Every finding on record at Hudson Springs Nursing and Rehab

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and interview, the facility failed to ensure Resident #3 was appropriately dressed for an outside appointment. This finding affected one (Resident #3) of three residents reviewed for dignity and respect. The facility census was 66.Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, chronic respiratory failure with hypercapnia and fibromyalgia.Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was unable to complete the interview.Review of Resident #3's progress note dated 04/30/26 at 11:03 A.M. revealed the resident was out on an appointment at this time and no distress at the time of the appointment.Review of Resident #3's Employee/Resident/Witness Statement dated 04/30/26 authored by Certified Nursing Assistant (CNA) #806 revealed the resident had an appointment on this date. CNA #806 was told to get the resident dressed and ready. The resident had a gown on her because the aide thought the resident was getting a cot transfer. A blanket was put on Resident #3 and the gown was tied. A shoe or sock was not placed on the resident due to the resident having a dressing on the foot with a brace on it.Review of Resident #3's Employee/Resident/Witness Statement dated 04/30/26 authored by CNA #806 revealed the aide had been told before not to change the resident's clothing or hair wraps if the resident had not had a bed bath. The bed bath days were on the night shift so the aide did not want to put something clean on the resident when the resident did not have a bed bath. The aide stated she wanted to do what the daughter had asked the facility not to do.Interview on 05/29/26 at 7:35 A.M. with CNA #806 revealed Resident #3 was sent out to the appointment in a hospital gown.Interview on 05/29/26 at 7:47 A.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #807 revealed she was aware Resident #3 was sent out in a hospital gown to an appointment and the staff member was educated.Review of the Supporting Activities of Daily Living (ADLs) policy revised 03/2024 revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.The deficiency was corrected on 05/05/26 when the facility implemented the following corrective actions.-On 04/30/26, CNA #806 was educated by the DON to ensure residents were dressed and presentable for appointments. -On 04/30/26, RN Staff Development #808 completed education to include dressing residents appropriately for appointments, emptying trash bags, appropriately repositioning residents and using wedge pillows. The education included 10 RNs, 14 Licensed Practical Nurses (LPNs) and 24 CNAs.-On 04/30/26, signage was placed by RN ADON #807 in Resident #3's room alerting staff to the resident's shower days and that the resident's preference for clothing to be placed on the resident and not hospital gowns. The signage was observed on the side of the dresser by the bathroom in the resident's room.-On 04/30/26, RN ADON #807 updated Resident#3's care plans to reflect the family's preferences for the resident's shower days and clothing to be placed on the resident.-Beginning 05/01/26 to 05/28/26, The DON and RN ADON #807 completed audits to ensure residents were dressed appropriately for appointments with no negative findings. -On 05/05/26, the Administrator held a care conference with Resident #3's daughter, two granddaughters and the Director of Nursing (DON). The Administrator acknowledged and expressed understanding of Resident #3's family members frustration regarding the resident being transferred to the hospital wearing a gown. The Administrator further expressed confusion among staff regarding the resident's dressing preferences for a pain management appointment on 04/30/26. The daughter was informed immediate education had been provided to the CNA regarding the resident's dressing preferences and signage was placed in the resident's room for care preferences. -The Administrator indicated the issue of residents dressed appropriately for appointments and weather would be brought to the quality assurance committee (QA) once a month for the next three months.This deficiency represents non-compliance investigated under Complaint Numbers 3006266 and 3005520.

Based on observation and interviews, the facility failed to serve food at hot and palatable temperatures, with accurate portion sizes to meet nutritional needs, and in timely meals. This affected nine residents (Residents #7, #17, #18, #29, #38, #57, #62, #72 and #75) and had the potential to affect 67 residents who received food from the kitchen. There were six residents (Residents #8, #13, #14, #31, #64 and #84) who received no food or beverages from the kitchen. The facility census was 73.Findings include: Interview with Resident #29 on 04/19/26 at 11:10 A.M. revealed, Meals have very small portions of meat. They serve a lot of noodles, and they combine leftovers into a new meal.Interview with Resident #72 on 04/19/26 at 11:35 A.M. revealed, Food (expletive). It's cold sometimes and the presentation on the plate makes it unappealing.Interview with Resident #17 on 04/19/26 at 11:46 A.M. revealed, The food taste is poor.Interview with Resident #57 on 04/19/26 at 12:04 P.M. revealed, The food is terrible. Don't know what you are eating sometimes. I get a lot of mashed potatoes. Interview with Resident #7 on 04/19/26 at 12:10 P.M. revealed, The food is a huge concern. Food is almost always cold. Cold items are warm like milk and yogurt. The kitchen will put hot and cold food on the same plate, such as lasagna and salad. Ice cream becomes like a milkshake when served.Interview with Resident #38 on 04/19/26 at 12:16 P.M. revealed, The kitchen is the worst part. Sometimes dinner is at 7:00 P.M. or 7:15 P.M. Interview with Resident #75 on 04/19/26 at 12:20 P.M. revealed, Food is terrible and the menu is not correct.Interview with Resident #18 on 04/19/26 at 12:28 P.M. revealed, Food is warm at best.Interview with Resident #62's family on 04/19/26 at 2:06 P.M. revealed, The food is terrible.Observation of lunch tray line on 04/21/26 at 12:38 P.M. revealed the following food temperatures and portion sizes: Beef and broccoli stir fry was 151 degrees Fahrenheit (F) for regular texture and 151 degrees F for the puree. A four-ounce portion was served until it was corrected by the surveyor. Soft fried noodles were 165 degrees F for regular texture and 165 degrees F for the puree. A four-ounce portion was served.Mini egg rolls were 162 degrees F for regular texture and 168 degrees F for the puree. The cold beverage was 38 degrees F, and an eight-ounce portion was served. All items were at a safe temperature.Review of the Week at a Glance menu for 04/21/26 revealed the correct items were served.Review of the diet spreadsheet for 04/21/26 revealed the portion size of the beef and broccoli stir fry was two #8 (four-ounce) scoops. [NAME] #232 served one #8 scoop of both regular and puree broccoli stir fry until corrected by the surveyor. The plates already dished up were then corrected. This was verified by [NAME] #232 and Administrator in Training (AIT) #318 at the time of correction.Observation of a test tray on 04/21/26 revealed at 1:35 P.M. the 200-hall trays were started. At 1:51 P.M. the test tray left the kitchen, and at 1:53 P.M. the tray arrived at the 200-hall. All the 200-hall trays were passed by 1:56 P.M. and the food on the test tray was then checked for food and beverage temperatures. The mini egg roll was 122 degrees F. The soft fried noodles were 125 degrees F. The beef and broccoli stir fry was 104 degrees F. The cold beverage was 39 degrees F. The hot food, in particular the beef and broccoli stir fry, at 104 degrees F, was not at a palatable temperature. The lunch mealtimes were posted as being served from 12:30 P.M. to 1:30 P.M. The 200-hall was served at 1:53 A.M, and then 400-hall was served afterwards. The lunch meal was late. Interview at the time of the observation with Dietary Manager #304, the Administrator, and AIT #318 verified the test tray findings and the meal being late.This deficiency represents non-compliance investigated under Complaint Numbers 2746202 and 2738451.

Based on observation and interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 73 residents residing in the facility.Findings include: Observation of the facilities dumpster area on 04/19/26 at 1:54 P.M. revealed the two garbage dumpsters had their top lids open. One dumpster also had the side door open. There was a pile of gloves, straws, plastic bottles and wrappers beside one dumpster. Interview at the time of the observation with Dietary Manager #304 verified the condition of the dumpster area.This deficiency represents non-compliance investigated under Complaint Number 1397116 (OH00165273).

Based on observation and interviews, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 67 residents who received food from the kitchen. There were six residents (Residents #8, #13, #14, #31, #64 and #84) who received no food or beverages from the kitchen. The facility census was 73.Findings include: Observation during the initial kitchen tour conducted on 04/19/26 at 1:54 P.M., the following was noted:The shelf over the stove had accumulated grease and dust.The inside of the microwave had accumulated build-up of food from spatters.The under-counter refrigerator had spills dried onto the floor.The bucket of sanitizing solution used to wipe the counters did not meet the correct level of sanitizer.Interview at the time of the observation with Dietary Manager #304 verified the findings.Observation on 04/21/26 at 12:15 P.M. of the three-compartment sink used to wash and sanitize equipment and utensils did not meet the correct level of sanitizer. Interview at the time of the observation with [NAME] #278 and Administrator in Training #318 verified the findings. This deficiency represents non-compliance investigated under Complaint Number 1397116 (OH00165273).

Based on observation, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to use appropriate infection control practices by performing hand hygiene and changing gloves during incontinence care. This affected one resident (Resident #51) out of one resident observed for incontinence care. The facility identified 45 residents (Residents #2, #5, #8, #10, #12, #14, #19, #20, #21, #22, #23, #24, #29, #30, #32, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, #47, #48, #50, #51, #52, #56, #57, #58, #59, #60, #61, #62, #63, #65, #70, #71, #73, #74, and #75) who required incontinence care. The facility census was 73.Findings include:Review of the medical record for Resident #51 revealed an admission date of 12/18/25 and diagnoses of Parkinson's disease, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, benign prostatic hyperplasia, chronic kidney disease stage three, acute kidney failure, periodic limb movement disorder, disorder of the brain, anxiety disorder, and depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition, was frequently incontinent of bowel and bladder, and dependent for incontinence care. Review of the physician's orders for Resident #51 dated 02/16/26 revealed an order to check and change every two hours and as needed per shift for incontinence care. Observation on 04/22/26 at 9:34 A.M. with Certified Nursing Assistants (CNAs) #280 and #286 of incontinence care for Resident #51 revealed both CNAs washed their hands prior to the procedure. CNA #286, while wearing clean gloves, removed Resident #51's soiled brief and cleansed the area from front to back. CNA #286 then removed the soiled gloves, performed hand hygiene and applied clean gloves. Both CNAs rolled Resident #51 to the left side and then CNA #280, wearing clean gloves, cleansed Resident #51's buttocks area. CNA #280 then obtained a clean brief with the now soiled gloves and placed it onto the resident without changing gloves or performing hand hygiene prior. Afterwards, both CNAs discarded their gloves and washed their hands. Interview at the time of the observation with both CNAs #280 and #286 confirmed CNA #280 did not change gloves or perform hand hygiene after cleansing Resident #51's buttocks area and before handling and applying a clean brief. Interview on 04/22/26 at 9:50 A.M. with the Director of Nursing verified soiled gloves should be changed and hand hygiene performed before placing a clean brief on a resident as a proper infection control practice.Review of facility policy titled, Urinary Continence and Incontinence - Assessment and Management, dated 09/2024 revealed staff would properly screen and manage individuals with urinary incontinence which would include avoidance of infection and use infection control aspects of incontinence care. Review of the guidelines from the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, located at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24 revealed gloves should be changed and hand hygiene performed if gloves become soiled with blood or body fluids after a task.This deficiency represents non-compliance investigated under Complaint Numbers 2746202, 2659759, and 2572446.

