Every finding on record at Huntington Woods Care & Rehab Center

Based on record review and staff interview, the facility failed to ensure accurate advanced directive information was accurate throughout the medical record. This affected one (Resident #36) of one resident reviewed for advanced directives. The facility census was 81.Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of brain, dementia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had moderately cognitive impairment and required supervision for activities of daily living (ADLs).Review of the physicians' orders for Resident #36 revealed an order dated [DATE] for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest.Review of the paper chart revealed a full code status for Resident #36 without evidence of the DNRCC order.Interview on [DATE] at 4:26 P.M. with Licensed Practical Nurse (LPN) #320 verified Resident #36's medical records did not match as the electronic chart stated DNRCC, and the hard chart stated Full Code.

Based on observation, interview and record review, the facility failed to honor food preferences. This affected three residents (#35, #55, and #71) out of three residents for food preferences. The facility census was 81. Findings include:1. Review of the medical record for Resident #35 revealed an admission date of 07/01/24. Diagnoses included but are not limited to dementia, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/03/26, revealed the resident had severely impaired cognition. The resident required supervision for eating and other activities of daily living (ADLs). Review of physician's orders for June 2026 revealed Resident #35 received a consistent vegetarian diet, regular texture with thin consistency liquids. Review of the Resident #35's diet tray ticket revealed Resident #35 received vegetarian diet, regular texture with thin consistency liquids. Resident #35's diet ticket stated that she wanted cottage cheese. Observation and interview on 06/02/26 at 11:55 A.M. revealed Resident #35's tray was put into the food cart. Resident #35's tray did not have cottage cheese on her tray. [NAME] #281 stated that Resident #35 did not want the cottage cheese anymore but stated that it was not documented anywhere to the best of her knowledge. Dietary Manager (DM) # 239 stated to [NAME] #281 that Resident #35 is to get her cottage cheese. This was verified by Dietary Aide #218 at time of observation. 2. Review of the medical record for Resident #55 revealed an admission date of 07/25/25. Diagnoses included but not limited to Alzheimer's Disease, diabetes mellitus, and hypopituitarism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/07/26, revealed the resident had severely impaired cognition. The resident required set up for eating. Review of physician's orders for June 2026 revealed Resident #55 received a low concentrated sweet, regular texture with thin consistency liquids small portions. Review of the Resident #55's diet tray ticket revealed Resident #55 received low concentrated sweet, regular texture with thin consistency liquids small portions. Resident #55's diet ticket stated he wanted soup on tray. Observation and interview on 06/02/26 at 11:53 A.M. revealed Resident #55's tray was put into the food cart. Resident #55's tray did not have soup on his tray. This was verified by Dietary Aide #218 at time of observation. 3. Review of the medical record for Resident #71 revealed an admission date of 01/23/24. Diagnoses included but not limited to anxiety disorder, diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/26, revealed the resident had intact cognition. The resident required set up for eating. Review of physician's orders for June 2026 revealed Resident #71 received a low concentrated sweet, regular texture with thin consistency liquids small portions. Review of the Resident #71's diet tray ticket revealed Resident #71 received low concentrated sweet, cut up food texture with thin consistency liquids small portions. Resident #71's diet ticket stated that she did not want canned fruit. Observation and interview on 06/02/26 at 12:09 P.M. revealed Resident #71's tray was put into the food cart. Resident #71's tray had canned fruit on her tray, but her ticket stated that she does not like canned fruit. Resident #71 asked for a salad but did not have salad dressing on the tray as a condiment. This was verified by Dietary Aide #218 at time of observation. This deficiency represents non-compliance investigated under Complaint Number 2629657.

