was no documentation for turning and repositioning on [DATE] and [DATE]. On [DATE], [DATE], [DATE] there was only one entry for the care provided and there should have been two. The CNA's document the one time on a twelve hour shift indicating they have turned and repositioned the resident every two hours. Review of the EHR for the CNA documentation for Resident #216 dated [DATE] to [DATE] titled intake and output revealed revealed five entries. There was no documentation for any oral fluid intake on [DATE] and [DATE]. On [DATE] at 1:41 A.M., [DATE] at 11:35 P.M. , [DATE] at 12:05 A.M. revealed was only one entry for 120 cubic centimeters (cc) of intake daily. Interview on [DATE] at 1:21 P.M. with the Director of Nursing (DON), verified the CNA documentation for Resident #216 was not completed as it should have been. Interview on [DATE] at 2:40 P.M. with the Administrator verified the lack of documentation related to turning and repositioning, meal intakes and intake and output of fluid for Resident #216. This deficiency represents non-compliance investigated under Complaint Number OH00163136.

Based on medical record review, observation, review of facility in-service records, review of a personnel file, review of the safety inspection bus checklist, review of the facility's Self-Reported Incidents (SRIs), review of facility policies, review of the emergency medical services (EMS) run report, review of hospital documentation, resident interview, and staff interview, the facility failed to ensure a resident was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility bus from an activity department outing. This resulted in Immediate Jeopardy when one resident (#05) was placed at potential risk for serious life-threating harm and/or injuries when on 05/28/24, Activity Director (AD) #300 abruptly stopped the facility bus, causing Resident #05 to fall forward out of his wheelchair, hitting another resident, and then landing on the floor. During the fall, Resident #05 sustained a degloving/laceration (a traumatic injury that results in the top layers of skin and tissue being torn away from the underlying muscle, connective tissue or bone) to his right lower leg, requiring 35 sutures, and a right chest contusion near his chemotherapy port-a-cath port. AD #300 pulled over and, with the help of Activities Assistant (AA) #315, attempted to lift Resident #05 off the floor of the bus. When they were unable to lift Resident #05, they summoned assistance from EMS, who arrived and transported Resident #05 to the emergency room (ER) for treatment. Resident #05 was treated in the ER and sent back to the facility with orders for antibiotics. On 06/01/24, four days following the bus accident, Resident #05 complained of chest pain with movement and pain, redness, warmth, and swelling to the open area on his right lower extremity. Resident #05 was sent to the hospital, admitted for cellulitis of the right leg, and remained in the hospital for four days for intravenous (IV) antibiotic treatment. This affected one (Resident #05) of three residents reviewed for use of assistive devices during transportation. The facility identified a total of 52 residents who utilized a wheelchair and the facility transportation. The facility census was 99. On 06/13/24 at 11:29 A.M., the Administrator was notified that Immediate Jeopardy began on 05/28/24 at approximately 2:15 P.M. when Resident #05 was placed in the facility bus, with his wheelchair secured to the floor of the bus, but with no seatbelt to secure the resident into the wheelchair. AD #300 abruptly stopped the facility bus, causing Resident #05 to fall forward out of his wheelchair, hitting another resident, and then landing on the floor of the bus. During the fall, Resident #05 sustained a degloving/laceration to his right lower leg, requiring 35 sutures, and a right chest contusion near his chemotherapy port-a-cath port. AD #300 pulled over and, with the help of AA #315, attempted to lift Resident #05 off the floor. When they were unable to lift Resident #05, they summoned assistance from EMS, who arrived and transported Resident #05 to the ER for treatment. Resident #05 was treated in the ER and sent back to the facility on antibiotics. On 06/01/24, Resident #05 complained of chest pain with movement and pain, redness, warmth, and swelling to the open area on his right lower extremity. Resident #05 was sent to the hospital, admitted for cellulitis of the right leg, and remained in the hospital for four days for intravenous (IV) antibiotic treatment. The Immediate Jeopardy was removed on 05/31/24 at approximately 12:45 P.M. when all education was completed for staff, which included that the transportation bus was not to be driven, and competency checks were completed on staff that were authorized to drive the other facility vehicle, which was the transport van, by ensuring proper securing of residents during transport. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was verified as corrected on 06/28/24 when the facility implemented the following corrective actions: On 05/28/24 at 2:45 P.M., AD #300 notified Assistant Director of Nursing (ADON) #320 of the incident on the facility bus involving Resident #05. On 05/28/24 at approximately 2:45 P.M., ADON #320 notified the DON of the incident on the facility bus involving Resident #05. On 05/28/24 at 2:50 P.M., ADON #320 and the DON notified the Administrator of the incident on the facility bus involving Resident #05. On 05/28/24 at approximately 3:00 P.M., the Administrator interviewed Transportation Driver (TD) #335 regarding the procedure for bus outings. He was not on the outing on the facility bus in which Resident #05 was injured. On 05/28/24 at approximately 3:00 P.M., Licensed Practical Nurse/Unit Manager (LPN/UM) #350 notified Resident #05's representative by phone regarding the incident. On 05/28/24 at approximately 3:30 P.M., the Administrator, the DON, and ADON #320 interviewed AD #300, upon her return to the facility, following the incident on the facility bus involving Resident #05. On 05/28/24 at approximately 3:45 P.M., the Administrator left a voice message for the Director of Transportation (DOT) #330 to return her call. On 05/28/24 at approximately 3:50 P.M., the Administrator interviewed Maintenance Director (MD) #325 regarding safety check procedures for the facility vehicles. On 05/28/24 at 4:00 P.M., the Administrator issued a directive for the facility bus (the vehicle in use during the incident involving Resident #05) and the facility van to not be used until further notice. On 05/28/24 at 4:00 P.M., involved parties, AD #300, DOT #330, MD #325, and TD #335 were put on suspension pending the outcome of the investigation. On 05/28/24 at 4:00 P.M., Unit Clerk (UC) #355 started calling transportation companies to make arrangements for upcoming appointments already scheduled for the current week and the following week as the Administrator had issued the directive for staff not to use the bus or the van until further notice. On 05/28/24 at approximately 4:30 P.M., a safety meeting was held with the Administrator, DON, ADON #320, LPN/UM #350, and Compliance Officer (CO) #345. Topics of the safety meeting included the following: the incident which occurred on 05/28/24 in the facility bus for Resident #05, education to be performed as a follow-up to the incident, who needed to be educated, taking the facility vehicles out of service temporarily, and delegated procedures to be completed. On 05/28/24 at approximately 5:00 P.M., the facility initiated an SRI with the Ohio Department of Health (ODH). On 05/29/24 at 9:00A.M., CO #345 created education for TD #335, DOT #330, MD #325, Maintenance Assistant (MA) #305, and AD #300. On 05/29/24 at 9:00 A.M., the DON created a nursing education packet. On 05/29/24 at 9:00 A.M., CO #345 developed an auditing system for the facility van and reviewed and updated the inspection checklist and competency skill list for drivers and maintenance staff. On 05/29/24 at 11:00 A.M., the DON, LPN Supervisor #360, and State tested Nursing Assistant (STNA) #365 began in-servicing staff regarding gait belts and abuse, neglect and misappropriation. The education was completed on 05/31/24 at approximately 5:30 P.M. On 05/29/24 at approximately 11:45 A.M., the Administrator, DON, ADON #320, and CO #345 interviewed DOT #330 via telephone. On 05/29/24 at approximately 2:00 P.M., a safety meeting was held with the Administrator, DON, ADON #320, LPN/UM #350, CO #345, and MA #305. At the meeting staff reviewed the status of the education and training following the incident. Facility management decided TD #335 and MD #325 would return to work on 05/31/24 and would be educated on 05/31/24 at 11:00 A.M. prior to resuming their work duties. On 05/31/24 at 9:00 A.M., TD #335 and MD #325 returned to work. On 05/31/24 from 11:00 A.M. to 1:00 P.M., CO #345 educated TD #335, MD #325, and MA #305. The education included the following: viewing a vehicle safety video, reviewing and signing education packets, review of competency, vehicle checklists and audit forms. On 05/31/24 at approximately 12:45 P.M., MA #305, who had prior transportation knowledge from previous employment, performed competency checks on the facility van with assistance from ADON #320 and LPN/UM #350. Beginning on 06/01/24 at approximately 10:00 A.M., TD #335 began audits of the facility van and MA #305 signed off on the audits. The audits were to be completed on days of driving the van, prior to driving the van, daily for two weeks, then three times per week for two weeks, and then monthly thereafter. On 06/03/24 at 8:21 A.M., ODH requested additional information regarding the SRI. The facility sent the requested information to ODH at approximately 12:00 P.M. On 06/03/24 at 12:15 P.M., the Ohio State Highway Patrol (OSHP) inspected the facility bus, and the bus passed the inspection. On 06/03/24 at 3:00 P.M., CO #345 reviewed and updated the policy regarding transportation drivers and outings. The updates to the policy included staff would bring information regarding resident's code status on the outing and the driver of the