Based on record review and interview the facility failed to ensure the advanced directives were consistently documented in the medical record. This failure resulted in conflicting code status information for one resident (Resident #57) of 28 residents reviewed for advanced directives. The facility census was 73.Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/08/25. Diagnoses included cerebral infarction, diabetes, aphasia, major depressive disorders, and chronic obstructive respiratory disease (COPD).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition.Review of physician orders for Resident #57 revealed an order for Do Not Resuscitate-Comfort Care (DNR-CC) dated 08/12/25. There were no changes in the advanced directive orders made after 08/12/25.Review of the hard copy Advanced Directive form revealed Do Not Resuscitate-Comfort Care- Arrest (DNR-CC-Arrest) was signed by the physician on 10/27/25.Interview on 04/27/26 at 11:29 A.M. with Assistant Director of Nursing #301 verified the advanced directives in the physician orders and the signed advanced directive form did not match.

Based on record review and interview, the facility failed to develop a comprehensive and individualized care plan for Resident 78 to address turning and repositioning needs and interventions for pain. This affected one resident ( Resident #78) of four residents reviewed for care plans. The facility census was 75.Findings include:Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including but not limited to nontraumatic intracerebral hemorrhage, vomiting, pneumonia, metabolic encephalopathy, muscle weakness, symbolic dysfunction, history of transient ischemic attack, shortness of breath, acute respiratory failure, dysphagia, chronic pulmonary disease, disease of digestive system, hemiplegia, severe protein malnutrition, malaise, tracheostomy, disorder of brain, and hypothyroid.Review of Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE] revealed Resident #78 was nonverbal and had impaired cognition. Resident #78 was dependent on staff to roll left and right in bed and to transfer from bed to chair. Resident #78 was on a scheduled pain regimen and received as needed pain medication. Resident #78 had one unhealed pressure injury that was a stage three pressure injury. Review of the Pain assessment dated [DATE] revealed Resident #78 was unable to answer if she was hurt in the past five days, was unable to answer how much pain she experienced over the past five days, was unable to answer if pain made it difficult to fall asleep, unable to answer if unable to participate in rehab therapy related to pain, unable to answer if pain affected day to day activities. Resident #78 was unable to answer a verbal descriptor scale of worst pain over the past five days. Review of physician orders dated 07/22/25 revealed Resident #78 was to receive Acetaminophen 325 milligrams by PEG tube three times a day for pain and Acetaminophen 325 milligrams by PEG every six hours as needed for pain.Review of physician orders dated 08/19/25 revealed Resident #78 was ordered Tramadol (narcotic pain medication) 50 milligrams by PEG tube every 12 hours as needed for pain.Review of the care plan dated 07/28/25 and revised 10/20/25 revealed Resident #78 had impaired skin integrity. Interventions include assist with hygiene and general skin care and keep skin clean and dry. There were no interventions related to turning and repositioning the resident to offload pressure to promote skin integrity. There was no care plan developed for the pain medications ordered, no measurable goals pertaining to pain or the pain medications and no interventions for pain developed in the care plan. Review of Resident #78 ' s physician orders for October 2025 to November 2025 revealed no orders related to turning and repositioning. There were also no orders pertaining to an individualized pain assessment for a resident who could not verbally communicate.An interview on 01/22/26 at 8:39 A.M. with Registered Nurse (RN) #426 revealed Resident #78 had a wound on her bottom and stated staff were to turn and reposition Resident #78 at least every two hours. Also, since Resident #78 was non-verbal, staff would need to assess level of pain by physical assessment such as if Resident #78's face would tense up with care.An interview on 01/22/26 at 1:45 P.M. with the Director of Nursing (DON) confirmed Resident #78's physician orders had not included to turn and reposition Resident #78 at least every two hours and the facility should have implemented a care plan to turn and reposition. The DON also confirmed the facility did not implement a plan of care related to pain for Resident #78.Review of the facility policy titled Pain Assessment and Management, revised March 2023, revealed the pain management program was based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management. Review of the facility policy titled Pressure Ulcer Prevention and Risk Identification,undated, revealed a care plan would be developed and updated routinely with identified skin risk and/or actual wound development. Interventions would be implemented as indicated by the physician and as determined by the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number 2714382.

Based on observation, record review, interview and review of facility policy, the facility did not ensure timely notification to the physician of a change in condition for Resident #78. This affected one resident (#78) of three residents reviewed for change of condition. The facility census was 75. Findings include : Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia, nontraumatic intracerebral hemorrhage, vomiting, pneumonia, metabolic encephalopathy, dysphagia, chronic pulmonary disease, severe protein malnutrition, tracheostomy, and disorder of brain, unspecified.Review of physician orders for Resident #78 dated 07/22/25 revealed residuals (the amount of stomach contents left in the stomach at a specific time during tube feeding measured to see if the stomach is emptying properly and tolerating the tube feeding) were to be checked and to call the physician if equal to or greater than 150 milliliters (ml) every shift prior to feedings every shift.Review of the care plan with a date initiated of 07/31/25 revealed Resident #78 had potential for alteration in nutrition and hydration due to intercerebral hemorrhage and did not eat by mouth (NPO) so required tube feeding and water flushes for nutrition and hydration. Interventions included providing the tube feeding and flushes per physician orders and monitor. Review of physician orders dated 10/23/25 revealed Resident #78 was receiving enteral tube feeding of Jevity 1.5 at 50 ml per hour for 22 hours with 125 ml water flush every four hours.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #78 had severely impaired cognition and was dependent on staff for all activities of daily living (ADL). Resident #78 had an indwelling urinary catheter, received oxygen therapy, had a tracheostomy and gastrostomy tube feeding. Review of the Medication Administration Record and Treatment Administration Record for November 2025 revealed the tube feeding and water flush administration for Resident #78 was signed off as administered as ordered on 11/24/25 day turn by Licensed Practical Nurse (LPN) #509. The gastric residual check was signed off as completed on day turn by LPN #509. Review of the Practitioner Progress Note dated 11/24/25 at 10:09 A.M. authored by Nurse Practitioner (NP) of Pulmonary Medicine #510 revealed the resident was seen and examined, in no distress. There was no mention the NP was notified Resident #78 had been having emesis during the earlier morning hours, increased residuals or tube feeding on hold. Review of the Respiratory Therapy Note dated 11/24/25 at 2:46 P.M. written by Respiratory Therapist (RT) #352, revealed Resident #78 was suctioned throughout the day and resident has been throwing up throughout the day. There was nothing in the note to indicate the physician was notified. Review of the Nursing Note dated 11/24/25 at 3:37 P.M. written by LPN #509 revealed Resident #78 had increased residuals, emesis times two this shift with a lot of tf (tube feeding) output. Tube feeding on hold for this time, will continue to monitor and restart tube accordingly. There was no evidence in this note that the physician was notified. Review of the Nursing Note dated 11/24/25 at 5:59 P.M. written by LPN #509 revealed Resident #78's family at side stating the resident is in distress and shaking resident saying something is wrong with her, get help immediately. LPN #509 wrote she assured family Resident #78 displayed anxious behavior and was not in distress. LPN #509 stated family was educated Resident #78 secretions were very thick at this time and her breathing was a normal response to this . Vital signs were obtained and RT assessed resident along with suctioning and the resident tolerated it well. There was no evidence the physician had been updated regarding the tube feeding on hold, the emesis earlier in the day or that the family was expressing concern about the resident. Review of the vital signs dated 11/24/25 at 5:59 P.M. recorded by LPN #509 revealed the vital signs were within normal range with blood pressure 126/78, pulse 81, temperature 97.8 degrees Fahrenheit and oxygen 96 percent. Review of the Respiratory Therapy Note dated 11/24/25 at 7:00 P.M. written by RT #342 revealed the RT was in the room to assess the resident and Resident #78 was breathing harder than normal, breath sounds were clear, tracheostomy clear and free of obstruction, breathing not labored and respiratory rate in the 30's. Unable to get an accurate sat (oxygen saturation reading) so increased oxygen to four liters per minute. RN called to room to assess, and ambulance called to take to ER for further evaluation. Review of document titled Stow Fire Department Patient Care Record dated 11/24/25 revealed emergency services received a call at 7:04 P.M. from the facility, were dispatched at 7:05 P.M. in route at 7:06 P.M., on scene at 7:15 P.M. and at the patient at 7:18 P.M. due to Resident #78 had a change in condition and being less responsive. Resident #78 was found with a pulse and respirations with pupils unequal, shallow breathing and departed to the hospital at 7:36 P.M. Review of the Physiatry progress note dated 11/24/25 at 9:43 P.M. authored by Physiatry Physician Assistant (PPA) #511 revealed the family requested transfer to another facility due to concerns with her not getting proper care. The resident was noted to be NPO with PEG feeding tube. Per nursing the patient had an episode of vomiting. Defer management to primary care team. There was no evidence in this note that the physician was made aware of the resident's vomiting.An interview on 01/13/26 at 10:00 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #402 revealed if a resident was having a change in condition, then the nurse was expected to call the physician or 911 if it was cardiac or respiratory distress. An interview on 01/13/26 at 12:10 P.M. with Primary Care Physician/Medical Director (MD) #523 revealed Resident #78's baseline was nonverbal, and cognition was at most resident could track with eyes. MD #523 stated Resident #78 was a candidate for hospice, but the family did not want hospice. MD #523 stated due to her high-risk multiple comorbidities, the tube feeding and tracheostomy, Resident #78 was an intensive care unit candidate if hospitalized . MD #523 did not mention being made aware Resident #78 had been vomiting prior to hospital transport on 11/24/25. An interview on 01/13/26 at 4:11 P.M. with Certified Nurse Assistant (CNA) # 507 revealed she worked the early morning of 11/24/25 and was Resident #78's aid. CNA #507 verified Resident #78 had been vomiting during the shift and that was not normal for her. CNA #507 stated she had told RN #424 it was not normal and the resident did not seem herself. An interview on 01/14/26 at 8:20 A.M. with CNA #326 revealed Resident #78 normally was stable and did not vomit her tube feeding. An interview on 01/14/26 at 8:40 A.M. with RN # 426 revealed Resident #78's family would visit often and would be able to see if Resident #78 was not in normal condition. Resident #78 usually was stable and tolerated her tube feeding. An interview on 01/14/26 at 10:28 A.M. with RT #352 verified she worked on 11/24/25 during the day and cared for Resident #78. RT #352 stated Resident #78 needed more suctioning on 11/24/25 than usual. RT #352 stated she notified LPN #509 that Resident #78 had emesis on 11/24/25. RT #352 stated Resident #78 needed an escalation of care considering emesis during the day and need for more suctioning than usual. An interview on 01/14/26 at 11:06 A.M. with RN #394 verified she worked 11/24/25 from 6:00 P.M. to 11/25/25 at 6:00 A.M. RN #394 stated during report LPN #509 stated Resident #78 had emesis during the day but did not say it was not reported to the physician. RN #394 stated she was alerted by RT #342 of her vitals, which she called 911 immediately. RN #394 stated she verified Resident #78 vitals after RT #342 alerted her of his concern. An interview on 01/14/26 at 12:30 P.M. with LPN # 509 verified she worked 11/24/25 from 6:00 A.M. to 6:00 P.M. and cared for Resident #78 that day. LPN #509 verified Resident #78 had high gastric residuals but did not specify nor document exactly how much. LPN #509 confirmed she did not call the physician to notify him of the residuals and multiple episodes of Resident #78 vomiting or that she had put the tube feeding on hold. LPN #509 stated she did not remember the family reporting the resident was in distress. LPN #509 stated she had no concerns with how to notify a physician if needed.An interview on 01/14/26 at 4:46 P.M. with RT #342 verified he worked 11/24/25 from 6:00 P.M. to 11/25/25 6:00 A.M. and verified he cared for Resident #78 that night. RT #342 stated he observed Resident #78 at the start of his shift because family was concerned with how the resident was breathing. An interview on 01/15/26 at 9:18 A.M. with Nurse Practitioner (NP) of Pulmonary Medicine #510 revealed she visited Resident #78 the morning of 11/24/25 but did not obtain vitals on Resident #78 that day and was not informed that Resident #78 had been having emesis and high residuals. An interview on 01/15/26 at 1:59 P.M. with Physiatry Physician Assistant (PPA) #511 revealed she was in the facility on 11/24/25 and did visit Resident #78 in the morning. She revealed LPN #509 mentioned to her that Resident #78 had an episode of vomiting that day. PPA #511 verified she did not inform the physician or family and did not assess the resident for it or do anything about it. An observation was conducted on 01/22/26 at 4:30 P.M. with the Director of Nursing (DON) of Ring camera video footage submitted with permission by Resident #78's family from the live camera recordings in Resident #78's room. At the time of the observation, the DON verified the following time and date stamps and staff members in the room on the following video footage: On 11/24/25 at 3:42 A.M. Registered Nurse (RN) #424 and Certified Nurse Assistant (CNA) # 507 were in Resident #78's room at 3:45 A.M. CNA #507 stated oh she vomited. Observation of video revealed vomit was observed on the right side of Resident #78's mouth while RN #424 and CNA #507 were in the room. CNA #507 stated there was puke all over her. Both staff cleaned the resident up and the nurse obtained vital signs. Observation of video footage at 9:07 A.M. revealed LPN # 509 walked into Resident #78's room and stated she was going to turn this off for a minute, she is full. LPN #509 was observed to provide medication by syringe and shut off the tube feeding administration pump that was next to the resident's bed. At 10:50 A.M. PPA #511 walked into resident's room, the resident was alert and in no obvious distress. PPA #511 looked over the residents arms and legs briefly, picked up her computer and left the room. PPA #511 took no vitals or other assessments. The tube feeding pump was still off. Observation at 11:04 A.M. of RT #352 with a student-in-training revealed Resident #78 had a large amount of emesis that poured out of her mouth three times while the student- in-training used a [NAME] suction around resident's chest area and mouth. The tube feeding pump was still off. Review of video footage at 5:43 P.M. revealed Resident #78's daughter entered Resident #78's room, set her belongings down near the camera, walked over to Resident #78 and was observed asking the resident if she was ok. The resident was noticeably breathing heavier than in prior video segments. The DON verified these findings at the time of the observation. Further review of the medical record for Resident #78 revealed no evidence RN #424 documented that Resident #78 had emesis, if the resident was assessed and there was no evidence of the physician being notified by RN #424. Review of the facility policy titled Change in a Resident's Condition or Status dated May 2024, revealed the facility shall promptly notify the attending physician, and representative of changes in the resident medical status. This deficiency represents noncompliance investigated under Complaint Number 2714382.