Based on record review, observation and interview, the facility failed to ensure medications were not left unattended at the bedside. This affected one resident (Resident #19) of three reviewed for drug storage. The facility census was 81Findings include:Review of Resident #19's medical records revealed an admission date of 03/04/26. Diagnoses included diabetes, chronic pain, depression, anxiety and hypertension (high blood pressure).Review of Resident #19'squarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition. Resident #19 required substantial assistance with toileting, bathing and partial assistance with personal hygiene. Review of Resident #19's physician orders for June 2026 revealed an order for Fluticasone Propionate Suspension 50 microgram/actuation (MCG/ACT) to administer 2 sprays in each nostril one time a day for congestion. Observation and interview on 06/03/26 at 8:36A.M., during medication administration, revealed a bottle of Propionate Suspension 50 MCG/ACT medication was on Resident #19's bedside table. Resident #19 reported she keeps her nasal spray in her room and administers herself. Interview on 06/03/26 at 8:37 A.M. with Licensed Practical Nurse (LPN) #224 confirmed resident #19 is not permitted to have the nasal drops in her room and removed the drops from the room.Interview on 06/03/26 at 10:12 A.M. with Director of Nursing (DON) confirmed medications are not permitted in resident rooms, unless they have been assessed to self-administer and have a physicians or nurse practitioner order to do so safely. DON revealed Resident #19 was not able to self administer medication. Review of facility policy, Medication Storage, revised 07/23/2019, revealed medication are to be stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member authorized to administer medication. Medication rooms, carts, and medication supplies are locked or attended by personnel with authorized access. Review of facility policy, Self-Administration of Medication, undated, revealed each resident who desires to self-administer medication is permitted to do so if the interdisciplinary team has determined the practice would be safe for the resident and other residents in the facility. Further stated, upon request, offered opportunity to self-administer medications once physician and interdisciplinary team concur the practice is safe.

Based on record review and interviews the facility failed to administer insulin medication per physician orders. This affected one resident (Resident #77) out of three residents reviewed for insulin medication. Facility census was 81.Findings include:Review of the medical record for Resident #77 revealed an admission date of 04/03/25. Diagnoses included but were not limited to vascular dementia, type 2 diabetes mellitus and congestive heart failure.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had intact cognition. Review of the physician orders dated February 2026 for Resident #77 revealed an order for Insulin Glargine subcutaneous Solution 100 units per milliliter (Units/ML), inject 28 units subcutaneous (SQ) one time a day for diabetes mellitus.Review of the February 2026 medication administration records (MARS) and treatment administration records (TARS) revealed Insulin Glargine subcutaneous Solution 100 Units/ML, inject 28 units SQ one time a day for diabetes mellitus for 02/09/26 had a #9 code, which means see nurses note.Review of the nurses notes dated 02/09/26 at 10:30 A.M. revealed Registered Nurse (RN) #406 contacted pharmacy regarding the insulin Glargine not being available. Interview on 06/01/2026 at 10:28 A.M. with Resident #77 revealed he gets insulin in the morning, but it was not always timely, and one time his insulin was not available.Interview on 06/01/26 at 11:41 A.M. with RN #406 confirmed she worked on 02/09/26 and Resident #77's insulin was not available. RN #406 confirmed he did not receive his insulin that day.Interview on 06/03/26 at 10:04 A.M. with Director of Nursing (DON) confirmed Resident #77 did not receive his insulin due to it not being available.Review of facility policy, Medication Administration, Insulin Administration, revised 06/21/2017, revealed insulin is a high-risk drug and warrants additional precautions for the safe and effective administration. This deficiency represents non-compliance investigated under Complaint Number 2747704.