vehicle would complete a final walk-through safety check of the residents before driving off. On 06/13/24 at 3:00 P.M., MA #305 educated employees permitted to drive the facility bus (MD #325 and TD #335) on how to properly secure residents into the facility bus. MA #305 LPN/UM #350, and ADON #320 completed facility bus competencies with MD #325 and TD #335. Competencies will be completed on all authorized drivers for all facility vehicles quarterly. Beginning on 06/14/24 facility bus audits were initiated. TD #335 will perform these audits Monday through Friday every day for 2 weeks, then 3 times a week for 2 weeks, and then monthly thereafter. Interviews on 06/17/24 between 4:15 P.M. and 4:30 P.M. with TD #335 and MD #325 confirmed they were educated on the facility van on 05/31/24 and educated on the facility bus on 06/13/24. On 06/28/24 between 8:22 A.M. and 9:10 A.M., observations, review of facility audit records, and interviews with TD #335, MD #325 and MA #305 were conducted. TD #335 was observed conducting the daily audit on the facility bus and van. TD #335 confirmed he has been completing audits of the bus and van daily on days worked (Monday-Friday). Review of the audits revealed they had been completed as indicated through 06/28/24 and no further issues were identified. TD #335 stated part of his daily audit is to check the mileage of each vehicle. TD #335, MD #325, and MA #305 confirmed the bus had not been driven since 06/03/24, when it was taken to the OSHP for inspection. The bus remains out of service. Findings include: Review of the medical record for Resident #05 revealed an admitted [DATE] with diagnoses including, morbid obesity, cirrhosis of liver, dementia, chronic atrial fibrillation, bradycardia, malignant neoplasm of vertebral column and kidney, congestive heart failure, peripheral vascular disease, depression, anxiety, and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #05 dated 04/20/24 revealed the resident had intact cognition and required supervision or touching assistance for bed mobility, transfers and ambulation. Resident #05 utilized a walker and wheelchair for mobility. Review of the prehospital care report summary (ambulance run report) for Resident #05 dated 05/28/24 revealed medics were dispatched on 05/28/24 at 2:23 P.M. for a person injured in a fall. Resident #05 was noted with an avulsion (pulling or tearing away) injury to the right lower leg. Resident #05 was noted stuck in a position with both legs under him under the wheelchair in front of him and his wheelchair stuck behind him and latched into place. Resident #05's wheelchair and multiple tie down points for the wheelchair had to be removed to access and extricate the resident. Once removal began, the resident slid backwards and a large skin tear on his lower right leg was observed. Medics bandaged the wound with a blood stopper and bleeding was controlled. Resident #05 was removed from the facility bus on the scoop stretcher and taken to the ER. Review of the hospital ER after visit summary for Resident #05 dated 05/28/24 revealed the resident was diagnosed with a large complex right leg laceration, a left knee contusion, and a right chest wall contusion. The laceration on the right leg measured 25 centimeters (cm.) in length and required 35 sutures. Following the laceration repair, a piece of skin was noted to be missing from the superior aspect of the wound. The missing piece of skin was found crumpled within Resident #05's sock, but it was completely devitalized and not able to be replaced. Resident #05 was given IV antibiotics in the ER and was prescribed oral antibiotics upon his return to the facility. Review of a nursing progress note for Resident #05 dated 05/28/24 at 6:49 P.M. revealed the activities department called ADON #320 and informed her Resident #05 fell from the wheelchair in the facility bus while returning from an outing. Resident #05 was noted to be on his knees with his legs under his wheelchair and fell forward and into the resident sitting in a wheelchair in front of him. The facility transport vehicle was pulled into a parking lot and nine-one-one (911) was called. EMS arrived and transported Resident #05 to the ER. Review of the SRI dated 05/28/24 revealed Resident #05's representative alleged neglect when the resident flew out of his wheelchair and was pinned under the chair in front of him. Resident #05's representative said if the resident had been secured, the incident would not have happened. The incident was described as follows: on 05/28/24, while returning from an activity outing, Resident #05 fell out of his wheelchair on the bus, into another resident. The bus was moved to a safe location. Staff were unable to assist Resident #05 up from the floor, so they called 911 and the resident was assisted from the floor to a stretcher and transferred to the hospital. An emergency safety meeting was conducted, and all involved staff were interviewed. Resident #05 was assessed at the ER and returned to the facility at approximately 10:00 P.M. on 05/28/24. The facility did not substantiate the allegation of neglect. Review of a nursing progress note for Resident #05 dated 05/29/24 at 1:59 A.M. revealed the resident returned from the hospital via ambulance. Review of a nursing progress note for Resident #05 dated 06/01/24 at 4:00 P.M. revealed Resident #05 complained of chest pain with movement and pain, redness, warmth, and swelling to the open area on the right lower extremity. The physician gave an order to transport Resident #05 to the hospital. EMS transported Resident #05 to the hospital and the resident's representative accompanied him. Review of a nursing progress note for Resident #05 dated 06/01/24 at 11:43 P.M. revealed the resident was admitted to the hospital for cellulitis of the right leg. Review of the hospital continuity of care and after visit summary for Resident #05 dated 06/05/24 revealed the resident was admitted to the hospital on 06/01/24 for cellulitis of the right lower extremity. Resident #05 required IV antibiotics for methicillin-resistant staphylococcus aureus (MRSA) infection to the wound the resident sustained during the accident in the facility bus on 05/28/24. Review of a nursing progress note for Resident #05 dated 06/05/24 at 2:57 P.M. revealed Resident #05 returned to the facility from the hospital. Review of the employee file for AD #300 revealed a hire date of 11/03/03. AD #300 completed a road test checklist on 06/02/06 and an employee driver training on 06/07/06. AD #300's employee file did not include driver training after 2006. AD #300 resigned from her position effective 06/12/24. Review of the driver/vehicle examination report and bus safety inspection report per the OSHP dated 06/03/24 revealed the facility bus passed the safety inspection. Interview on 06/12/24 at 9:10 A.M. with Resident #05 confirmed on 05/28/24 he went on an outing to a local restaurant in the facility bus along with seven or eight other residents. Resident #05 confirmed some residents were sitting in bus seats, and there were four residents, including himself, in wheelchairs.? Resident #05 stated he was sitting in his wheelchair in the back of the bus, next to the lift.? Resident #05 stated the staff had fastened his wheelchair to the floor of the bus, but no one had applied a seat belt to secure him into the wheelchair itself. Resident #05 further confirmed that as the bus pulled out of the restaurant to return to the facility, the driver hit the brakes suddenly and he fell forward out of his wheelchair and his right chest hit the wheelchair of the resident in front of him.? Resident #05 stated the other resident was on top of him and his legs were bent back behind him.? Resident #05 confirmed he repeatedly asked the driver (AD #300) to pull over, but she told him there was no place to pull over.? Resident #05 stated she finally pulled over in a parking lot and called EMS.? Resident #05 stated EMS got him out from under the other resident's wheelchair and transported him to the hospital.? The resident stated he was treated and released from the hospital and then ended up in the hospital for four days for IV antibiotics.? Interview on 06/12/24 at 11:17 A.M. with AA #315 confirmed on 05/28/24 he was riding near the front of the bus on a facility outing when the bus came to a sudden stop, and he heard Resident #05 say he was in pain. AA #315 stated he turned around and saw Resident #05 had slid out of his wheelchair and was on the floor of the bus. AA #315 stated he alerted the driver, AD #300, but it was a few minutes before the driver was able to pull over into a parking lot. AA #315 stated Resident #05 was on his knees, with his chest pressed up against the wheelchair in front of him. AA #315 stated there were four wheelchairs on the bus and all four wheelchairs remained in the upright position and secured when the bus came to a sudden stop. AA #315 confirmed Resident #05 was not secured into his wheelchair by a seat belt or any type of chest restraint when the bus stopped suddenly. Interview on 06/12/24 at 1:39 P.M. with AD #300 confirmed on 05/28/24, she and AA #315 took eight residents on an activity outing to a local restaurant for lunch. AD #300 stated after lunch she loaded everyone on the bus, including Resident #05 who was placed in the spot without a seatbelt. AD #300 confirmed sometimes they used a gait belt in that spot without a seat belt. AD #300 confirmed she did not restrain Resident #05's body into the wheelchair with anything on the way back from lunch on 05/28/24. AD #300 stated, on the day of the incident, she was driving and slowed down for traffic when AA #315 told her Resident #05 was on the floor of the bus. AD #300 stated as soon as it was safe she pulled over, and she and AA #315 attempted to lift Resident #05 off the floor of the bus. When they were unable to lift Resident #05, they called 911 and waited for EMS to arrive. AD #300 confirmed at the time of the incident, she was told a new seatbelt would be ordered and had previously been told she could use a gait belt to restrain residents in the fourth wheelchair spot, since there