Based on interviews and record review, the facility failed to honor Resident #78's power of attorney's (POA) right to manage the residents' financial affairs by allowing the POA to select the insurance payer for the resident's stay. This affected one Resident (Resident #78) of three residents reviewed for resident rights. The facility census was 75.Findings include:Review of the medical record for Resident #78 revealed an admission date of 07/22/25. Medical diagnoses included nontraumatic intracerebral hemorrhage, metabolic encephalopathy, acute respiratory failure, hemiplegia, severe protein malnutrition, and tracheostomy. Resident #78 discharged to the hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE] revealed Resident #78's cognition was severely impaired. Resident #78 was dependent on staff to provide all activities of daily living. Further review of the medical record revealed on 07/22/25 Resident #78's primary payer source was Aetna Managed Medicare. On 08/01/25 the primary payer source changed to Medicare A. On 10/30/25 the payer source changed to private pay. Review of the admission Agreement dated 07/25/25 revealed Business Office Manager (BOM) #513 was listed as the representative on the Designation of Authorized Representative page for the Ohio Department of Medicaid. The form indicated the representative was authorized to act on my behalf in all matters with the agency (agency refers to all departments of the county of job and family services, the Ohio Department of Medicaid (ODM) and all of ODMs contracted designees). At the bottom of the page, a hand-printed first initial and hand-printed last name of Resident #78's POA was listed in the box marked signature of person granting authority. There was no signature from the authorized representative. The form stated, this form has no effect unless signed by both the person granting authority and by the authorized representative. Review of the document titled [NAME] Springs Amount Due, dated 08/01/25, revealed Resident #78 was sent an invoice dated 08/01/25 for coinsurance for the period of 08/11/25 to 08/31/25 for a total of $4,399.50 that was due by 09/05/25.Further review of the medical record revealed no evidence documented that the facility had discussed at any time with Resident #78's POA the change of insurance on 08/01/25 or the invoice generated from the facility dated 08/01/25 prior to the bill due date of 09/05/25. An interview on 01/13/25 at 1:20 P.M. with Resident #78's Family Member #800 revealed when Resident #78 was admitted to the facility on [DATE] the payer source was Aetna Medicare Advantage PPO. As of 08/01/25 the insurance was changed without the family's knowledge or consent which resulted in a $209.00 per day copay while a resident at the facility. Family Member #800 stated they believed (first and last name provided) BOM #513 made the change to Resident #78's insurance without consent of the POA since Resident #78 was unable to speak for herself or sign documents. Family Member #800 stated if the insurance had not been changed, no copays would have accumulated for Resident #78. An interview on 01/20/26 at 9:15 A.M. with the Accounts Receivable Supervisor (ARS) #512 and BOM #513 verified Resident #78 had been charged 209 dollars per day due to a change in insurance payer effective 08/01/25 and verified Resident #78 had been issued a bill due 09/05/25 due to that change. ARS #512 stated that change would not have been related to therapies. ARS #512 and BOM #513 both denied changing the insurance and stated they did not know who changed it or why it was changed. BOM #513 verified Resident #78 changed to private pay in the system on 10/30/25, however, Resident #78's insurance was reinstated on 11/01/25 so the facility was actively trying to receive backpay from the insurance instead of charging Resident #78 as private pay from 10/30/25 to 11/24/25. An interview on 01/21/26 at 11:53 A.M. with Resident #78's POA revealed she did not make any changes to Resident #78's insurance on 08/01/25, and the family did not authorize the transfer of insurance on 08/01/25. The POA stated that because of the disenrollment, Resident #78 accrued expenses from the facility and other providers. The POA stated she was not asked by the facility for permission to make any changes to Resident #78's insurance payer source. This deficiency represents non-compliance investigated under Complaint Number 2714382.

Based on observations, resident and staff interviews, and record review, the facility failed to provide timely assistance to residents who were dependent on staff for activities daily living with incontinence care. This affected one (Resident #25) of three residents reviewed for incontinence care. The facility census was 69. Findings include: Review of the medical record for Resident #25 revealed an admission date 05/18/24. Diagnoses included morbid obesity, major depression, anxiety, chronic pain, lymphedema, urinary retention, and chronic kidney disease stage III. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and was dependent on staff for toileting hygiene, was always incontinent of bowel, and had a indwelling catheter. Review of Resident #25's care plan revealed she had deficit in self-care performance related to morbid obesity and pulmonary disease. Interventions included Resident #25 was totally dependent on two staff for toilet use and bed mobility. Resident #25's care plan revealed she had impaired skin integrity to right lateral thigh due to bedfast and impaired mobility. Interventions included to check and change approximately every two-to-three hours and as needed related to incontinence, assist with hygiene and general skin care, and keep skin clean and dry. Interview with Resident #25 on 10/20/25 at 9:55 A.M. revealed she has been waiting to be cleaned up after having a bowel movement earlier in the morning. Resident #25 stated she has not been checked and changed since night shift left. Resident #25 stated she put her call light on around 8:00 A.M. and when Certified Nursing Assistant (CNA) #819 came into her room, CNA #819 told Resident #25 she would be right back in a few. CNA #819 turned off the call light. Resident #25's linens were visibly soiled with an extra-large bowel movement. Observation on 10/20/25 at 11:12 A.M. revealed CNAs #819 and #820 were going to provide Resident #25 with incontinence care for the first time on their shift. Resident #25 did not wear a depends due to irritates her skin. Resident #25 required a full bed linen change and complete perineal cleansing due to the extent of the soiling. Resident #25 had an extra-large bowel movement (BM) down her thighs, in her skin creases and all around her catheter. Interview on 10/20/25 at 12:15 P.M. with CNA #819 verified she had not changed Resident #25 since starting her shift at 7:00 A.M. and she knew earlier that Resident #25 had had a BM and needed changed. CNA #819 explained she had to assist other residents before she provided incontinence care to Resident #25. This deficiency represents non-compliance investigated under Master Complaint Number 2649075 and Complaint Number 2642045.