Based on medical record review and staff interview, the facility failed to ensure Resident #31 and #56 were free from unnecessary psychotropic medications. This affected two residents (Residents #31 and #56) of five residents for unnecessary medications. The facility census was 81. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 04/20/26 with diagnoses to include diabetes mellitus, parkinsonism, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/24/24, revealed the resident had intact cognition. The resident required set up for eating and supervision for other activities of daily living (ADLs). Review of the care plan for Resident #31 dated 04/20/26 revealed that Resident #31 experienced alteration in mood and behavior. Interventions included but were not limited to offer snacks, offer reassurance, provide activities, and medicate as ordered. Review of the physicians' orders for May 2026 revealed orders for one tablet of 0.5 milligrams (mg) of Lorazepam (anti-anxiety medication) by mouth every four hours as needed (PRN) for agitation related to dementia with behavioral disturbance, psychotic disorder with delusions and was ordered one tablet of 25 mg of Hydroxyzine (antihistamine to relieve anxiety) HCL by mouth every four hours PRN for agitation, anxiousness. Review of Resident #31's Medication Administration Record (MAR) revealed Resident #31 received PRN Lorazepam on 05/30/26 at 7:33 P.M., 06/01/26 at 12:53 P.M., 06/01/26 at 5:47 P.M., and 06/02/26 at 8:43 A.M., and PRN Hydroxyzine on 05/30/26 at 7:33 A.M., 06/01/26 at 8:28 A.M., 06/01/26 at 5:47 P.M. The medical record did not contain evidence the reason the medication was given or non-pharmacological intervention attempted prior to administration of the PRNs. Interview on 06/03/26 at 8:48 A.M. with Director of Nursing (DON) verified that Resident #31 was ordered one tablet of 0.5 milligrams (mg) of Lorazepam by mouth every four hours as needed (PRN) for agitation related to dementia with behavioral disturbance, psychotic disorder with delusions and was ordered one tablet of 25 mg of Hydroxyzine HCL by mouth every four hours PRN for agitation, anxiousness. DON revealed nurses were to document why PRN medication was given in the progress notes or in the electronic medication administration record (e-MAR). DON revealed staff have a behavior book on the units, to document behaviors and interventions that were tried when residents show a behavior that did not work. She stated nurses may also document within the 24-hour report given between staff. DON verified that no documentation as to why Resident #31 was administered PRN Lorazepam on 05/30/26 at 7:33 P.M., 06/01/26 at 12:53 P.M., 06/01/26 at 5:47 P.M., and 06/02/26 at 8:43 A.M. DON also verified that there was no documentation as to why Resident #31 was administered PRN Hydroxyzine on 05/30/26 at 7:33 A.M., 06/01/26 at 8:28 A.M., 06/01/26 at 5:47 P.M. Interview on 06/03/26 at 9:28 A.M. with Assistant Director of Nursing (ADON) #283 revealed the last documented entry for Resident #31 in the psych behavior book was 05/18/26 and there were no behaviors noted for Resident #31 in the nurses' 24-hour reports for 05/30/26, 05/31/26, 06/01/26, or 06/02/26. Interview on 06/03/26 at 10:33 A.M. with Psych Certified Nurse Practitioner (PCNP) #401 revealed she looks for documentation for the use of PRN medications. Interview on 06/03/26 at 4:00 P.M. with Regional Administrator (RA) #330 revealed Licensed Practical Nurse (LPN) #320 wrote a late progress note for 06/02/26 about why she gave the PRN Lorazepam and PRN Hydroxyzine given at the same time. Review of the late entry progress note, documented on 06/03/26 at 3:26 P.M. with an effective date of 06/02/26 at 10:14 A.M. revealed LPN #320 documented prior to administering medication, Resident #31 was showing signs of agitation and was combative with LPN #320 while attempting to get his blood sugar. First attempt was unsuccessful. During second attempt resident swung at LPN #320. LPN #320 stated to his aide that when she was ready to help him with his activities of daily living (ADLs) to come get them for assistance. Aide and nurse approached once again as the resident began to swing, hit, and kick them. Per nursing judgement both Ativan (Lorazepam) and Vistaril (Hydroxyzine) given at the same time. 2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with relevant diagnoses of cognitive communication deficit, delusional disorder, dementia, and anxiety disorder. Review of the MDS 3.0 5-day assessment dated [DATE] and the MDS 3.0 Quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment), and assistance with activities of daily living (ADL) ranging from staff supervision to substantial staff assistance. Review of the medical record care plan, revealed a care plan for a risk of adverse effects related to psychoactive medications. Interventions included to utilized the PRN medications only after non-drug measures are ineffective. The care plan did not include individualized non-pharmacological interventions to assist the resident before PRN medications are administered. On 05/13/26, Resident #56 was ordered Vistaril (antihistamine to relieve anxiety) oral capsule 25 milligram by mouth PRN every 8 hours for anxiety/agitation. Review of the MAR for May 2026, revealed Resident #56 received one dose of Vistaril 25 mg on 05/16/26 at 10:01 P.M., 05/17/26 at 7:36 P.M., 05/20/26 at 8:01 P.M., and on 05/31/26 at 2:30 P.M. Review of the medical record progress notes on 05/16/25 at 10:01 P.M. by LPN #213, on 05/17/26 at 7:36 P.M by LPN #315, on 05/20/26 at 8:01 P.M. by LPN #315, revealed no documentation regarding attempted non-pharmacological interventions prior to medicating the resident. Interview with DON on 06/03/26 at 9:00 A.M. verified the findings.

Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 7.14% and included two medication errors of 28 medication administration opportunities. This affected one resident (#113) of three residents observed for medication administration. Findings include: Record review for Resident #113 revealed an admitted [DATE]. Resident #113 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/24/22 at 10:39 A.M. Licensed Practical Nurse (LPN) #303 was observed to obtain Resident #113's blood sugar using a glucometer. The resident's blood sugar was 276 at that time. At 10:42 A.M. LPN #303 administered five units of [MEDICATION(S)] subcutaneously and an additional six units of [MEDICATION(S)]. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If blood sugar was 111 - 150 give no insulin, 151 - 200 give two units, 201 - 250 give four units, 251 - 300 give six units, 301 - 350 give eight units and 351 - 400 give 10 units. The resident also had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/24/22 interview with LPN #303 confirmed the insulin medications were administered outside the ordered time frames. Resident #113 received and consumed breakfast at approximately 8:15 A.M. LPN #303 confirmed the routine order for [MEDICATION(S)] insulin should have been given with resident's breakfast and Resident #113 should have had the blood sugar assessed prior to the meal and the sliding scale ordered insulin should have been given prior to or during the resident receiving breakfast if needed. LPN #303 verified she then administered the next routine ordered dose of the [MEDICATION(S)] five units at 11:40 A.M. and [MEDICATION(S)] sliding scale insulin six units at 11:40 A.M. (within an hour of the previous blood sugar assessment and insulin). On 02/24/22 at 11:50 A.M. interview with Resident #113 revealed she received her medications including insulin at various times. The resident revealed often the nurses checked her blood sugar hours after eating her meal when it should have been checked prior to the meal to provide the proper dose of insulin. The resident revealed she had not said anything to anyone because she didn't want staff to feel like she was complaining. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/24/22 at 12:15 P.M. interview with LPN #312 revealed the LPN believed insulin could be given an hour before or an hour after scheduled times even when ordered to be given with meals. On 02/28/22 at 10:42 A.M. interview with the Director of Nursing (DON) revealed blood sugars should be assessed prior to a resident eating a meal and if the order for insulin was to be given with meals, then the insulin should be administered with the meal. Review of facility policy titled Medication Administration, dated 06/21/17 revealed medications would be administered consistent with accepted standards of practice. This deficiency substantiates Complaint Number OH 101.

Based on review of Centers for Disease Control (CDC) recommendations, observation and interview, the facility failed to ensure proper infection control practices were maintained on the first floor unit. This had the potential to affect 14 residents (#23, #24, #38, #45, #46, #58, #59, #261, #262, #264, #265, #267, #313, #316) that resided on the first floor. Findings include: Review of the medical record for Resident #313 revealed he admitted to the facility on [DATE] and was on isolation precautions due to recent admission. Review of the medical record for Resident #264 revealed he admitted to the facility on [DATE] and was on isolation precautions due to recent admission. Observation on 07/26/21 at 10:30 A.M. revealed an isolation container at the entrance of Resident #264 and #313 room who both resided on the facility first floor unit. Observation revealed there were no gloves, mask or gowns to enter the room to maintain proper infection control practices. Interview on 07/26/21 at 10:30 A.M. with Resident #264 and #313 revealed they were both on isolation precautions due to recent admission to the facility. Observation on 07/26/21 at 12:40 P.M. revealed STNA #579 passing meal trays for the first floorunit. Observation revealed STNA #579 checking multiple isolation containers to locate personal protective equipment (masks and gowns). Interview on 07/26/21 at 12:40 P.M. with Licensed Practical Nurse (LPN) #560 confirmed STNA #579 could not locate any masks or gowns in multiple isolation containers. Observation on 07/26/21 at 12:45 P.M. revealed four isolation containers located on first floor unit. Observation revealed isolation containers were not stocked with mask and gowns. Observation revealed all four containers did not have mask and gowns to enter the isolation rooms. Observation on 07/26/21 at 12:45 P.M. revealed LPN #560 walking down the residents' hall without a face mask on checking isolation containers for a face mask. Observation revealed LPN #560 obtained a face mask from the receptionist desk. Interview on 07/26/21 at 12:45 P.M. with LPN #560 confirmed there were no face masks located in isolation containers and a face mask had to obtained from the receptionist desk. Review of in-service records dated 01/13/21 and 02/18/21 revealed all departments were trained on infection control that included hand washing protocol, personal protective equipment, donning and doffing, and contact and droplet isolation. Review of the CDC, Coronavirus Disease 2019 (Covid-19), Interim Infection Prevention and Control recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated 02/23/21, stated Healthcare Personnel (HCP) should wear a face mask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Review of the facility document titled Infection Prevention and Control Program (IPCP) revised 11/28/17, revealed the facility had a policy in place to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the document revealed supplies necessary for adherence to proper personal protective equipment use (gloves, gowns, masks) were readily available in resident care areas (i.e., nursing units, therapy rooms). Review of the document revealed the facility did not implement the policy regarding the infection control.