was not a seatbelt. AD #300 stated DOT #330 told her a year or two ago he was going to order a new harness/seatbelt and told her to use the gait belt until it arrived. AD #300 stated DOT #330 told her the previous administrator told him he could use a gait belt instead. AD #300 stated she was trained to drive the bus when the facility first got the bus back in 2006 but had not received any further training or competency checks. Interview on 06/12/24 at 2:15 P.M. with the Administrator confirmed she was unaware there was not a fourth seatbelt in the facility bus. The Administrator stated, following the incident, she learned the previous administrator had instructed staff to use a gait belt since there was no seatbelt in the fourth wheelchair spot. The Administrator confirmed the use of a gait belt in place of a seatbelt was not an appropriate practice. The Administrator stated, following the incident, DOT #330, AD #300, MD #325, and TD #335 were suspended. MD #325 and TD #335 were permitted to return to work on 05/31/24 as they were not present the day of the incident. The Administrator stated DOT #330 was responsible for overseeing the use of the bus and keeping everyone who was permitted to drive the facility vehicles up to date on safety measures. The Administrator stated facility vehicle competencies with return demonstration were completed with employees trained to drive facility vehicles using the facility van following the incident. Interview on 06/12/24 at 2:30 P.M. with DOT #330 confirmed he replaced the seatbelts in the bus approximately three years ago and stated there was another seatbelt on order at the time of the incident on 05/28/24 involving Resident #05. DOT #330 stated he was not sure when the fourth seatbelt for the bus came up missing. DOT #330 stated he ordered a replacement seatbelt approximately two years ago and installed the seatbelt with TD #335. DOT #330 stated the previous administrator allowed staff to use gait belts to restrain residents if the seatbelts were unavailable or not working. Interview on 06/12/24 at 2:53 P.M. with the Administrator confirmed she instructed staff not to use the facility bus or the facility van until further notice. The Administrator confirmed the facility was trying to decide if they could get a new bus because it required frequent repairs or if they might resume use of the bus involved in the incident with Resident #05. The Administrator confirmed the root cause of the incident involving Resident #05 had nothing to do with any mechanical failures of the bus. The Administrator confirmed the root cause of the incident causing injury to Resident #05 was AD #300's failure to properly secure Resident #05 in his wheelchair on the bus. Interview on 06/13/24 at 11:32 A.M. with the Administrator confirmed the education which included competencies and return demonstrations provided to drivers of the facility vehicles on 05/31/24 was completed using the facility van. The Administrator confirmed the staff had not been educated on using the facility bus which was the vehicle in use during the incident with Resident #05 on 05/28/24. Interview on 06/13/24 at approximately 12:00 P.M. with TD #330 confirmed DOT #335 had trained him in the past to use a gait belt as a substitute for the seat belt for the spot in the facility bus without a restraint. TD #330 confirmed he was unsure if this was a safe practice, but he did not report his concerns to the current facility Administrator. Observation on 06/13/24 at 12:05 P.M. of the facility bus (the vehicle in use at the time of the incident involving Resident #05) with TD #330 and MA #305 revealed the staff demonstrated how they used straps from two different restraint systems in order to be able to restrain three residents in wheelchairs prior to driving the bus. There was a fourth wheelchair seat in the bus which did not have any type of seatbelt or restraint. Interview on 06/13/24 at 12:10 P.M. with TD #330 and MA #305 confirmed the fourth wheelchair seat in the bus had no seatbelt or restraint. Further interview confirmed AA #315 told them Resident #05 had been sitting in the fourth wheelchair spot, which had no seatbelt or restraint when the resident was injured on 05/28/24. Review of the facility policy titled Activity Outings dated 06/01/24 revealed staff should secure residents in the vehicle before driving using an appropriate restraint or seat belt. The driver should conduct a final walk-through inspection to ensure everyone was properly secured before leaving for the destination. This deficiency represents noncompliance investigated under Complaint OH00154499 and Complaint OH00154442.

Based on medical record review, staff interviews and policy review, the facility failed to obtain additional instructions/orders from the physician when a vacuum-assisted closure (wound vac) was not available and/or not applied as ordered. Additionally, the facility failed to obtain instructions/orders to provide care for a residents peripherally inserted central catheter (PICC) line. This affected one (#130) of three reviewed for quality of care. The facility census was 103. Findings include 1. Review of the medical record for Resident #130 revealed an admitted [DATE] and a transfer to the hospital on 10/13/23. Diagnoses include surgical aftercare following surgery on the digestive system, ulcerative colitis with complications, rectal abscess, ileostomy, moderate protein calorie malnutrition, depression, hypokalemia, ileus, and hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #130 revealed the resident had an intact cognition. Resident #130 was coded with rejection of care one to three days during the assessment period. Resident #130 required set up assistance with eating and extensive assistance with transfers, bed mobility and toileting. Resident #130 was coded with a surgical wound. Review of the plan of care for Resident #130 was in progress. Review of the physician orders for Resident #130 dated 10/09/23 revealed an order to change wound vac to rectal abscess area every Tuesday, Thursday and Saturday on day shift. Review of the Treatment Administration Record (TAR) for Resident #130 for October 2023 revealed wound vac was not applied on the 10/10/23 as ordered. Further review of the TAR revealed the wound vac was applied on 10/11/23. Review of the nurse's progress notes dated 10/09/23 and 10/10/23 for Resident #130 contained no documentation for physician notification of wound vac not being applied as ordered. Review of the progress notes for Resident #130 dated 10/11/23 at 11:03 A.M. revealed the resident's wound vac was placed on this day. Resident #130 tolerated procedure well. Interview on 11/14/23 at 10:10 A.M. with the Administrator stated Resident #130 had initially refused the wound vac at the hospital so when she was admitted it was ordered and was told it would ship overnight from the supplier. Due to Resident #130's late arrival, it was not shipped until the 10/10/23 and arrived at the facility on 10/11/23. Interview on 11/14/23 at 1:45 P.M. with the Director of Nursing (DON) and the Unit Manager Licensed Practical Nurse (LPN) #22 verified the physician was not notified of the delay in application of the wound vac and should have been. Additionally, the DON and Unit Manager LPN #22 verified there was not an order for a wet to dry dressing until the wound vac arrived. Interview on 11/14/23 at 2:16 P.M. with Nurse Practitioner (NP) #200 verified both perineal wound and abdominal wound were draining malodorous drainage. NP #200 stated she was not notified of the delay in wound vac placement. 2. Further review of the nurse's admission note for Resident #130 dated 10/09/23 revealed resident had a PICC that flushes easily and was patent (operational). Review of the physician orders for Resident #130 revealed there were no orders or instructions related to the PICC line. Review of the Medication Administration Record (MAR) for the month of October 2023 revealed there was no documentation regarding monitoring, dressing changes or flushes to PICC line. Interview on 11/14/23 2:16 P.M. with NP #200 verified the PICC line was in place when Resident #130 had her follow up appointment on 10/13/23 and further stated it was not placed during the appointment with her. Interview on 11/14/23 at 3:12 P.M. with LPN #2 states she started the admission assessment for Resident #130 and confirmed a PICC line was present on admission. LPN #2 stated she did not fully complete Resident #130's assessment so another LPN at the facility took over at the change of shift. Interview on 11/14/23 at 4:45 P.M. with the DON and Unit Manager LPN #22 verified the medical record contained no orders, treatments or monitoring for Resident #130's PICC line. Review of the facility policy titled Flushing Intravenous Access Devices undated stated to check physicians order noting flushing solution and amounts. The policy further states a PICC line should be flushed every 12 hours. This deficiency represents non-compliance investigated under Complaint Number OH00147507.

Based on observation, staff interview and policy review, the facility failed to ensure food items were properly sealed and dated and that the ice machine was clean. This had the potential to affect all 97 residents residing in the facility. All 97 residents were served food from the kitchen. The facility census was 97. Findings include: Observation on 02/13/23 at 6:45 P.M. of the walk-in refrigerator revealed two bags of undated shredded cheese, an open and undated box of assorted pastries, an undated bag of carrots, and an undated bag of hard-boiled eggs, which were all confirmed by Dietary Staff #405 at the time of the observation. Observation on 02/13/23 at 6:53 P.M. of the ice machine in the kitchen revealed a black discoloration on the inside of the lid and the side of the ice machine, which was confirmed by Dietary Manager #690 at the time of the observation. Review of the undated facility policy titled DATE MARKING revealed any ready-to-eat, potentially hazardous food prepared and held in refrigeration should be marked utilizing an established procedure to ensure food safety.