Based on review of video camera footage, interviews with staff and a police detective, and record review, the facility failed to implement the comprehensive, person-centered care plan for Resident #2. This affected one (#2) of three residents reviewed for care plans. The facility census was 69. Findings include: Review of the medical record for Resident #2 revealed an admission date 01/24/25. Diagnoses included Parkinson's disease, wedge compression fracture of third lumbar vertebra, chronic respiratory failure, severe osteoporosis, dementia, tracheostomy, and above the knee amputee. Review of the care plan revealed Resident #2 had a self-care performance deficit related to disease process Parkinson's disease, impaired balance, limited mobility and impaired range of motion due to bilateral hand/wrist contractures. Interventions included Resident #2 required two staff assistance for repositioning, dressing, personal hygiene/oral care and toileting. A video provided on 10/22/25 at 12:34 P.M. by Detective #850 revealed on 09/15/25 at 11:30 A.M., two staff members came into Resident #2's room to provide incontinence care. One staff member walked away and the other staff member repositioned resident one assist. On 09/21/25 at 10:53 A.M. one staff member repositioned Resident #2. At 4:08 P.M. one staff member started preforming incontinence care. Interview on 10/22/25 at 10:20 A.M. with Registered Nurse (RN) #803 revealed Resident #2 was a two-persons assist for incontinence care and repositioning. Interview on 10/22/25 at 11:30 A.M. with Certified Nursing Assistant (CNA) #819 and #820 verified Resident #2 was two-persons assistance for incontinence care and repositioning. Interview on 10/22/25 at 12:13 P.M. with Detective #850 stated she received a complaint from Resident #2's daughter and was provided with videos of Resident #2 being repositioned and incontinence care with one assist and Resident #2 was a two-persons assistance for incontinence care and repositioning. Detective #850 verified he spoke with the Administrator on 10/16/25 of the allegations. Detective #850 stated she would email her report and documents that were given to her. She stated Resident #2's daughter would not give consent to review Resident #2's medical records. Interview on 10/22/25 at 2:21 P.M. with the Administrator and Director of Nursing (DON) verified Resident #2 was a two-persons assist for all transfers, repositioning and incontinence care. The Administrator verified she was contacted by Detective #850 and was told she was looking into a complaint. At this time, the Administrator and DON were notified that the surveyor had received videos that showed Resident #2 was being repositioned and being provided with incontinence care of one staff assist. At that time, the DON verified Resident #2 was a two-persons assistant with incontinent care and repositioning. This deficiency represents non-compliance investigated under Complaint Number 2649075.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure sufficient linens were available for resident care and ensure residents have a clean and sanitary homelike environment. This affected one (Resident #25) of the residents reviewed for hygiene and linens. The facility census was 69.Findings include: Review of the medical record for Resident #25 revealed an admission date 05/18/24. Diagnoses included morbid obesity, major depression, anxiety, and lymphedema. Interview with Resident #25 on 10/20/25 at 9:55 A.M. revealed she has been waiting to be cleaned up after having a bowel movement earlier in the morning. Resident #25 stated she put her call light on around 8 A.M. and when Certified Nursing Assistant (CNA) #819 came in, she told Resident #25 she would be right back in a few. She turned off the call light. At 10:11 A.M. CNA #819 came into Resident #25's room and again Resident #25 told her she needed changed. CNA #819 stated she came on at 7:00 A.M. and had not checked and changed Resident #25, yet. CNA #819 stated she did not have clean washcloths and towels to change her until 10:00 A.M. CNA #819 stated she could change her when she was finished with another resident's shower. Observations on 10/20/25 revealed at 10:55 A.M., Resident #25 had not been changed yet. At 10:58 A.M., CNA #819 walked by the nursing station and told the nurse there were only two more sets of linens in the closet. The nurse stated she knew about the linen situation. At 11:03 A.M., CNA #819brought clean linens into Resident #25's room and stated she was gathering her supplies. Observation on 10/20/25 at 11:12 A.M. of incontinence care for Resident #25 with CNA #819 and CNA #820 revealed Resident #25's sheets were dirty with feces Resident #25 does not wear a depends due to irritation her skin. CNA #820 had only two washcloths and had to use bathing towels to clean her up. Resident #25 had an extra-large bowel movement (BM) down her thighs and in her skin creases. CNA #819 ran out of supplies and had to go back out of the room to get more. CNA #819 stated all she could find was towels and no washcloths. Interview on 10/20/25 at 12:15 P.M. with CNA #819 and #820 revealed they run out of linens and towels all the time and have to wait to get residents cleaned up until laundry brings clean linens to their floor. CNA #819 and #820 stated they have to go to another unit or go to laundry for find clean linens, if there were some. They have to wait until laundry washes them. Observation on 10/20/25 at 12:18 P.M. of 300-Hall clean linen closet with Licensed Practical Nurse (LPN) #818 revealed no towels or washcloths were in the clean linen closet. Interview on 10/20/25 at 12:40 P.M. with Housekeeping/Laundry Supervisor (HLS) #821 verified the lack of linen supplies for staff to utilize. HLS #821 stated she does not know if staff were throwing them away or what. HLS #821 will have to do a search for the facility to see where staff were hiding all of the clean linens. Staff will put linens in empty rooms, in residents' drawers and anywhere they think someone will not find them, so they don't have to go get any when they were running low. Interview with the Administrator on 10/20/25 at 1:00 P.M. revealed management did a search, of the facility to find all the clean linens and found dozens of towels and washcloths in resident rooms, empty rooms and different hiding spots. This deficiency represents non-compliance investigated under Complaint Number 2593016.

Based on record review and interview, the facility failed to ensure respiratory treatments were administered and performed as ordered. This affected one (Resident #38) of three residents reviewed for respiratory care. The facility census was 74. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, Rett's Syndrome (rare neurological genetic disorder that causes severe muscle movement disability), cerebral palsy (condition that affects movement and posture, epilepsy, tracheostomy status, ileostomy status and gastrostomy status. Review of the physician's orders for Resident #38 revealed he had an order dated 01/17/25 for a chest vest (used to help break the cycle of excess mucus, lung infections and lung damage) to be applied twice daily, every 12 hours, at 6:00 A.M. and 6:00 P.M. He also had an order for Albuterol Sulfate Inhalation Nebulization Solution 0.083% (medication that relaxes airway muscles and increases air flow to the lungs), 3 milliliters via trach every 12 hours for shortness of breath dated 01/17/25 to be done at 6:00 A.M. and 6:00 P.M. Review of the Respiratory Administration Record for January 2025 for Resident #38 revealed on 01/17/25 at 6:00 P.M. his chest vest and Albuterol Sulfate were not administered. Review of the nursing progress notes dated 01/17/25 at 8:58 P.M. revealed Respiratory Therapist (RT) #211 had not administered the chest vest because he was uncomfortable using the wrap over Resident a#38's tube sites as he was afraid it would dislodge them. RT #211 also did not administer the Albuterol as it was to be used in conjunction with the vest but he did not use the vest. On 01/18/25 at 5:57 A.M., RT #210 educated RT #211 on how to utilize the chest vest on Resident #38. There was no indication RT #211 updated the physician on not administering and performing the respiratory treatments on 01/17/25. Review of the facility investigation dated 01/18/25 revealed RT #211 was educated on 01/18/25 on the chest vest for Resident #38. It was noted Nurse Practitioner (NP) #212 was updated on 01/18/25 at 7:00 A.M. of the Albuterol and chest vest not being administered on 01/17/25 at 6:00 P.M. Interview on 02/20/25 at 10:31 A.M. with the Administrator verified Resident 38's chest vest and Albuterol were not administered and performed as ordered on 01/17/25 at 6:00 P.M. She also verified there was no indication the physician or nurse practitioner was updated until the following day. Review of the facility policy titled, Chest Vest, revised April 2023, revealed staff were to document and communicate the date and time, how resident tolerated the procedure, who performed the procedure and to collaborate with the clinical team significant or changes in resident's normal tolerance or complications with the procedure.