Based on observation, interview, and record review the facility failed to ensure call lights were within reach for residents (Resident's #16, #27 and #28) who were dependent on the facility staff for their care. This affected three residents (Resident's #16, #27 and #28) out of three residents reviewed for accommodation of needs. Findings include: 1. Review of Resident #27's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment, dated 05/19/21 revealed resident was cognitively intact, was one person physical assist and required extensive assistance with bed mobility and transfers. Review of Resident #27's care plan, dated 07/20/21, revealed the resident was at risk for injury related to falls due to unsteady gait, balance, incontinence, impaired cognition with poor safety awareness and impulsivity, risk of medication side effects, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A goal was included to minimize potential risk factors related to falls. An intervention dated 12/3/19 stated to encourage use of call light when assistance was needed. Observation on 7/26/21 at 11:54 A.M. of Resident #27 laying in bed, the call light was on the floor behind her bedside table, out of reach, and was not able to be used by the resident. Interview on 07/26/21 at 11:55 A.M. of Resident #27 revealed the call light was not in reach if she needed to use it, it did not work properly and in order for it to work the button must be continually held down. Resident #27 stated the call light had not been working properly for quite a while. Interview on 7/26/21 at 12:02 P.M. of Unit Manager/Licensed Practical Nurse (UM/LPN) #519 confirmed Resident #27's call light was laying on floor out of the residents reach and did not work when pressed unless the button was continually held down. Interview on 07/26/21 at 12:05 P.M. of Resident #27 indicated the call light had been been broken for quite awhile, she told nurses and State tested Nursing Assistants the light was not working but could not remember their names. Resident #27 stated she told STNA $582 the call light was not working. Attempts on 07/29/21 at 10:08 A.M. and 07/30/21 at 10:10 A.M. to contact STNA #582 were unsuccessful. Interview on 7/26/21 at 12:06 P.M. of Maintenance Director (MD) #532 confirmed Resident #27's call light was broken and he would get it fixed. Interview on 07/26/21 at 12:26 P.M. of MD #532 stated he checked the call light system monthly to be sure the lights were working properly. MD #532 stated he needed to replace Resident #27's call light because there was something wrong with the wires. 2. Review of Resident #28's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's MDS 3.0 assessment, dated 05/20/21, revealed resident had severe cognitive impairment, was a one person physical assist and required extensive assistance with bed mobility and transfer. Review of Resident #28's care plan, dated 05/20/21, revealed the resident was at risk for falls, had poor safety awareness related to dementia with behavioral disturbances, muscle weakness, received [CONDITION(S)] medication, and required some assistance with transfers. Interventions included ensure call light was within reach. Observation on 07/26/21 at 11:09 A.M. of Resident #28 sleeping in bed, revealed the call light was located behind the head of bed and not able to be used by the resident. Observation on 07/26/21 at 4:37 P.M. and 4:52 P.M. revealed Resident #28 was laying on her right side in bed, was sleeping, and the call light was out of reach behind the head of the bed. Observation on 7/27/21 at 4:25 P.M. revealed Resident #28 was laying in her bed and the call light was behind the head of the bed and out of resident reach. Observation and interview on 7/28/21 at 10:41 A.M. of Resident #28 with LPN #556 revealed Resident #28 sitting on the side of the bed, the call light was behind the head of the bed and out of the resident's reach. LPN #556 stated Resident #28 could not use the call light or reach the call light where it was located and moved the call light so it was within Resident #28's reach. 3. Review of Resident #16's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment, dated 04/27/21, revealed Resident #16 was unable to complete the Brief Interview for Mental Status (BIMS) due to she was rarely if never understood. Further review revealed Resident #16 was a two person physical assist and required extensive assistance for bed mobility, and was a two person physical assist and total dependence for transfers. Review of Resident #16's medical record revealed she was placed in hospice care on 01/15/21. Observation on 07/26/21 at 4:02 P.M. revealed Resident #16 was laying in bed on her left side, and the call light was on the floor at the foot of her bed and unable to be reached by the resident. Observation on 7/27/21 at 2:38 P.M. and 4:23 P.M. revealed Resident #16 was laying in bed on left side, and the call light cord and button were looped around area where it met the wall. The call light was far from resident reach. Interview on 07/27/21 at 4:30 P.M. of STNA #580 confirmed the call light was looped around area where it met the wall and far from Resident #16's reach. STNA #580 moved the call light so Resident #16 was able to reach it if needed. Interview on 07/30/21 at 3:45 P.M. of Administrator #606 revealed the facility did not have a call light policy.