Based on observations and staff interview the facility failed to ensure proper storage of medications including ensuring that expired medications were not being used. This affected one of the three medication carts reviewed and one out of two medication storage rooms in the facility. This had the potential to affect 18 residents (#1, #8, #12, #19, #27, #33, #42, #55, #57, #61, #73, #78, #86, #155, #245, #247, #346, #347) due to expired medications. The facility census was 97. Findings include: Observations on 02/14/23 at 8:24 A.M. of the 3rd floor medication room revealed outdated medications. The outdated medications found were Certavite Senior multivitamins dated 08/2021, Iron 325mg dated 12/2022, Calcium 600mg dated 05/2022, Vitamin D 400 iu dated 11/2019, Zinc 50mg dated 11/2022, Calcium Citrate plus Vitamin D dated 07/2017, Fish Oil 1200mg dated 11/2021, Vitamin B6 dated 03/2021. Interview on 02/14/23 at 8:27 A.M. with Licensed Practical Nurse (LPN) #505 confirmed the above outdated medications. Observations on 02/14/23 at 9:00 A.M. of the 3rd floor, Team 2 medication cart revealed outdated medications. The outdated medications found were Vitamin D 10mcg dated 07/2022, and Ferrous Gluconate 240mg dated 10/2021. Interview on 02/14/23 at 9:05 A.M. with LPN #700 confirmed the above outdated medications. The facility was unable to provide a written policy for medication storage.

Based on observations, family and staff interviews, the facility failed to provide a clean and homelike environment. This affected five (#30, #82, # 347, #349, and #350) of five residents reviewed for environment. The facility census was 97. Findings include: Interview on 02/14/23 at 2:32 P.M., with Resident #30's daughter, during a family interview, revealed she was concerned with the dust and debris hanging from Resident #30's bathroom vent in the ceiling. Resident #30's daughter stated she has brought this to the attention of management in the past and it has not been resolved. Resident #30's daughter stated she is concerned that her mother is breathing the dust and debris in each time she uses the restroom. Observation on 02/14/32 at 2:35 P.M., revealed Resident #30's bathroom ceiling vent had visible debris and powdered like substance that appeared to be dust hanging from he ceiling vent. Interview on 02/15/23 at 2:14 P.M., with the Housekeeper (HK) #1000 revealed the housekeeping staff will clean the resident rooms and bathrooms daily. HK #1000 could not confirm how often he bathroom ceiling vents are cleaned. Observation on 02/15/23 at 2:15 P.M., with HK #1000, confirmed Resident #30, #82, #347, #349, and #350's bathroom had visible debris and powdered like substance that appeared to be dust piled up and hanging from the ceiling vents. Interview on 02/16/23 at 9:15 A.M., with the Administrator confirmed housekeeping will clean the resident rooms and bathrooms daily. The Administrator confirmed she cannot say how often the Resident bathroom vents are cleaned.

Based on observation, record review, and staff interview, the facility failed ensure residents were provided form of communication, to communicate the needs of the resident and have their personal needs met. This affected two resident (#87 and #60) of two residents reviewed for communication. The facility census was 97. Findings include: Review of the medical record for Resident #87 revealed she was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, type two diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, Parkinson's disease, bipolar disorder, mixed hyperlipidemia, thrombocytopenia, major depressive disorder, vitamin d deficiency, and unspecified psychosis not due to a substance or known physiological condition. Review of the admission Minimum Data Set (MDS) assessment, dated 01/17/23, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 02. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Review of the plan of care initiated on 01/11/23 revealed Resident #87 was at risk for impaired communication. Interventions included allow adequate time for resident's response, educate representative/staff on anticipation of resident's needs until an alternate communication method can be established, incorporate alternate means of communication such as music, song, or visual demonstration, resident speaks in native language at times (Spanish), encourage resident to speak in English as resident can speak English fluently but chooses not to at times, and if resident refuses or cannot speak English at that time, anticipate resident needs until an alternate communication method can be established. Interview on 02/14/23 at 12:25 P.M., with State tested Nursing Assistant (STNA) #365 revealed she had no way to communicate with Resident #87 when she spoke Spanish. STNA #365 stated she would try to encourage Resident #87 to speak English or attempt to identify Resident #87's needs. Observation on 02/14/23 at 1:29 P.M., revealed Resident #87 spoke some Spanish in addition to English, and no alternative communication methods were observed in Resident #87's room. 2. Record review for Resident #60 revealed she was admitted to the facility on [DATE]. Her diagnoses included hemiplegia, hemiparesis, speech and language deficits, syncope, epilepsy, aphasia, dysarthria, atrial fibrillation, and hypothyroidism. Review of the quarterly Minimum Data Set Assessment (MDS) for Resident #60, dated 01/02/23, revealed she had problems with her short term memory and was cognitively impaired. Further review of the MDS assessment revealed Resident #60 required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. She required limited assistance from staff with personal hygiene and supervision from staff with eating. Resident #60 was marked as unclear speech and rarely understood. Review of Resident #60's communication and cognition care plan revealed, I wish to improve my ability to make needs known by communication verbally and non-verbally. Please remind me of your name when caring for me. I have extreme difficulty with word finding. It is imperative that you are patient when conversing with me and allow ample time to form my thoughts and process what you are saying. I can use my communication board for communication with others. Interview on 02/15/23 at 9:54 A.M., with Licensed Practical Nurse (LPN) #775 stated the staff does not utilize a communication board for Resident #60 because the staff understands what Resident #50 trying to tell them. Observation on 02/14/23 at 9:45 A.M., revealed Resident #60 was seated in her wheelchair in the living room area by the nurse's station she was anxious and making sounds. However, no words were heard related to her diagnosis. Observed staff member Administrator in Training (AIT) #345 ask Resident #60 what she needed. Resident #60 anxiously voiced noises and grunts loudly, however, AIT #345 stated he could not help her right now because he was busy. Observed AIT #345 turn and walk away from Resident #60. Interview on 02/14/23 at 10:03 A.M., with AIT #345 confirmed he approached Resident #60 when she was making sounds and attempting to get his attention. AIT #345 confirmed he told Resident #345 he could not help her because he was busy and walked away from Resident #60. AIT #345 confirmed he did not attempt to get another staff member to help Resident #60.