Based on observation, policy review, diet order list review, and interview, the facility failed to store food in a sanitary manner. This had the potential to affect all residents who received food from the kitchen except Residents #19, #28 and #73 who were ordered nothing by mouth. The census was 75. Findings include: Observation on 12/10/24 at 12:45 P.M. during tour of the kitchen with Dietary Manager (DM) #1 revealed there was an opened 32-ounce cardboard jug of liquid eggs without an opened date, a two-quart plastic container of what appeared to be sausage links without a label or date and a two-quart plastic container of what appeared to be hash browns without a label or date in the walk-in refrigerator. There was an opened plastic bag of shredded cheese without an opened date, three opened and varying sizes bags of parmesan cheese without an opened date, an opened bag of hot dogs without an opened date, a plastic gallon bag of what appeared to be sliced deli meat without a label or date, an opened bag of tortillas without an open date, a sandwich plastic bag of what appeared to be Swiss cheese without a label or a date, a plastic wrapped item of what appeared to be sliced cheddar cheese without a label or a date, a plastic wrapped item of what appeared to be four hardboiled eggs without a label or a date, a plastic wrapped item of what appeared to be two hardboiled eggs without a label or a date, three opened and varying sizes of sticks of butter without a opened date, a 12-quart plastic container of chicken noodle soup dated 11/30/24 and a 12-quart plastic container of wilted shredded iceberg lettuce dated 11/23/24. Interview, during the observation, with DM #1 verified the above findings and verified all food should be labeled and dated. Interview on 12/10/24 at 2:50 P.M. with the Administrator revealed all food should be labeled and dated. Review of the facility's undated Food Storage policy revealed all products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use use by date on all food stored in refrigerators and use dates according to the timetable in the Storage of Food Guidelines. Review of the facility's undated Storage of Food guidelines revealed raw refrigerated salad should be kept one to two weeks and refrigerated soups should be kept for three to four days. Review of the diet order list dated 12/10/24 revealed all residents had a diet order except Residents #19, #28 and #73 who were ordered nothing by mouth. This deficiency represents non-compliance investigated under Complaint Number OH00159545.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to develop and implement a comprehensive pressure ulcer program for Resident #40 to prevent the development of a pressure ulcer and to ensure timely and necessary treatment was implemented. Actual harm occurred on 07/29/24 when Resident #40, who was cognitively impaired and dependent on staff for activities of daily living was identified to have an in-house acquired unstageable pressure ulcer (occurs due to prolonged pressure on a specific area of the skin resulting in the lack of blood and the wound cannot be properly staged until the layers of dead skin are removed) to his right leg. Following the development, the unstageable pressure ulcer deteriorated, resulting in debridement (procedure to remove dead, damaged, or infected tissue from a wound to improve healing) and the pressure ulcer was subsequently reclassified as a Stage IV (full thickness skin and tissue loss) pressure ulcer. Prior to the development, there was no evidence comprehensive, individualized and/or effective interventions were in place to prevent the development and/or to identify the pressure ulcer prior to it being unstageable. This affected one resident (#40) of two residents reviewed for pressure ulcer prevention and care. The facility census was 65. Findings include: Review of Resident #40's medical record revealed an admitted [DATE] with diagnoses including stroke with right sided weakness, right knee contracture, muscle weakness and aphasia (difficulty speaking). Review of Resident #40's care plan dated 07/16/24 revealed the resident was at risk for skin breakdown related to impaired mobility. Interventions included encourage soft heel protectors, dressing to area (area not identified) per orders, turn and reposition frequently when in bed and weekly wound management rounds. Further review revealed no interventions for pressure relieving devices, such as an air mattress or off-loading pressure points related to contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had no cognition score due to the resident being rarely understood. The assessment revealed Resident #40 required extensive assistance from two staff for bed mobility and toileting and total dependence (from staff) for transfers. Review of a skin assessment dated [DATE] revealed Resident #40 had an abrasion to his right upper back with no other skin impairments noted. Review of a wound physician note dated 07/29/24 revealed Resident #40 had an unstageable pressure ulcer to his right leg that measured 6.5 centimeters (cm) in length by 3.9 cm width with 0.1 cm in depth with moderate amounts of serous drainage (clear, watery fluid that comes from a wound after tissue damage) and 80% eschar (necrotic tissue). The note indicated treatment included to apply Santyl (topical enzymatic agent that removed dead tissue from a wound and helped to heal faster and reduce the risk of infection) daily for 30 days, cover with a gauze dressing and to off-load the wound and reposition (resident) per facility protocol. Review of a wound physician note dated 08/05/24 revealed Resident #40's unstageable pressure ulcer measured 6.0 cm in length by 4.0 cm width with 0.1 cm depth with heavy serous drainage. No change in treatments was recommended at this time. Review of Resident #40's physician orders, dated 08/08/24, revealed to cleanse right lower extremity with normal saline (NS), apply Santyl and cover with a foam dressing daily. Further review revealed no current physician orders related to turning and repositioning, off-loading or pressure reliving interventions. Lastly, Resident #40 had no physician ordered wound treatments for the right leg wound prior to 08/08/24. Review of a wound physician note dated 08/12/24 revealed Resident #40's unstageable pressure ulcer measured 5.9 cm in length by 3.2 cm width with 0.2 cm in depth with heavy serous drainage. No change in treatments was recommended at this time. Observation on 08/15/24 at 2:24 P.M. of Resident #40, with State tested Nursing Assistant (STNA) #432 and Registered Nurse (RN) #407, revealed the resident was in bed on his right side. STNA #432 and RN #407 repositioned Resident #40 which revealed a large amount of greenish colored dried drainage on Resident #40's sheets, underneath his right leg. The foam dressing on Resident #40's right leg was dated 08/14/24. The dressing was saturated with a greenish and brownish colored drainage and a foul odor was detected. Concurrent interview with RN #407 confirmed the observations. RN #407 stated he was not aware of specific information regarding Resident #40's wound. RN #407 removed the soiled dressing, cleansed the area with NS and applied Santyl and a new foam dressing. Interview with STNA #432 at time of observation revealed she recalled Resident #40 having the wound a few weeks ago; however, she was unable to recall any specific information. Continued observation of Resident #40's wound revealed the outer area was reddened and had slough and eschar present. Resident #40 was not interviewable. Interview on 08/19/24 at 11:05 A.M. with Wound Physician (WP) #493 revealed she had only been treating Resident #40 for a few weeks. WP #493 stated she could not recall how she had been notified of Resident #40's wound to his right leg, but stated she had seen the resident and assessed the area on 07/29/24 during her wound rounds. WP #493 stated the wound was an unstageable pressure ulcer and she had ordered Santyl as a debridement agent. Observation on 08/19/24 at 11:20 A.M., with WP #493, Licensed Practical Nurse (LPN) #458 and RN #407 revealed Resident #40's foam dressing was dated 08/18/24 and was saturated with a brownish colored drainage and a foul odor was detected. There was dried drainage on Resident #40's sheets, underneath his right leg. Interview with WP #493 at time of observation confirmed the odor and stated the drainage appeared to be heavier than she previously observed. WP #493 proceeded to surgically debride Resident #40's wound and stated after debridement the resident's wound was to be classified as a Stage IV pressure ulcer that measured 5.3 cm in length by 4.0 cm in width with 0.5 cm in depth. WP #493 had informed LPN #458 to continue the current treatment and add silver alginate (absorbent, antibacterial dressing to promote wound healing). A telephone interview on 08/19/24 at 1:27 P.M. with STNA #426 revealed she only worked on the weekends. The STNA stated a few weeks ago, on a Sunday, she and STNA #432 prepared Resident #40 for a shower and removed a foam boot from his right leg. STNA #426 stated, upon removal of the boot, she observed a large black area to Resident #40's right leg as well as black skin that had stuck to the boot. STNA #426 stated she had immediately informed RN #407 and he had looked at the area. STNA #426 stated she had cared for Resident #40 the previous day but was unable to recall if she removed the boot. STNA #426 stated Resident #40 was supposed to be turned at least every two hours and stated she would place a pillow between the resident's legs due to his contracture. Interview on 08/19/24 at 1:40 P.M. with RN #407 revealed an STNA (unable to recall her name) informed him on the weekend a few weeks ago that Resident #40 had an area to his leg. RN #407 stated he went to Resident #40's room and the resident had a boot on his right leg. RN #407 stated he removed the boot and observed an open area to Resident #40's right leg. RN #407 stated the area appeared to be reddened and dark purple in some areas. RN #407 stated he cleansed the area and placed a bandage over the wound. RN #407 revealed he did not notify the physician at that time because he was scheduled to work the next day, which was a Monday, and he was going to tell the wound nurse (Licensed Practical Nurse (LPN) #458) when she arrived on Monday. Interview on 08/19/24 at 2:18 P.M. with LPN #458 revealed she did not recalled RN #407 notifying her of Resident #40's wound on 07/29/24; however, she had observed the area during wound rounds with WP #493. LPN #458 stated she observed the wound to be an open area that was reddened with slough present. LPN #458 stated she was unaware Resident #40 did not have physician orders in place for pressure relieving interventions and stated the facility had recently changed computer programs and the orders were placed into the new computer system manually and it may have been missed. LPN #458 stated she had recently reviewed Resident #40's current physician orders and discovered the orders for the Santyl had not been in place (initially ordered on 07/29/24) and stated she had added the orders on 08/08/24 (10 days after the treatment was recommended). LPN #458 verified there was no evidence Resident #40's wound care treatments were provided as recommended (beginning on 07/29/24) due to the lack of physician orders in place. Review of facility undated policy titled Pressure Ulcer Prevention and Risk Identification revealed the physician and responsible party would be notified by the licensed nurse promptly of a newly identified skin area and a treatment would be initiated according to the physician order. Interventions would be implemented as indicated by the physician and as determined by the Interdisciplinary Team.

Based on observation, staff interview and review of facility policy, the facility failed to ensure dietary staff performed hand hygiene prior to handling food and beverage items. This had the potential to affect all residents who received food from the kitchen. The facility identified two residents (#53 and #63) as receiving nothing from the kitchen. The facility census was 65. Findings include: Observation on 08/13/24 from 4:25 P.M. to 5:43 P.M. of the dinner tray line revealed at 5:11 P.M., Dietary Aide (DA) #439 took the 200-hall cart out of the kitchen. DA #439 did not perform hand hygiene upon return to the kitchen at 5:13 P.M. DA #439 proceeded to restock a snack cart. Continued observation revealed at 5:27 P.M., [NAME] #447 took the 300-hall cart out of the kitchen. [NAME] #447 returned to the kitchen at 5:29 P.M., did not wash her hands, and proceeded to place plated food and beverages onto trays and then placed the trays into a food cart. Interview on 08/13/24 at 5:39 P.M. with Dietary Manager #444 confirmed DA #439 and [NAME] #447 should have washed their hands upon entry to kitchen. Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2019, revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors, Situations where handwashing/hand hygiene procedures were to be followed included before handling food.

Based on review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report and staff interview, the facility failed to ensure MDS assessments were submitted in a timely manner. This affected 11 residents (#7, #9, #13, #15, #21 #23, #24, #33, #39, #41, and #48) of 23 residents reviewed for MDS submission. The facility census was 65. Findings include: Review of the iQIES MDS Final Validation Report submitted on 08/09/24 at 2:22 P.M. revealed each of the following resident's MDS assessments were submitted more that 14 days late: Resident #7's quarterly MDS assessment dated [DATE] Resident #9's quarterly MDS assessment dated [DATE] Resident #13's quarterly MDS assessment dated [DATE] Resident #15's comprehensive MDS assessment dated [DATE] Resident #21's quarterly MDS assessment dated [DATE] Resident #23's quarterly MDS assessment dated [DATE] Resident #24's quarterly MDS assessment dated [DATE] Resident #33's quarterly MDS assessment dated [DATE] and discharge MDS assessment dated [DATE] Resident #39's quarterly MDS assessment dated [DATE] Resident #41's quarterly MDS assessment dated [DATE] Resident #48's quarterly MDS assessment dated [DATE] Interview on 08/20/24 at 12:46 P.M. with MDS Nurse #423 verified the above MDS assessments were submitted on 08/09/24 and were late. MDS Nurse #423 stated she had issues with the electronic health record and accessing iQIES. MDS Nurse #423 stated she informed her corporate office well in advance, sometime in the beginning of July, that she had issues with accessing to iQIES to timely submit the MDS assessments.

Based on resident interview, observation, review of resident fund account records, staff interview and review of facility policy, the facility failed to ensure residents who had a financial account with the facility received quarterly statements as required. This affected five residents (#7, #31, #40, #48, and #57) of five residents reviewed for personal funds. The facility census was 65. Findings include: Interview on 08/12/24 at 11:14 A.M. with Resident #48 revealed she had a resident funds account at the facility. Resident #48 stated she had not received quarterly statements from the facility to show her account activity. Review of resident fund account records for five residents (#7, #31, #40, #48, and #57) revealed no evidence quarterly statements had been given over the past year to the resident and/or resident representative. Interview on 08/14/24 at 2:16 P.M. with Administrative Assistant (AA) #409 confirmed there was no evidence quarterly statements for Residents #7, #31, #40, #48, and #57 had been given to the resident and/or resident representative. AA #409 stated the facility's previous owner took the computer, which housed the statements, and the new owner had no access to the previous quarterly statements. Interview on 08/15/24 at 8:25 A.M. with Resident #48 revealed she had received a quarterly financial statement the previous night, which was the first time ever. Resident #48 stated the facility had her sign for her statement and was told it's a little bit late when she was handed the statement. Observation at the time of interview revealed the resident had been given a document titled Patient Fund PNA Quarterly Statement from 04/01/24 thru 06/30/14. Interview on 08/15/24 at 8:45 A.M. with AA #409 revealed corporate staff reached out to staff from the previous owner and they were able to get the quarterly financial statements from last quarter. The quarterly statements were hand delivered the night before to residents by the evening receptionist. AA #409 confirmed the quarterly statements should have been delivered at the beginning of the quarter (July) and had not been delivered until the evening of 08/14/24. Review of facility policy Accounting and Records of Resident Funds, revised April 2017, revealed individual accounting records were to be made available to the resident through quarterly statements and upon request.