Based on record review and interview, the facility failed to ensure resident significant weight change was addressed by the physician. This affected one resident (#32) of one resident reviewed for nutrition. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the dietary assessment narrative dated 03/09/2021 at 2:30 P.M. revealed the resident continued on Regular diet order and fed self in the dining room with no chewing or swallowing difficulty. The resident's current diet provided 2230 calories and 93 grams protein and the resident's meal intakes were approximately 25-100%. The resident needed cueing from staff due to advanced dementia. The resident's height was 63 inches, weight on 03/04/21 was 135.5 pounds, weight on 11/04/20 was 156 pounds, and weight on 09/04/20 was 157.5 pounds. The resident triggered for significant weight loss of 20.5 pounds which was 13.1% from the weight on 10/12/2020 of 156.5 pounds. The weight loss was probable related to decreased intake and appetite due to COVID 19 diagnosis. Review of the nursing notes dated 03/01/21 through 04/20/21 revealed no evidence the physician addressed Resident #32's weight loss. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had weight loss that was not physician prescribed. Interview on 07/29/21 at 2:48 P.M. with the Administrator and the DON verified the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to provide the necessary supervision for Resident #57 to prevent injuries and transportation to the local Emergency Department. This affected one resident (Resident #57) out of one resident reviewed for dementia care. Findings include: Review of Resident #57's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment dated , 07/06/21 revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment revealed Resident #57 was a one person physical assist and needed extensive assistance with locomotion and walking in corridor. The assessment revealed Resident #57 was not steady but able to stabilize without staff assistance for walking. Review of Resident #57's care plan, dated 06/04/20, revealed the resident experienced alteration in behavior as evidenced by wandering the halls on the unit, wandering in and out of other resident rooms, and taking items belonging to others at times. Interventions ,dated 06/04/20, included distraction and redirection as needed and an intervention, dated 07/03/20, included staff were to monitor location on the unit to provide cueing to discourage wandering into other resident rooms, and assist with movement to common area or assist with finding her own room. 1. Review of Resident #57's progress notes on 04/09/21 at 6:39 P.M. revealed Licensed Practical Nurse (LPN) #564 heard yelling coming from the hallway. When she arrived at the location of yelling, State tested Nursing Assistant (STNA) ##599 was re-directing Resident #57 out of Resident #48's room. STNA #599 stated Resident #48 slapped Resident #57 on the left side of the face. The left side of Resident #57's face was observed to be red with no swelling and the skin was intact. A small red spot on Resident #57's back was also noted. Interview on 07/30/21 at 8:45 A.M. of LPN #564 confirmed Resident #57 was slapped by Resident #48 and the left side of her face had a red mark. LPN #564 stated the residents were immediately separated, Resident #57 was re-directed away from Resident #48's room and a stop sign barrier was placed on Resident #48's door. Attempt to contact STNA #599 on 07/29/21 at 2:00 P.M. was unsuccessful due to STNA #599 no longer working in the facility. Review of Resident #57's shower sheet dated 04/12/21 revealed resident had a red area on her left cheek and right upper back. Review of STNA #599's witness statement on 04/09/21 at 6:20 P.M. included she was walking in the hallway and heard a resident yell don't hit her and by the time she arrived to the scene of yelling she observed Resident #48 smack Resident #57 in the face and yelled get out of my room. STNA #599 separated the residents, re-directed Resident #57 away from Resident #48 and reported the incident to LPN #564. 