Based on observation, resident and staff interview, and record review, the facility failed to provide a resident with dignity and respect regarding his personal possessions. This affected two (#21 and #27) of three residents reviewed for dignity and respect of personal possessions. The facility census was 97. Findings include. 1. Record review for Resident #21 revealed and admitted [DATE]. Resident #21's diagnoses included: essential primary hypertension, gastro- esophageal reflux disease, heart disease, respiratory failure, hyperlipidemia, anxiety disorder, insomnia, edema, major depressive disorder, tachycardia, dysarthria following cerebral infarction, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #21 he was mildly cognitively impaired. Further review of the MDS assessment revealed Resident # 21 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing. Resident #21 required supervision from staff with eating. Resident #21 required the assistance of two or more staff members for transfers in the bed, out of the bed, and personal care. Review of Resident #21's nursing progress notes dated, 02/06/23 revealed Resident #21 has experienced increased confusion. Further review of the progress notes revealed Resident #21 was started on an antibiotic on 02/09/23 for a possible urinary tract infection. The nursing progress notes revealed on 02/14/23 a note stating Resident #21 will play with the bed remote and have his bed up high at times. Review of Resident #21's care plans revealed he had a care plan for mental wellness and his interventions included, If I appear restless or complain of anxiety offer to take me to a quiet area for conversation, talk to me about my family as a distraction. Listen to my concerns and encourage me to express my feelings and assist me with finding ways to cope with these feelings of anxiety. Please offer non- pharmacological coping tools also, such as reading, food and fluids, coloring, music. Encourage me to express my feelings and offer active listening and emotional support. A care plan for cognition revealed Resident #21 has short term memory problems. Resident #21 had a care plan for, a change in mood and his interventions included, Please reassure me that my family and friends are able to be contacted by phone and mail. Help me contact them as I desire. Help me create a MY STORY Notebook so I can show my family and friends what I have been doing while we were apart. Encourage reminiscence while I am working on, MY STORY book. Listen and encourage me to verbalize my feelings. Observe for signs and symptoms of mood disorder or change in behaviors and offer reassurance and comfort. 2. Record review for Resident #27 revealed she was admitted to the facility on [DATE]. Her diagnoses included, essential primary hypertension, peripheral vascular disease, anemia, congestive heart failure, history of Coronavirus-2019 (COVID-19), duodenal ulcer, history of pulmonary embolism, and anemia. Review of the quarterly MDS assessment for Resident #27, dated 02/03/23, revealed she was cognitively intact. Resident #27 required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Further review of the MDS assessment revealed Resident #27 required limited assistance from staff with personal hygiene and supervision from staff with meals. Interview on 02/15/23 at 1:34 P.M., with Resident #27 revealed she is the spouse and roommate of Resident #21. Resident #27 stated she did not feel the facility staff treated her husband with dignity and respect following the incident that occurred during the night on 02/14/23. Resident #27 stated she is the voice of her husband because is unable to communicate well and is bed bound. Resident #27 stated she was very upset because the staff was very rude to her husband for accidentally knocking his personal items of his bedside table while sleeping. Resident #27 stated the staff entered the room and found Resident #21's personal items all over the floor. Resident #27 stated the night shift nurse aide appeared agitated and she stated, she did not have time for this. Resident #27 stated the State tested Nurse Aide (STNA) from last night threw all of Resident #21's personal belongings that he kept within reach at this bedside in a plastic trash bag and placed them out of reach from Resident #21. Resident #27 stated she felt very uncomfortable to see someone treat her spouse (Resident #21) this way because she knew it was an accident. Resident #27 stated Resident #21 did not mean to spill his personal items on the floor. Observation on 02/15/23 at 1:50 P.M., revealed the Activity Director (AD) #715 assisted Resident #27 to her room. Resident #27 stated, I may have said too much. AD #715 ask Resident #27 what she had said. Resident #27 stated she told the state surveyor how uncomfortable and upset she felt with the way the night STNA treated her spouse (Resident #21). Interview on 02/15/23 at 1:55 P.M., interview with Resident #21 revealed he was in bed with his bedside table over the bed. Resident #21 appeared to be alert with confusion, however, he was alert to himself. When questioned about the previous evening, Resident #21 pointed at his bed side table and then pointed toward the closet. Resident #21 was unable to verbalize what he pointed at. Observed a basket on his bed side table that included, a comb, a picture book, a list of phone numbers, a stress ball, glasses, and other personal items. Beside the bed toward the back of the headboard, several papers were piled, however, they were not within reach. Interview on 02/15/23 at 2:03 P.M. with STNA #875 revealed she was not the nurse aide for Resident #21, however, she stated she was told when she arrived at work that Resident #27's personal items from this bedside table were thrown in a bag and put in his closet out of reach by a night shift stna. Interview on 02/15/23 at 2:22 P.M. with Resident #30 revealed used to live across the hall from Resident #21 and #27. Resident #30 stated she was so glad that Resident #27 shared what happened to her husband the previous night. Resident #30 stated Resident #27 is her friend and she has never seen her so upset before. Interview on 02/15/23 at 2:24 P.M. with STNA #270 revealed she was the STNA#270 that found Resident #21's personal items in a trash bag and out of reach of Resident #21. STNA #270 stated the bag contained all the personal items that were important to Resident #21 including cards from family, a picture book, a list of phone numbers, lotion, a brush, a stress ball, a pencil pouch, and his glasses. STNA #270 stated she was confused on why the nightshift STNA #480 did not put his items back on this bedside table instead of throwing them in a trash bag and out of reach. STNA #270 stated this was the first time she had ever heard of Resident #21 dumping his items on the floor and thought it must have been an accident. Interview on 02/15/23 at 5:30 P.M., with STNA # 480 confirmed she was the night shift STNA who worked with Resident #21 on 02/14/22. STNA #480 stated Resident #21 is alert with confusion and would get confused with which button was his call light and which button operated his bed. STNA #480 stated Resident #21 knocked everything off his bed side table all over the floor. STNA #480 stated she walked into Resident #21's room and saw the mess of personal items on the floor and stated, Why did you do this?. STNA #480 stated she went and got the other staff members (nurse and aides) to see the mess he made all over the floor. STNA #480 stated she took all his items and placed them in a bag and put them out of reach. STNA #480 stated she was saving that for first shift to clean up because she did not have time for that. STNA #480 stated she should have taken a picture of the mess. STNA #480 stated she was not going to clean that up again, so she placed the items out of reach for Resident #21. STNA #480 stated the items all over the floor was just a bunch of stuff, like greeting cards, papers, and items he kept on the bedside table. Interview on 02/15/23 at 5:45 P.M., interview with STNA #350 confirmed she worked the night shift on 02/14/23. STNA #350 stated Resident #21 is confused and will put his call light on in place of using the button that controls that adjust his bed. STNA #350 stated she went into Resident #21's room at one point in the evening related to his call light on, and Resident #21 was asleep. STNA #350 stated there was no unusual behavior from Resident #21. STNA #350 stated the STNA #480 came and got her and the nurse to see the items all over Resident #21's room that fell off his bedside table. STNA #350 stated she helped STNA #480 pick up the items and place them in a bag. STNA #350 stated she did not question why the items were placed in a bag she was there to help. STNA #350 stated she heard #480 say to Resident# 21, Look what you did. Interview on 02/15/23 at 5:58 P.M., interview with Registered Nurse (RN) #300 confirmed she was the nurse caring for Resident #21 on the night shift of 02/14/23. RN #300 stated she did not know why STNA #480 wanted to see mess of personal items on the floor, she just knew this was not normal behavior for the Resident #21 and wanted to confirm he was ok. RN #300 stated she spoke to Resident #21 and believed he may have been dreaming and accidentally knocked the items off the bedside table. RN #300 stated the bedside table was not knocked over and it was just papers and personal items on the floor. RN #300 stated she did not understand why STNA #480 made a big deal about the personal items on the floor or why she bagged them up and put them out of reach. RN #300 confirmed this was the first time this has happened with Resident #21 that she was aware of.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the resident's attending physician was notified of significant weight loss. This affected one (#22) of eight residents reviewed for nutrition. The facility census was 97. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE], with diagnoses including fracture to the right tibia and right fibula, Alzheimer's disease, chronic kidney disease, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 01/18/23, revealed resident was cognitively impaired and required supervision and one-person physical assistance with activities of daily living (ADLs). Resident's height was 67 inches and weight was 161 pounds. Review of the admission physician orders for Resident #22 dated 01/12/23 revealed orders for a regular diet with thin liquids and Boost nutritional supplement 120 milliliters (ml) twice daily. Review of the nutrition and hydration care plan for Resident #22 dated 01/13/23 revealed care plan resident received a regular diet with highly variable meal intakes and appetite. Resident had variable self-feeding abilities and occasionally needed limited staff assistance depending on mood and energy levels surrounding meal times. Interventions included the following: Boost Plus to encourage by mouth and protein intakes while appetite remains variable, provide select menu, meals served in the dining room or resident's room depending on mood and need for meal encouragement, provide reminders about mealtimes, remind and encourage fluid intakes at and between meals. Review of the dietary progress note for Resident #22 dated 01/13/23, revealed the resident was in the facility for short term rehab status post hospitalization related to a fall at home with a fracture to the right tibia right fibula. Resident was on a regular diet and fed self with supervision and set up assistance. Resident had all natural teeth in good condition, no overt signs of chewing/swallowing difficulty or aspiration noted. Resident's family requested staff to encourage resident at meals. Resident was determined to be at moderate nutritional risk and was started on a nutritional supplement twice daily to increase protein. The dietitian was to monitor resident and the need for further nutrition interventions. Review of meal intake records for Resident #22 dated 01/12/23 to 02/16/23 revealed resident average meal intakes were 51-75 percent (%.) Review of the weight records for Resident #22 revealed weight on 01/16/23 was 159.2 pounds. Weight on 01/18/23 was 161 pounds. Weight on 01/25/23 was 152.5 pounds which was noted to be a loss of 9.4 pounds or 5.9 % loss from the comparison weight of 159.2 Weight on 02/13/23 was 149.5 which was noted to be a loss of 10.2 pounds or a 6.4% loss from the comparison weight of 159.2. Interview on 02/15/23 at 10:18 A.M., with Registered Dietitian (RD) #235 confirmed Resident #22 had experienced a weight loss of 10.2 pounds or 6.4% since admission to the facility. RD #235 confirmed the physician had not been notified of the resident's significant weight loss. Interview on 02/16/23 at 4:00 P.M., with the Director of Nursing (DON) confirmed the facility had not notified Resident #22's physician of resident's significant weight loss since admission. Review of the policy titled Weight and Height dated 02/10/21 revealed a weight loss of 5.0% in one month was considered significant. If there was a significant weight loss, therapeutic intervention by the RD, the physician, and the Interdisciplinary Team (IDT) will begin to assist resident in maintaining weight and preventing further unplanned weight loss or gain. Review of the policy titled Change in Resident's Condition or Status dated 03/01/17 revealed the facility would promptly notify the resident his or her attending physician, and representative of changes in the resident's condition or status.