Based on observation, resident interviews, staff interviews, review of staff schedules and punch detail, review of Resident Council meeting minutes and review of the facility assessment, the facility failed to have sufficient staff to meet the acuity needs of each resident. This affected two (#57 and #29) of two residents reviewed for staffing with the potential to affect all 41 residents residing on the 100 and 200 halls. The facility census was 65. Findings include 1. Interview on 08/14/24 at 9:20 A.M. with Registered Nurse Supervisor (RNS) #405 and State tested Nursing Assistant (STNA) #424 revealed there was one aide for 19 residents on the 100 hall and one aide for 22 residents on the 200 hall. RNS #495 and STNA #424 stated a third, unidentified, aide was assigned to the 100/200 halls but had been sent out with a resident for an appointment. STNA #424 stated showers were not being completed as scheduled but did not provide any specific resident who had not received care. RNS #405 stated she had to deal with staffing for an hour before she could start her medication pass this morning. Observation on 08/14/24 at 4:48 P.M. of the call light screen at the 200 hall nurse's station, which displayed how long a call light had been on, revealed Resident #57's call light had been on for 54 minutes. Interview on 08/14/24 at 4:52 P.M. with STNA #440 confirmed Resident #57's call light had been on for a long time. STNA #440 stated the call light had not been answered because a number of residents, who required two-person assistance, required care and there were not enough staff to answer the call lights. Interview on 08/14/24 at 4:53 P.M. with Resident #57 confirmed he had been waiting a long time for his call light to be responded to and needed assistance to use the restroom. Interview on 08/15/24 at 1:32 P.M. with STNA #400 revealed, at times, there was only one aide on the 100 hall and one aide on the 200 hall. STNA #400 stated when each hall only had one aide, there was not enough staff to assist with the residents' care needs. 2. Observation on 08/19/24 at 7:39 A.M. of the call light system screen at the nurse's station revealed Resident #29's call light had been on for 51 minutes. Subsequent interview with Resident #29 revealed the call light had been on for a while and she needed incontinence care. Resident #29 stated it usually took a while for call lights to be answered, with typical wait times being 30 to 45 minutes. Review of Resident Council meeting minutes from 08/17/23 to 07/25/24 revealed on 10/26/23, 11/20/23, 02/29/24 and 05/30/24 residents voiced concerns regarding STNAs being short staffed and long wait times for care. Interview on 08/21/24 at 1:06 P.M., and concurrent review of the daily assignment and punch detail for 08/14/24, with Human Resources (HR) #403 revealed STNA #449 had been assigned to the 100 and 200 halls but had been sent out to an appointment with a resident. HR #403 verified until 10:38 A.M., when STNA #553 clocked in, there were only two STNAs to provide care for 41 residents on the 100 and 200 halls. Review of the Facility Assessment, dated 08/08/24, revealed the facility would provide adequate staff as evidence by the residents' needs being met and resident council review. The goal of staffing would be to meet resident needs and have happy residents.

Based on observation, staff interviews, review of the facility menu, review of the dietary spreadsheet and review of facility policy, the facility failed to ensure the spreadsheet was followed for residents on a mechanically altered diet. This affected eight (#5, #7, #13, #29, #32, #46, #59 and #76) of eight residents identified by the facility as being on a mechanically altered diet. The facility census was 65. Findings include: Review of the menu for dinner service on 08/13/24 revealed the meal consisted of baked fish, tartar sauce, boiled red potatoes with parsley, creamed spinach and strawberry trifle. Review of dietary spreadsheet for dinner service on 08/13/24 revealed mechanical soft diets were to receive two ounces of baked fish with one ounce of broth or sauce, one tablespoon of mayonnaise (instead of tartar sauce), boiled white potatoes (in place of boiled red potatoes with parsley), creamed spinach and strawberry trifle. Observations on 08/13/24 between 4:25 P.M. and 5:43 P.M. revealed all residents received the same food items of fish with no broth, red potatoes with parsley, creamed spinach with long pieces of red onion (onion was approximately two inches long), two packets of tartar sauce and strawberry trifle. There was no observation of any broth or sauce for the fish, boiled potatoes with no parsley, creamed spinach without long pieces of red onion or mayonnaise on the tray line. Interview on 08/13/24 at 5:08 P.M. with Assistant Dietary Manager ADM #419, who plated the food during tray line, confirmed all residents received the same meal, regardless of diet texture. ADM #419 confirmed the meal served to residents on a mechanically altered diet included fish with no sauce or broth, red potatoes with parsley, tartar sauce and creamed spinach with onion. ADM #419 confirmed the pieces of onion were long and stated the recipe called for frozen onion but the facility did not have any so she cut up fresh white and red onion. Observation of a test tray on 08/13/24 at 5:51 P.M. with Registered Dietitian (RD) #481 revealed the creamed spinach had one, approximately two-inch slice, of red onion. RD #481 confirmed the fresh onion pieces were not appropriate for a resident on a mechanically altered diet. Upon review of the dietary spreadsheet, RD #481 verified the menu had not been followed for mechanically altered diets. Review of the facility policy titled Mechanically Altered Diet Explanation, revised 05/06/19, revealed fish must be very tender and moist and vegetables should be soft, well cooked, and chopped.

Based on record review, interview, and review of facility policy the facility failed to prevent verbal abuse of Resident #21 by staff. Actual harm occurred on 09/09/21 when Licensed Practical Nurse (LPN) #1 became upset with Resident #21 yelling derogatory and threatening statements and using foul language with the resident within hearing distance. Witnesses indicated the resident overheard what was being said and she was crying and visibly distressed. She continued to experience anxiety through 09/23/21. This affected one of two residents (#21 and #47) reviewed for abuse. The facility census was 55. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21's memory was intact and she was independent or required only minimal assistance with activities of daily living. Review of the nurses notes dated 09/09/21 authored by Licensed Practical Nurse (LPN) #1 revealed Resident #21 had a verbal interaction with another resident about the established schedule of the TV lounge. No other notes were written on or after 09/09/21 that described the incident of verbal abuse. Review of the Self-Reported Incident (SRI) dated 09/09/21 at 6:38 P.M. revealed Resident #21 came to ask Registered Nurse (RN) #210 about the schedule for the TV lounge. LPN #1 who was present started making derogatory comments about Resident #21. The SRI indicated the resident was upset LPN #1 had the wrong information about the schedule. The facility unsubstantiated it because LPN #1 denied making derogatory statements and the resident denied hearing them. Review of the facility investigation dated 09/09/21 revealed three witness statements, not included in the SRI, all dated 09/09/21. Review of the witness statement dated 09/09/21 authored by RN #209 revealed during change of shift at the nurses station he overheard Resident #21 asking RN #210 to clarify the TV lounge schedule because another resident was using it and she thought it was her turn. LPN #1 raised her voice saying it wasn't her turn. RN #209 interjected confirming it was Resident #21's turn. At this point LPN #1 said (regarding Resident #21) You blind f---ing b---h!, and continued I wish a truck would hit the b---h while she's smoking and Stupid f---ing alcoholic. Resident #21 was well within earshot. Review of the witness statement dated 09/09/21 authored by RN #210 revealed she was giving report to LPN #1 when Resident #21 came and asked about the TV lounge schedule. RN #210 said LPN #1 became antagonistic, calling Resident #21 a b---h and went of for five minutes or so using unbecoming and inappropriate language about Resident #21. LPN #1 was described as nasty, rude and belligerent. Review of the witness statement dated 09/09/21 authored by RN #211 revealed Resident #21 came to the nurses station asking RN #210 about the TV lounge schedule. LPN #1 yelled saying it was not her turn. LPN #1 continued yelling and said Resident #21 always gets her way and called the resident a f---ing b---h! and said to the nurses she's a drunken b---h!. LPN #1 then said to the other nurse Figure out what that f---ing b---h wants and get her the f--- away from the desk and me!. Her statement revealed the resident was looking straight at the nurses during the incident. The investigation also included interviews conducted on 09/10/21 by the Administrator with Resident #21 and her roommate, Resident #22, who according to the interviews both residents denied hearing any comments. Licensed Social Worker (LSW) #200 conducted interviews on 09/10/21 with residents who lived on the hallway(s) where LPN #1 had worked. There was no evidence contained in either the SRI or the investigation that any of the three witnesses were interviewed. Review of statement made by Resident #21 dated 09/23/21, obtained and authored by LSW #200 revealed the resident remembered the incident on 09/09/21. The resident recalled RN #209, RN #210 and LPN #211 were trying to tell LPN #1 she was wrong about the TV lounge schedule. Resident #21 said she backed up in her wheelchair because of the yelling and heard LPN #1 say when you're out there smoking, I hope a truck runs over you and kills you. Resident #21 stated she had a dream about it that night and had frequently been anxious and afraid since then when she went out to smoke. Interview on 10/05/21 at 3:25 P.M. with LSW #200 revealed the Activity Director (AD) #201 came to her on 09/23/21 stating Resident #21 was still distressed about the incident on 09/09/21. LSW #200 informed the Administrator who then asked LSW #200 to get a statement from Resident #21. Interview on 10/05/21 at 3:38 P.M. with Resident #21 revealed she remembered the comments from 09/09/21 and reported it on 09/23/21 to AD #201 who then told LSW #200. She stated it all started when LPN #1 chimed in on a question she was asking another nurse. Resident #21 said RN #209, RN #210 and LPN #211 tried to correct LPN #1 about the TV schedule and to stop her from yelling derogatory comments without success. Resident #21 said LPN #1 said something about going out to the sidewalk and having a cigarette and a truck hitting me. Resident #21 said she had a nightmare about that and was anxious the next several days when she went out to smoke. Resident #21 stated she would not want LPN #1 to come back. Interview on 10/05/21 at 3:56 P.M. with AD #201 revealed she spoke to Resident #21 on 09/23/21 because she noticed the resident looked distressed. Resident #21 told her LPN #1 called her a f-----g alcoholic and made a comment about a truck hitting her. AD #201 verified she reported this to LSW #200. Interview on 10/05/21 at 4:16 P.M. with RN #203 revealed he was surprised when LPN #1 returned to work. He stated he questioned the Interim Director of Nursing/Regional Nurse Consultant (DON) about it. Subsequently the Administrator told him the resident said she had a dream. Interview on 10/06/21 at 9:47 A.M. with Staff Coordinator/Human Resources (HR) #208 revealed LPN #21 was immediately suspended on 09/09/21 by the DON via phone. After the investigation was done, LPN #1 returned to work on 09/18/21. On 09/23/21 she was going to be suspended again based on the new information provided by LSW #200. LPN #21 quit during the meeting with the Administrator, DON and HR #208. Interview on 10/06/21 at 2:06 P.M. with RN #210 revealed she witnessed verbal abuse of Resident #21 by LPN #1 on 09/09/21 and confirmed the incident occurred as written in her statement. She stated her and the other nurses tried to stop LPN #1 once she started making derogatory comments toward Resident #21, however, LPN #1 kept going for about ten minutes. RN #210 said she was relatively sure Resident #21 could hear what was being said even though it was not being said directly to Resident #21. RN #210 put her witness statement under the DON's door the same night. RN #210 stated she was not interviewed or asked any questions by anyone after turning in her statement. Interview on 10/06/21 at 2:16 P.M. with RN #209 revealed he witnessed verbal abuse of Resident #21 by LPN #1 on 09/09/21 and confirmed the incident occurred as written in his statement. He stated he tried to correct LPN #1 about the schedule with the TV lounge and to stop her from making derogatory comments without success. He said LPN #1 went on for ten minutes making comments towards Resident #21 before she finally stopped to continue with change of shift report. He said the resident absolutely heard the comments as he saw Resident #21 looking at them; she had tears in her eyes and her face was bright red. RN #209 said the incident occurred while giving report (between 5:30 P.M. and 6:00 P.M.). They were counting narcotics and could not leave their cart at that time, but he said he checked on Resident #21 immediately after and found her with friends in the lounge. LPN #1 left immediately after her shift at 6:00 P.M. RN #209 called the DON to report incident then slid the witness statement under the DON's door and another copy under HR #208's door. He verified he was not interviewed nor questioned after turning in his witness statement for clarification on any comments such as the resident was within earshot of LPN #1. Interview on 10/06/21 at 4:31 P.M. with LPN #211 revealed she witnessed verbal abuse of Resident #21 by LPN #1 on 09/09/21 and confirmed it happened as written in her statement. She stated she slid her statement under the DON's door that night. She verified she was not interviewed after review of her statement by the Administrator or DON. She confirmed Resident #21 was looking straight at the nurses and stated the resident was no more than ten feet away. She said she and the other three nurses were behind the counter by a table and the resident was immediately on the other side of the counter. Interview on 10/06/21 at 4:35 P.M. with the Administrator revealed the DON called her after 6:00 P.M. on 09/09/21. The Administrator started the SRI and asked the DON to suspend LPN #1. On 09/10/21 the Administrator interviewed Resident #21 who denied hearing any derogatory comments though she could see LPN #1 mumbling. The Administrator also interviewed Resident #21's roommate who was nearby when the incident happened. Resident #22 denied hearing anything. The Administrator asked LSW #200 to interview other residents who resided on the hallway LPN #1 worked. There were no concerns. The Administrator said LPN #1 was suspended, was written up for the incident and had to complete customer service training before returning to work on 09/18/21. Further interview with the Administrator on 10/06/21 revealed Resident #21 came to her on 09/23/21 and she asked LSW #200 to interview Resident #21 and write a statement. The Administrator said she was surprised the resident initially denied hearing the comments on 09/09/21. The Administrator, DON and HR #208 met with LPN #1 on 09/23/21 in the office to discuss the new information and anticipated suspending her. LPN #1 quit at that time. When asked after review of the witness statements dated 09/09/21 from RN #209, RN #210, and LPN #211, indicating the resident heard what was said and was obviously distressed, if she had conducted interviews with the nurses the Administrator stated she did not believe she had to since the resident had denied hearing it. Interview on 10/07/21 at 9:30 A.M. with the DON revealed she had received a call from RN #203 around 6:30 P.M. on 09/09/21 who reported he had been made aware of the incident. She questioned if LPN #1 was gone and if Resident #21 was alright. She stated she was told the resident did not hear anything. She asked RN #203 and the other nurses to write a statement and put under her door (no statement for RN #203 was found). She verified she did not interview the three witnesses after receiving their statements. The DON said she called the Administrator who started the SRI. The DON did not know of any other witnesses and had no documented evidence of interviews with RN #209, RN #210, or LPN #211. She suspended LPN #1 over the phone. The Administrator took over the investigation as she gave the witness statements to her. Interview on 10/07/21 at 12:21 P.M. with the Administrator verified Resident #21 was verbally abused by LPN #1. Review of facility policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, dated 2016, revealed the facility was to prevent abuse, including verbal abuse of residents. The policy stated to interview the resident, the accused and all witnesses, obtain written statements and to have documented evidence of the investigation. This deficiency substantiates Master Complaint Number OH 095 and Complaint Number OH 065.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility COVID-19 policy, observations and interviews with staff, the facility failed to implement effective and recommended infection control practices on the yellow quarantine unit to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 11/02/20 when the facility did not implement appropriate personal protective equipment (PPE) including isolation gowns, gloves, N95 respirator masks and goggles/face shields while caring for eight residents (Residents #6, #8, #20, #24, #26, #36, #40 and #53) who were placed in droplet transmission-based precautions on the yellow quarantine unit (200 hall) following exposure to COVID-19. The facility failed to properly disinfect equipment use between residents on the yellow quarantine unit (Residents #8 and #36). The lack of effective infection control practices related to COVID 19 placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 55. The facility tested all residents and staff on 11/02/20 with the facility point of care (POC) machine and identified six residents (Residents #29, #35, #36, #38, #65 and #66) residing on the 200 unit and two staff members (STNA #127 and Admissions #801) who were positive for COVID-19. STNA #127's last date of work was on 11/01/20 and she worked the 200 unit. On 11/02/20, the facility moved the positive residents to the dedicated red COVID-19 unit (400 hall) and placed the residents potentially exposed to COVID-19 on the 200 hall and identified the hall as a yellow quarantine unit with all residents placed on droplet transmission based precautions. Additional COVID-19 POC testing on 11/05/20 confirmed four staff members (Dietary Aide #120, STNA #121, STNA #122 and Assistant Director of Nursing #123) and seven residents (Residents #5, #7, #21, #25, #27, #31 and #51) tested positive for COVID-19 and were moved to the red COVID unit. STNA #121 last worked on 11/02/20 on the yellow quarantine unit and STNA #122 last worked on 10/31/20 on the yellow quarantine unit. On 11/07/20 polymerase chain reaction testing (PCR) via nasal swab was completed on the residents who tested positive via the POC machine and confirmed Residents #5, #7, #21, #25, #31, and #51 were positive for COVID-19. Resident #36 who previously tested positive with POC test, now tested negative during the confirmation testing and was moved back to the yellow quarantine unit on 11/07/20. Observation and interview on 11/09/20 of the yellow quarantine unit confirmed Registered Nurse (RN) #119 provided care to Resident #36 and the nurse did not remove and replace the contaminated isolation gown or N95 respirator mask when entering or exiting the resident's room. Observation and interview on 11/09/20 with State tested Nursing Assistant (STNA) #108 revealed the blood pressure machine was used to obtain Resident #8 and Resident #36's blood pressures on the yellow quarantine unit and was not appropriately cleaned and sanitized between the two residents to prevent cross contamination and the possible spread of COVID-19. On 11/09/20 at 2:15 P.M., the Executive Director (Administrator) and RN Regional Director #124 were notified the Immediate Jeopardy began on 11/02/20 when the facility was notified of COVID-19 positive results for six residents and two staff members and staff did not implement appropriate PPE usage while caring for residents who were potentially exposed to COVID-19 and placed in droplet contact precautions on the yellow quarantine unit. Interview on 11/09/20 at 2:20 P.M. with the Administrator confirmed 11 residents, Residents #5, #7, #21, #25, #27, #29, #31, #35, #38, #51, #65, currently resided on the dedicated red COVID-19 positive unit and eight residents, Residents #6, #8, #20, #24 #26, #36 #40, #53, currently resided on the yellow quarantine unit. Resident #53 was moved from the yellow quarantine unit to the dedicated red COVID-19 unit later in the day on 11/09/20 due to a positive COVID-19 result. The Immediate Jeopardy was removed on 11/12/20 when the facility implemented the following corrective actions: · On 11/09/20, all 53 residents in the facility had been tested for COVID-19. On 11/09/20, the dedicated red COVID-19 unit's census of 12 residents included Residents #5, #7, #21, #25, #27, #29, #31, #35, #38, #51, #53, and #65. Resident #53 tested positive for COVID-19 on 11/09/20 and was moved on that date. · As of 11/09/20, seven residents remained in the yellow quarantine unit including Residents #6, #8, #20, #24, #26, #36, and #40. · On 11/09/20 at 5:00 P.M., RN Regional