Based on observation, medical record review, staff, local health department and family interviews, risks versus benefits review, and review of the facility policy, the facility failed to seek information and determine whether the recommended COVID-19 safety measures provided to Resident #01's family were followed upon the return from a visit in the community, failed to ensure there was a policy implemented for community visits during a pandemic, and failed to ensure the residents in the facility were protected from the potential spread of the COVID-19 virus. This resulted in Immediate Jeopardy for 69 residents (#01, #07, #10, #11, #12, #14, #17, #21, #22, #23, #25, #26, #27, #28, #30, #32, #34, #37, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53, #54, #56, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #71, #72, #73, #75, #76, #77, #78, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, and #220) when Resident #01 was not screened after a community visit, contracted COVID-19 and subsequently the COVID-19 virus spread throughout the facility. The census was 78. On 11/18/20 at 10:51 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 09/27/20 when the facility failed to screen and quarantine Resident #01 upon return to the facility after a community visit with family. On 10/03/20, Resident #01 exhibited a fever of 101.4 degrees Fahrenheit (F), increased confusion and a non-productive cough. On 10/05/20, Resident #01 exhibited signs and symptoms of shortness of breath. He had an oxygen saturation of 88 percent and was given oxygen. He was tested for Covid-19. On 10/07/20, test results revealed the resident was positive for COVID-19. Prior to Resident #01's community visit, the facility had no COVID-19 positive cases. By 10/20/20, the facility had 69 residents test positive for COVID-19. The Immediate Jeopardy was removed on 11/20/20 when the facility implemented the following corrective actions: · On 10/07/20, Resident #01 was moved to the second floor and isolated in a barrier unit. · All residents with positive and negative previous results are tested for COVID-19 every week on Wednesday starting on 10/07/20 via Polymerase Chain Reaction (PCR) specimens submitted to a laboratory with results returned in 1-2 days. · The physician of any resident indicating signs or symptoms of developing infectious process will be contacted and offered facility-performed tests using BD Veritor POC [MEDICATION NAME] test (rapid test). If ordered, the test will be completed by a trained nurse (via BD Veritor video) when order is received. Physician will be notified of [MEDICATION NAME] test results within 15 minutes of collection. Nurses received training for performance of POC [MEDICATION NAME] test via BD Veritor video training when the system was received on 09/13/20. · The Quality Assurance and Performance Improvement (QAPI) - Performance Improvement Plan (PIP) subcommittee including the Administrator, DON, Nursing Home Infection Preventionist Coordinator (NHIPC), Medical Director (MD), Assistant Director of Nursing, (ADON/NHIPC), Care Manager, Business Office Manager (BOM) #132, communicated in-person and telephonically on 11/19/20 and 11/20/20 and reviewed the positivity results, staff and residents results trending, and infection control and prevention practices related to the outbreak. The subcommittee formulated and implemented the plan on 11/20/20. Additionally, they communicated with the local county health department (LHD) of epidemiology via e-mail and phone on 11/20/20 to request review of QAPI-PIP. · Visitation Policy has been revised to include temporary restriction of in person visits (inside facility, outside facility, community, or home visits) in accordance with local, state, and federal guidelines. Effective 11/20/20. The revision to this policy included: Screen and increase monitoring for signs and symptoms. Test a resident for COVID-19 if signs or symptoms are present or if a resident or their family reports possible exposure to COVID-19 while outside the nursing home. Consider the option to test residents without signs or symptoms if they leave the nursing home frequently or for a prolonged length of time, such as over 24 hours. Place the resident on transmission-based precautions (TBP) if the resident or family member reports possible exposure to COVID-19 while outside of the nursing home, or if the resident has signs or symptoms of COVID-19 upon return. Please note that residents and loved ones should report to the nursing home staff if they have had any exposure to COVID-19 while outside of the nursing home. Place residents on TBP in quarantine area times 14 days if they were away from the nursing home for more than 24 hours. · On 11/20/20, the Centers for Medicare and Medicaid Services (CMS) Holiday Alert (which was included in the policy revision for Visitation revision) has been e-mailed and mailed to all resident's families. · Additionally, each Power of Attorney (POA) will be telephoned by a clinical staff member with the results for the resident by 11/21/20 by 5:00 P.M. and will include notification of Visitation policy revision and CMS Holiday Alert (which was included in the policy revision for Visitation revision) in the conversation. · A hard copy of the CMS Holiday Alert (which was included in the policy revision for Visitation revision) has been provided to and reviewed with residents and posted in the building at entrances on 11/20/20. · An e-mail was sent to all staff on 11/20/20 at 1:52 A.M. by the DON to review attached CMS Holiday Alert (which was included in the policy revision for Visitation revision), contact DON NHIPC or ADON NHIPC with questions, and then sign attestation form indicating completion. · On 11/20/20 at 1:52 A.M., an e-mail was sent to all staff by the DON to view each video in Videos for Training Front Line Long-Term Care Staff - Mini Webinar training series for front-line staff to help protect residents from COVID-19, and to contact the DON/NHIPC or ADON/NHIPC with questions and then sign the attestation form indicating completion. · On 11/20/20 at 1:52 A.M., an e-mail was sent to all staff by the DON to review attached Infection Prevention and Control (IPC) Guidance for Memory Care Units recommendations according to CDC, and to contact the DON/NHIPC or ADON/NHIPC with questions and then sign the attestation form indicating completion. · All staff has been e-mailed and a message posted at the timeclock to complete in-services and submit attestation by 11/22/20 at 11:59 P.M. in order to remain on the schedule to work. Employees will be removed from the schedule and remain removed until completed attestation is received by the Administrator. · All resident visits will obtain prior approval from the Administrator or designee, will be logged, and documented in the medical chart (Point Click Care-PCC) and will be will monitored by Administrator or designee and reported to the QAPI for duration of the Public Health Emergency (PHE). · The DON will authorize in-person [MEDICATION NAME] Care visits (determining number of visitors, location, duration, rationale). Compliance will be monitored by the DON or designee and reported to the QAPI for the duration of the PHE. · Monitoring of screening results of residents will be done by the DON or designee every shift and reported to QAPI for the duration of the PHE. · Monitoring of screening results of employees will be done by the Administrator or designee every shift and reported to QAPI for the duration of the PHE. · Competency skills evaluations of Personal Protective Equipment (PPE), donning/doffing procedures and hand hygiene - all staff - will be reviewed with staff by NHIPC or designee every shift times two weeks and then randomly each week and reported to QAPI for the duration of the PHE. · Competency skills evaluations for Infection Prevention and Control (IPC) Guidance for Memory Care Units will be reviewed with staff by NHIPC or designee every shift times two weeks and then randomly each week and reported to QAPI for the duration of the PHE. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: 1. Review of medical record for Resident #01 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. On 04/08/20, the physician ordered a respiratory assessment on day shift and night shift, which included taking the resident's temperature, checking the oxygen saturation and assessing for shortness of breath. On 04/09/20, the physician ordered vital signs every shift which included blood pressure, pulse, respirations and oxygen saturations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was moderately cognitively impaired. He was coded as no behavior exhibited for wandering. His functional status was extensive assistance for bed mobility, transfers, and toilet use. He was independent for eating. Review of the MDS dated [DATE] revealed Resident #01 was not coded for wandering and no behaviors were exhibited. At the bottom of the facility document titled Risk Verses Benefit Analysis Outside Visit Trial, dated 09/22/20, there was an exception analysis for Resident #01. A request for home-pass visit was submitted repeatedly by Resident #01's family stating he just wants to see his own grass. The calls from the family were very emotional. Under RISK, it documented Resident #01 was accustomed to home-visits to work outside in the yard and has experienced psychosocial distress and depression resulting from the absence of this activity, as identified by his family. The resident had increased risk of adverse reaction to outside visits at facility due to elopement risk. On 09/22/20, Resident #01 was incapable of comprehending risks, exit seeking would increase following door/pathway to exits identification, psychosocial distress resultant from restrictions. As evidenced on 09/27/2020, the resident had an outside visit and tolerated well and enjoyed seeing family. On 09/01/20, Resident #01 was up throughout night, agitated, saying he wanted to go to his family's house. It was explained he was scheduled to go to a physician's appointment the next day, but resident was vehement that he was going to family's house. On 09/02/20, Resident #01 went out of the facility for a doctor's appointment with a family member and on 09/04/20 he was arguing with his roommate. Under BENEFIT, it was documented the family would supervise outside activity away from the facility property: reduce risk of elopement intentions and pathway awareness, reduce evidenced feelings of abandonment when family drives away to go home without him and thereby-reduce resultant agitation, sleeplessness, argumentativeness, depression; positive psychosocial experience related to reaffirmation of family involvement and concern during preference activity; same precautions can be observed with this visit off property as are practiced with an outside visit at facility (with the exception of duration and staff monitoring). Home pass approved for 3 hours, all family and resident to place a mask, utilize hand sanitizer, remain outside during visit, maintain social distancing with no physical contact. Resident will not be quarantined after visit but will be screened twice a day and observed for signs and symptoms of infection. Under DECISION, it was documented the off-campus visit would have a positive impact on Resident #01. The family agreed to trial an outside visit off the property on the outside deck of the family's home. The visit was approved for 3 hours portal to portal (a family member was to transport, someone who already transported to doctor appointments in a private car and appeared to keep resident out of facility longer than appointments should take.) All family (2-3) and resident to put on facility-provided medical mask, gloves, and utilize hand sanitizer if gloves are removed. They were to remain outside during visit, maintain social distancing greater than six feet with no physical contact. Resident #01 will not be quarantined after visit but will be screened twice a day and observed for signs and symptoms of infection. Review of the Medication Administration Record [REDACTED]. Review of a progress note, that was entered into the electronic charting system as a late entry on 09/29/20 at 2:58 P.M. for 09/27/20 at 2:52 P.M., written by Licensed Practical Nurse (LPN) #182, revealed Resident #01 returned from a visit with his family. The family visited outdoors, practiced social distancing, wore masks and no physical contact was made. Per Resident #01 Best day that I have had in a long time. Resident #01 said he had thought that his kids had forgot about him and were out enjoying playing sports and their boats. The family instructed siblings to wear a mask and sit away from resident. The family was very thankful for the time they got to spend with their father. Review of a progress note dated 10/03/20 revealed Resident #01 had slid from wheelchair with no injuries. He was assisted back into the wheelchair and brought into the dining room and then propelled himself back to his room. He had increased confusion, leaning to the left and had a temperature of 101.4 degrees F. He had clear nasal drainage and a non-productive cough. Medical Director (MD) #300 was made aware and a chest X-ray, urinalysis and urine culture and sensitivity were ordered. The physician also ordered [MEDICATION NAME], an antibiotic, 750 milligram (mg) daily for seven days. Resident #01 was moved from room [ROOM NUMBER], a semi-private room which he shared with Resident #203, to room [ROOM NUMBER], a private room. Review of a progress note dated 10/05/20 revealed Resident #01 was short of breath and coughing. He was placed on oxygen via nasal cannula for an oxygen saturation of 88 percent on room air. MD #300 ordered a test for Covid-19. Resident #203, his previous roommate, and Resident #07, who lived across the hall, were also tested this day. A progress note dated 10/06/20 at 2:09 A.M. documented Resident #01 was redirected multiple times to stay in his room due to isolation. After attempting to redirect the resident multiple times, the resident continued to get in his wheelchair and exit the room and wheeled into the common area. It was explained multiple times that he was in isolation and was expected to stay in his room until he was cleared to go back to his old room. At 3:33 P.M., Resident #01 had not been compliant with staying in his room and was redirected back to the isolation room. Review of the progress note dated 10/07/20 at 2:30 P.M. revealed the laboratory informed the facility Resident #01 was positive for COVID-19. He was then transferred from the third floor to the second floor, room [ROOM NUMBER], a quarantine unit room without a roommate. Airborne/droplet isolation was initiated. Review of a progress note dated 10/07/20 revealed Resident #203 also tested positive for COVID-19 and was transferred to the second-floor quarantine unit to room [ROOM NUMBER], where he was alone in the room. He was not exhibiting any signs and symptoms of [MEDICAL CONDITION]. Review of a progress note dated 10/07/20 revealed Resident #07, who lived across the hall from Residents #01 and #203, complained of a cough with thick sputum and stated she felt like she had the flu. She was also positive for [MEDICAL CONDITION]. On 10/07/20, she was transferred to room [ROOM NUMBER], on the second-floor quarantine unit. On 10/09/20, Resident #203 was moved to room [ROOM NUMBER], back with his former roommate, Resident #01, because they were both positive for [MEDICAL CONDITION]. Review of a progress note dated 10/09/20 at 1:53 P.M. revealed a call was received from Resident #01's family who expressed apologies for Resident #01 becoming infected with COVID-19 and really didn't think it would happen with a visit out of the facility to their home. The note stated the family was going to get tested and report back if anyone was positive. Review of the care plan for Resident #01, revised on 10/20/20, for isolation pandemic isolation precautions listed interventions to encourage hand washing frequently, use cough/sneeze etiquette, explain visitor restriction and offer to help to stay in connect with family/friends via phone and or video-chat. Offer support, reassurance, and reminders during this time. Educate on how to wear a face mask properly and that a mask must worn when I am out of my room. Explain therapy will take place in my room and that I need to remain in my room as much as possible. Explain that staff will have PPE on when providing care. Reassurance would be given that I am not being avoided-I am being protected and others are also being protected. Review of the care plan for Resident #01, dated 10/21/20, revealed he was COVID-19 positive. Interventions were to encourage alternating periods of rest and activity. Plan activity progression. Implement energy-saving techniques. Encourage nutritional and fluid intake. Provide assistance as needed for care activities, increase patient participation in care as tolerated. Provide comfort measures to promote rest. Provide supplemental oxygen as needed. The resident may be required to change rooms and/or roommates. Please help the resident adjust accordingly to these changes by introducing him to any new caregivers and/or new roommates. Orient to my new room and the areas surrounding the new room. Notify the resident of any changes in his normal routine that may be interrupted or changed related to this room move. Monitor for any changes in mood/behavior. Maintain infection control procedures as per Centers for Disease Control (CDC) and the state agency for the latest recommendations. Instruct on proper infection control procedures and encourage compliance. Report condition as required to local, state, and federal health agencies. Perform testing/retesting as per CDC and state agency guidelines. Keep family updated on condition, new orders, mood, and laboratory results. Monitor vital signs and assess respiratory status at a minimum every shift and report acute abnormalities as necessary. Assist me into a position that maximizes chest expansion. Administer prescribed medications and oxygen as ordered. Monitor laboratory values and chest X-rays as ordered. Monitor pulse oximetry at a minimum of every shift and report abnormalities as necessary. Review of a late entry progress note dated 11/19/20 for 09/27/20 at 1:50 P.M. by LPN #182 revealed the receptionist called to report the family arrived at the facility to pick up Resident #01 and a mask was applied. The release of responsibility was sent down. Review of another late entry which was entered on 11/19/20 at 7:00 P.M. for 09/27/20 at 7:00 P.M. revealed received a call from the receptionist that Resident #01 had returned from the visit and the on-coming nurse was made aware and the unidentified nursing aide was sent to bring Resident #01 back to the unit. Review of the testing results for COVID-19 on 10/08/20 revealed Resident #208 in room [ROOM NUMBER], Resident #205 in room [ROOM NUMBER], Resident #30 in room [ROOM NUMBER], Resident #62 in room [ROOM NUMBER], Resident #11 in room [ROOM NUMBER]-2, Resident #53 in room [ROOM NUMBER]-2, Resident #54 in room [ROOM NUMBER]-2, Resident #56 in room [ROOM NUMBER], Resident #210 in room [ROOM NUMBER]-1, Resident #207 in room [ROOM NUMBER]-2, Resident #51 in room [ROOM NUMBER], Resident #204 in room [ROOM NUMBER], Resident #209 in room [ROOM NUMBER] and Resident #206 in room [ROOM NUMBER], all tested positive for the COVID-19 virus. Review of the testing results for COVID-19 on 10/13/20 revealed Resident #10 in room [ROOM NUMBER]-2, Resident #25 in room [ROOM NUMBER]-2, Resident #61 in room [ROOM NUMBER]-2, Resident #50 in room [ROOM NUMBER]-1, Resident #212 in room [ROOM NUMBER], Resident #214 in room [ROOM NUMBER] , Resident #44 in room [ROOM NUMBER]-1 , Resident #47 in room [ROOM NUMBER]-2, Resident #52 in room [ROOM NUMBER]-2, Resident #41 in room [ROOM NUMBER], Resident #63 in room [ROOM NUMBER]-1, Resident #211 in room [ROOM NUMBER]-2, Resident #65 in room [ROOM NUMBER]-1, Resident #213 in room [ROOM NUMBER], Resident #60 in room [ROOM NUMBER]-1, and Resident #59 in room [ROOM NUMBER]-2, all tested positive for the COVID-19 virus. Review of the testing results for COVID-19 dated 10/20/20 revealed Resident #14 in room [ROOM NUMBER], Resident #21 in room [ROOM NUMBER]-2, Resident #27 in room [ROOM NUMBER]-2, Resident #39 in room [ROOM NUMBER]-2, Resident #40 in room [ROOM NUMBER]-2 , Resident #42 in room [ROOM NUMBER], Resident #43 in room [ROOM NUMBER], Resident #45 in room [ROOM NUMBER]-1, Resident #46 in room [ROOM NUMBER]-2, Resident #49 in room [ROOM NUMBER]-1, Resident #64 in room [ROOM NUMBER]-1, Resident #66 in room [ROOM NUMBER], Resident #67 in room [ROOM NUMBER]-1, Resident #68 in room [ROOM NUMBER]-2, Resident #71 in room [ROOM NUMBER], Resident #72 in room [ROOM NUMBER]-2, Resident #73 in room [ROOM NUMBER], Resident #75 in room [ROOM NUMBER]-2, Resident #76 in room [ROOM NUMBER]-2 , Resident #77 in room [ROOM NUMBER]-2, Resident #78 in room [ROOM NUMBER]-1, Resident #215 in room [ROOM NUMBER]-2, Resident #216 in room [ROOM NUMBER], Resident #217 in room [ROOM NUMBER], Resident #218 in room [ROOM NUMBER], Resident #219 in room [ROOM NUMBER]-2, and Resident #220 in room [ROOM NUMBER]-2, all tested positive for the COVID-19 virus. Review of the testing results for COVID-19 dated 10/27/20 revealed Resident #12 in room [ROOM NUMBER], Resident #17 in room [ROOM NUMBER], Resident #22 in room [ROOM NUMBER]-2, Resident #23 in room [ROOM NUMBER]-1, Resident #26 in room [ROOM NUMBER]-1, Resident #28 in room [ROOM NUMBER], Resident #32 in room [ROOM NUMBER], Resident #34 in room [ROOM NUMBER]-1, and Resident #37 in room [ROOM NUMBER]-1, all tested positive for the COVID-19 virus. Interview with the DON on 11/16/20 at 9:32 A.M. revealed the outbreak for the COVID-19 virus began on 10/07/20 with Resident #01. He had dementia, [MEDICAL CONDITION] and wandered. She stated he was sad and all he wanted to do was go outside and see his own grass. His family called numerous times, crying and upset, and said it would benefit the resident if he could come to his house and see his own grass. She said the facility continued to explain to the family this was really dangerous and high risk for him to have visits in the community. She stated she did a risk versus benefit analysis and determined to grant the visit in the community with his family. The family was instructed to only allow two to three people at the visit, outside, no physical contact, social distancing of six feet and for everyone to wear masks and to use hand sanitizer. The visit was supposed to be for an hour with transport an hour there and hour back to the facility. She stated evidently, the visit was more like four hours with over 10 people there. Two days after the visit, he developed signs and symptoms of a urinary tract infection and two days after that, ended up being COVID-19 positive. He shared a room with Resident #203. After the community visit, Resident #01 was placed back in that room because the facility considered the community visit an outside visit and didn't feel he should have to go into isolation after the visit since anyone who goes out to physician's appointments or [MEDICAL TREATMENT] was not in isolation after those visits. After he showed symptoms, Resident #01 was placed in a private room with isolation precautions, but he would not stay in his room or keep a mask on. Resident #203, his roommate and Resident #07, who lived across the hall both became positive and all three were moved to isolation precautions on the 200 hall and then [MEDICAL CONDITION] spread exponentially. She said the guidelines that were set forth by CDC to move the infected residents behind a barrier away from the non-sick residents didn't work out because then everyone was getting sick, so it was decided to isolate in place per the local health department instructions. During interview with the DON on 11/16/20 at 11:22 A.M., she stated the facility had been COVID-19 free until Resident #01 came down with [MEDICAL CONDITION]. She traced the COVID-19 spread back from Resident #01. The facility did everything they could do to keep him contained to his room. The residents are accustomed to going when they want and rolling into the areas they wanted. The facility was unable to put someone with him one-on-one and that's what would be required, and they could not do one-on-one staffing. When it became apparent the facility could not contain Resident #01, he was moved to an isolation room. By that time, he had already exposed his roommate. Interview with Care Manager (CM) #143 on 11/16/20 at 11:47 A.M. revealed she spoke to the family prior to the visit and felt like Resident #01 needed to see the family and with the summer coming to an end the family felt like a visit would be warranted. She stated she reported to the family Resident #01 was positive for COVID-19. The family was very upset by this and taking the blame for bringing COVID-19 into the facility. She stated she told the family they had to be tested . Interview with LPN #182 on 11/16/20 at 12:44 P.M. revealed she sent Resident #01 out for a community visit on 09/27/20 around 1:50 P.M. She spoke with the family at shift change around 7:00 P.M. when he returned. Resident #01's family stated only family members were included in the community visit and they wore masks but didn't give a number of how many family members were present. In a subsequent interview conducted on 11/18/20 at 4:36 P.M., LPN #182 revealed she worked on 09/27/20, 09/28/20, 09/30/20 and 10/01/20 and Resident #01 came out of his room, unmasked, and wheeled himself out into the common area. He sat around the fish tank with others and ate in the dining room while other residents were present. He would mingle with other residents and it was as if he did as he wanted to do. CM #143 relayed an e-mail dated 11/16/20 at 4:45 P.M. CM #143 had spoken with LPN #124, who was off on medical leave and wasn't available for an interview, that stated LPN #124 had spoken to Resident #01's family the weekend Resident #01 was tested for COVID-19. The family member stated there were no more than five people on the patio at a time with Resident #01, but there were about 10 people in the house. They rotated people in and out to the patio to see Resident #01 and everyone wore masks and social distanced. Interview with Resident #01's family member on 11/16/20 at 1:02 P.M. revealed Resident #01 was taken out for a community visit on 09/27/20 about 2.5 miles from the facility (which was not what the family initially told the facility. Originally the family said they were taking Resident #01 to his own home; however, they ended up taking Resident #01 to his family's home). The family member stated Resident #01 went to the family home and back to the facility after the visit. He stayed four to five hours and there were eight people at the visit. Everyone wore masks except two family members. There were three people in the group that tested negative for [MEDICAL CONDITION], but the rest of the family had not been tested prior to the visit. The family stayed four to five feet apart and ate dinner outside at a big table. As of 11/17/20 at 1:03 P.M., according to the DON, there were seven residents (#05, #24, #27, #28, #33, #55, #57) in the facility who remained positive for COVID-19. During an interview on 11/17/20 at 12:49 P.M., the DON stated Residents #01, #07 and #203 were moved to the second floor and they were a part of the back hall. The rest of the residents on the front part of the hall were not infected. At first there wasn't a barrier between the sick and uninfected, there was an imaginary barrier which was a supply cart. Then on 10/07/20, plastic was put up to try to make a barrier on the unit. The plastic kept billowing and wasn't weighted enough. On 10/09/20, a frame was made for the unit and the plastic barrier was put in place. Interview with the DON on 11/19/20 at 11:15 A.M. revealed she did not call the family to see how the visit went and said the family were given directions on how to have a safe visit with PPE, hand sanitizer, and social distancing. She stated she didn't feel it was her responsibility to check on the actions of the family. Interview with MD #300 on 11/19/20 at 12:37 P.M. revealed when COVID-19 was discovered in the facility, the facility response was adequate, and no protocols were breached. When asked if isolation would have helped the spread of [MEDICAL CONDITION] when coming back from the family visit in the community on 09/27/20, MD #300 stated isolation of patients was a challenge for the facility. Staff weren't doing respiratory assessments, they were doing vital signs and signs and symptoms of [MEDICAL CONDITION] and this was adhered to. Resident #01 was isolated with the first symptom. Review of the facility policy titled Visitation During Isolation, Emergency Mandate, revised on 09/01/20, indicated visitors must schedule an appointment for a pre-approved outside visit with the Activities department. Visits will be scheduled for 30 minutes. A limit of three visitors at a time may participate in the outside visiting session. Visitors and residents must remain contact free throughout duration of visit. If contact does occur, the resident shall wash hands thoroughly upon returning indoors and, if possible, change clothes upon returning indoors. Items such as wheelchairs or other touched items shall be cleaned and disinfected. The facility reserves the right to educate and intervene should a risk present during any visit. The facility policy did not address residents leaving the facility for a community visit off the facility grounds. This deficiency substantiated Complaint Number OH 092.