Director #124 conducted a medical equipment audit on the yellow quarantine unit. Each resident room was issued dedicated equipment including a blood pressure cuff, stethoscope and thermometers. The Executive Director or a member of the management team will conduct audits for medical equipment including the blood pressure cuff, stethoscope and thermometers on the quarantine unit daily for two weeks then random for two weeks. · On 11/09/20 at 5:10 P.M. the Executive Director received infection control training from RN Regional Director #124 with an emphasis on PPE use, hand hygiene, passing meal trays, and disinfection or dedicated use of medical equipment. · On 11/09/20 at 11:00 P.M., the Executive Director conducted an audit of all resident's COVID-19 test results and validated all residents were placed on the correct units including the dedicated red COVID-19 positive unit, yellow quarantine unit or green non-COVID/non-quarantine unit. · On 11/09/20 at 11:10 P.M., the Executive Director conducted an audit of all staff COVID-19 test results and symptoms screening forms and validated 10 staff members were directed to remain at home in quarantine precautions per the facility policy and were not currently working in the facility. · On 11/10/20 by 7:00 A.M., RN Regional Director #124 and the Executive Director initiated enhanced infection control audits of staff focusing on PPE use, hand hygiene, passing meal trays, and dedicated or disinfected medical equipment. · On 11/10/20 by 7:30 A.M., the first audits were completed by the Executive Director on the yellow quarantine unit to ensure staff used the appropriate PPE. The Executive Director or a member of the management team will conduct audits daily on each shift for two weeks and then random for two weeks to ensure staff were donning the appropriate PPE on all units. · On 11/10/20 at 9:30 A.M. the Director of Nursing (DON) received infection control training from RN Regional Director #124 with an emphasis on PPE use, hand hygiene, passing meal trays, and disinfection or dedicated use of medical equipment. · On 11/10/20 at 9:37 A.M., the infection control action plan and the audit plan were reviewed with the Medical Director by phone. The Medical Director had no additional recommendations. · On 11/10/20 at 2:00 P.M., the Quality Assurance (QA) Committee met to review the infection control plan and Immediate Jeopardy Removal Plan. · On 11/10/20 by 3:00 P.M., the DON and RN Regional Director #124 initiated mandatory infection control training for the facility staff with an emphasis on PPE use, hand hygiene, passing meal trays, and proper disinfection or dedicated use of medical for residents. All staff currently working will be educated including four nurses, eight nursing assistants, four dietary employees, three environmental service employees, four department leaders, and two receptionists. · On 11/10/20 by 5:00 P.M., all previously COVID-19 negative residents will have COVID-19 POC testing completed. · On 11/10/20 by 7:00 P.M., all previously COVID-19 negative staff will have COVID-19 POC testing completed. · By 11/12/20 by 12:00 P.M., all staff were educated by the DON (or designee) prior to the start of their next shift. · Interviews on 11/12/20 from 8:48 A.M. to 9:12 A.M. with Hospitality Aide #802, STNAs #803, #806 and #807, HR #115, Certified Nursing Assistant (CNA) #805 and Receptionist #804 confirmed they were inserviced on appropriate infection control procedures including dedicated blood pressure cuffs, thermometers and stethoscopes when entering and exiting yellow quarantine rooms and red COVID-19 rooms. Although the Immediate Jeopardy was removed on 11/12/20 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 was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: The facility currently had four resident units, the 100 and 200 units were on one side of the building and the 300 and 400 units were on the other side of the building. The 400 unit was identified as the dedicated red COVID-19 unit and the 200 unit was identified as the yellow quarantine unit. Interview on 11/09/20 at 7:05 A.M. with RN #119 confirmed residents who resided on the yellow 200 unit were placed in droplet transmission-based precautions because some of the other residents on the unit had recently tested positive for COVID-19. Observation on 11/09/20 at 7:23 A.M. revealed RN #119 donned goggles, an N95 respirator mask, a plastic isolation gown and gloves and went into Resident #24's room on the quarantine unit to administer medications. Signage on the resident's door indicated the resident was in droplet transmission-based precautions. At 7:28 A.M., RN #119 removed the contaminated gloves, sanitized his hands and exited Resident #24's room. The nurse put on new gloves and entered Resident #36's room with the same contaminated isolation gown and N95 respirator mask used in Resident #24's room to care for that resident. Signage on Resident #36's door revealed the resident was in droplet transmission-based precautions. At 7:29 A.M., RN #119 exited Resident #36's room wearing the same contaminated gloves, isolation gown and N95 respirator mask and walked to the medication administration cart. The nurse removed the contaminated gloves, reached into his pocket for keys and unlocked the medication cart before placing Resident #20's medications in a plastic cup. The nurse did not remove his contaminated gown or N95 respirator mask. He was not observed to sanitize his hands after he removed the contaminated gloves. He then prepared medications for Resident #20. At 7:38 A.M., RN #119 was observed putting on new gloves and entered Resident #20's room to administer the medications, while still wearing the same contaminated isolation gown and N95 respirator mask. Signage on Resident #20's door revealed the resident was in droplet transmission-based precautions. At 7:39 A.M., RN #119 exited Resident #20's resident room with the same isolation gown, N95 respirator mask and gloves and went to the medication cart. He was observed touching the computer mouse located on top of the mediation cart and entered information into the resident's record prior to removing the contaminated gloves and sanitizing his hands. During the observations, RN #119 was not observed to don a surgical mask over his N95 respirator mask when entering resident rooms for residents placed in quarantine precautions to prevent cross contamination of the N95 respirator mask or discard the contaminated N95 respirator mask when exiting resident rooms of those residents in quarantine precautions. Interview on 11/09/20 at 7:41 A.M. with RN #119 revealed he thought he was told he could use the same gown and N95 respirator mask throughout the quarantine unit but was unable to state who or when that education was provided. RN #119 also confirmed that he was not educated to use a surgical mask over his N95 respirator mask when entering resident rooms who were placed in quarantine precautions to prevent cross contamination of his N95 respirator mask. The surgical mask should be discarded when exiting the resident's room. Observation on 11/09/20 at 8:08 A.M. revealed STNA #108 donned a yellow isolation gown, goggles, N95 respirator mask and gloves prior to entering Resident #36's room, who was placed in droplet transmission-based precautions on the quarantine unit. STNA #108 attempted to obtain the resident's blood pressure but the resident refused. STNA #108 removed his contaminated gloves and sanitized his hands and exited the resident's room while wearing the same contaminated isolation gown and N95 respirator mask. At 8:10 A.M., STNA #108 donned clean gloves and using the same contaminated isolation gown and N95 respirator mask, he entered Resident #8's room to obtain their blood pressure. The blood pressure machine was not sanitized/disinfected after being in Residents #36's quarantine room. STNA #108 wore the same isolation gown and N95 respirator mask between the two residents on the quarantine unit. Observation on 11/09/20 at 8:14 A.M. revealed STNA #125, wearing an N95 respirator mask and goggles, removed a meal tray from the meal cart and entered Resident #6's room on the quarantine unit. The STNA did not have on an isolation gown or gloves when entering the resident's room and did not change her N95 respirator mask or have a surgical mask over top the N95 respirator mask to be discarded when she exited the resident's room who was in droplet transmission-based precautions. Observation on 11/09/20 at 8:14 A.M. revealed Human Resources (HR) #24, who had on an N95 respirator mask and goggles, removed a tray from the meal cart and entered Resident #8's room on the quarantine unit and was on droplet transmission-based precautions. HR #24 exited the room and sanitized her hands. HR #24 did not have on gloves or an isolation gown. At 8:15 A.M., HR #24, who had on the same N95 respirator mask and goggles, removed a second tray from the meal cart and entered Resident #24's room on the quarantine unit. HR #24 exited the room and sanitized her hands. HR #24 did not have on gloves or an isolation gown and the resident was on droplet transmission-based precautions. Observation on 11/09/20 at 8:18 A.M. revealed STNA #108, who had on the same isolation gown, goggles, and N95 respirator mask as when he obtain blood pressures, removed a tray from the meal cart and entered Resident #40's resident room on the quarantine unit. STNA #108 did not don gloves prior to entering the resident's room but was observed to sanitize his hands upon exiting the resident's room. At 8:19 A.M., STNA #108 indicated the facility educated him to use the same gown and N95 respirator mask unless he was entering a resident room who was confirmed positive for COVID-19. STNA #108 confirmed the blood pressure machine was not sanitized/disinfected between residents on the quarantine unit. STNA #108 confirmed he was not educated to use a surgical mask over his N95 respirator mask to prevent cross contamination of the N95 respirator mask while caring for residents on the yellow quarantine unit. Interview on 11/09/20 at 8:20 A.M. with HR #115 indicated she did not have to don an isolation gown when providing care for all residents on the yellow quarantine unit because the unit was considered green now as all COVID-19 positive residents had been moved to the red unit. When questioned, HR #115 was not able to provide how she received the education but indicated she would ask the Administrator for guidance. Interview on 11/09/20 at 8:24 A.M. with the Administrator indicated staff were educated on 11/02/20 regarding appropriate infection control procedures to follow including donning a isolation gown, gloves, N95 respirator mask and goggles or face shield following the outbreak of six residents who tested positive for COVID-19. Interview on 11/09/20 at 2:18 P.M. with the Administrator confirmed Housekeeper #126 tested positive for COVID-19 on 10/09/20. The Administrator revealed all staff and residents were tested on [DATE] with no new positive cases. The Administrator said all staff and residents were tested again on 10/14/20, 10/19/20, 10/21/20, 10/26/20 and 10/28/20 and no additional COVID-19 positive cases were identified. The Administrator revealed the facility completed POC testing on 11/02/20 and identified six positive residents (Residents #29, #35, #36, #38, #65, and #66) who resided on the 200 unit, and two positive staff members (STNA #118 and Admissions #801). STNA #118 had worked on the 200 unit. The facility moved the positive residents to a dedicated red COVID-19 unit (400 hall) and placed the 200 unit in yellow quarantine precautions on 11/02/20. The Administrator indicated additional COVID-19 POC testing on 11/05/20 revealed four staff members (Dietary Aide #120, STNA #121, STNA #122 and Assistant Director of Nursing #123) and seven residents (Residents #5, #7, #21, #25, #27, #31 and #51) tested positive for COVID-19. On 11/07/20, PCR testing was conducted to verify the POC results and the PCR testing determined Residents #5, #7, #21, #25, #31, and #51 were confirmed positive for COVID-19. Resident #36 who originally positive with the POC machine, now tested negative for COVID-19 and was moved back to the yellow quarantine unit on 11/07/20. Interview on 11/09/20 at 2:20 P.M. with the Administrator confirmed 11 residents including Residents #5, #7, #21, #25, #27, #29, #31, #35, #38, #51, #65 currently resided on the dedicated red COVID-19 unit and eight residents including Residents #6, #8, #20, #24 #26, #36 #40, #53 currently resided on the yellow quarantine unit. Later the same day, Resident #53 tested positive and was also moved from the yellow quarantine unit to the dedicated red COVID-19 unit. Interview on 11/10/20 at 9:47 A.M. with the DON confirmed Resident #36 had tested positive for COVID-19 on 11/02/20 and was moved to the dedicated COVID-19 unit. Resident #36 then tested negative on 11/04/20 and was moved to the yellow quarantine unit. On 11/05/20, Resident #36 again tested positive and was moved to the dedicated COVID-19 unit. On 11/07/20, Resident #36 tested negative and was moved back to the yellow quarantine unit. Per the above observations, staff members did not remove and replace the contaminated isolation gown or N95 respirator mask when entering or exiting the resident's room who was placed on droplet transmission-based precautions. Interview on 11/12/20 at 8:56 A.M. with the Administrator confirmed POC testing was completed this day and revealed six new positive residents including Residents #8, #14, #20, #34, #36 and #40. An additional red COVID-19 unit was implemented on the end of the 200 unit and Residents #8, #20 and #40 were placed on this unit. Residents #14 and #34 were moved to the original red COVID-19 unit and Resident #36 remained in her room on the yellow quarantine unit on the advice of the medical director. The Administrator confirmed LPN #808 and Laundry/Housekeeping #809 also tested positive for COVID-19 that day and were removed from the schedule. Interview on 11/12/20 at 10:33 A.M. with Local Health Department (LHD) #810 confirmed staff were required to wear an N95 respirator mask, gloves, gown and goggles or face shield when entering quarantine rooms and COVID-19 positive rooms. LHD #810 also indicated staff could don a surgical mask over their N95 respirator mask prior to entering resident rooms and discard the surgical mask, gown and gloves upon exiting resident rooms of those residents placed in quarantine precautions to prevent cross contamination of other residents who reside on the quarantine unit. An additional email interview on 11/12/20 at 4:17 P.M. with the Executive Director confirmed the facility did not have enough PPE to use it according to the manufacturer's guidelines. The Executive Director confirmed they educated facility staff on 11/09/20 to don a surgical mask over their N95 respirator masks and discard the surgical mask between residents when caring for those residents who reside on the quarantine unit. This would help them conserve adequate supply of the N95 respirator masks. Review of the CDC guidelines titled, Infection Control for Nursing Homes, updated 06/25/20 confirmed because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCPs is newly identified in the facility. Health Care Providers (HCP) should wear an N95 or higher-level respirator mask, eye protection, gloves and gown when caring for new admissions and readmissions. If the residents remain afebrile for fourteen days after their admission, they may be transferred out of the observation area to the main facility. Review of the CDC guidance, Optimizing N95 Respirator Supplies, dated 06/28/20 confirmed HCP can consider using a face shield or facemask over the respirator to reduce/prevent contamination of the N95 respirator mask. Review of the facility COVID-19 policy updated 10/27/20 confirmed the facility staff were to don recommended PPE which includes N95 respirator mask, eye protection including goggles or face shield, gown and gloves when delivering care and services to COVID-19 positive residents and quarantine residents.