2. Review of Resident #57's progress notes written by LPN #541 on 05/31/21 at 9:45 A.M. included staff heard a resident yell get out of my room. A loud thud was heard and Resident #57 was observed on the floor, lying on her back in front of Resident #40's room. Resident #57 stated he hit me. Resident #40 and #57 were separated. Resident #57 was assessed and her pupils were pinpoint and fixed, she was unable to express pain, swelling was noted to the back of her head, her upper back and left cheek were red. A pillow was placed under Resident #57's head and she was kept still. Certified Nurse Practitioner (CNP) #600 was notified, local Fire and Police Department staff arrived to the facility and Resident #57 was transported to the local hospital by Emergency Medical Services (EMS). Review of Resident #57's Emergency Department discharge instructions on 05/31/21 included instructions titled, Head Injury, Adult. The discharge instructions stated to follow up with primary care physician in the next two or three days for further evaluation and management. Please return to the Emergency Department for new or worsening symptoms. Take Tylenol every six hours as needed for pain. Review of Resident #57's Incident/Accident Body assessment dated , 05/31/21 revealed redness to left cheek, right upper back redness, and swelling to the back of her head. Interview on 07/28/21 at 1:22 P.M. of STNA #573 revealed on 05/31/21 she was working on the secured unit and she heard a loud noise like something hitting something really hard, heard a scream, and Resident #40 yelled get out of my room. STNA #573 observed Resident #57 sitting on the floor and Resident #40 standing in the doorway. STNA #573 asked Resident #40 if he pushed Resident #57 and he stated he did not want anyone in his room. STNA #573 stated she observed a bump on the back of Resident #57's head and redness under her neck between her shoulder blades. STNA #573 stated she reported the incident to LPN #541 and staff from the local Police and Fire Departments arrived to the facility and Resident #57 was taken to the hospital by EMS. STNA #573 further stated the STNA's try to keep an eye on the residents, but there was not always enough staff and things happen sometimes. STNA #573 stated two STNA's on the secured unit were not enough to supervise the residents, because the residents required a lot of care and could not be rushed. Interview on 07/28/21 at 2:54 P.M. of Certified Occupational Therapy Assistant (COTA) #603 revealed she was working with another resident on the secured nursing unit on 05/31/21 when she heard yelling and the words get out of my room, and saw Resident #57 fly backward and lose her balance. COTA #603 stated Resident #57 fell on her butt, and her head went back and hit the door frame. At the same time she saw Resident #40 standing in the doorway to his room. LPN #541 arrived on scene and assessed Resident #57. COTA #603 stated she left when LPN #541 arrived and did not stay for the assessment. Review of the daily assignment sheets for 05/31/21 revealed LPN #541 was assigned to the second floor secured unit. LPN #605 split her assignment between the first floor nursing unit and the second floor secured unit. Two STNA's (STNA #520 and #552) were assigned to the secured second floor nursing unit at the time of the altercation between Resident #40 and Resident #57. Observation on 07/26/21 at 1:00 P.M. of Resident #57 in Resident #10s room revealed there were no STNA ' s or nurses present. STNA #580 confirmed Resident #57 often wandered into resident rooms and needed to be re-directed to a different location. Interview on 07/26/21 at 1:02 P.M. with STNA #580 confirmed Resident #57 was in Resident #10 ' s room and there were no STNA ' s or nurses present in the room. Interview on 07/28/21 at 10:03 A.M. of LPN #556 revealed more nurses and STNA's should be assigned to the secured unit. LPN #556 stated it was hard to administer medications, give showers and keep an eye on the residents, especially the wandering residents. Observation on 07/28/21 at 3:00 P.M. of Resident #57 wander into Resident #16 ' s room and began touching the furniture. There was no observation of staff in the room or hall supervising Resident #57. Interview on 07/28/21 at 3:05 P.M. of STNA #607 confirmed Resident #57 was in Resident #16 ' s room and there were no STNA ' s or nurses in the room during that time. STNA #607 stated Resident #57 wandered a lot and was hard to keep track of. Interview on 07/29/21 at 2:20 P.M. of STNA #604 revealed Resident #57 wandered a lot and was hard to keep track of. STNA #604 stated she often wandered into other residents rooms and sometimes the residents were very upset when this happened. STNA #604 stated Resident #27 was really mean to Resident #57 recently when she wandered into her room. STNA #604 stated it would help keep an eye on the residents if there were more STNA's assigned to the secured unit. Interview on 07/29/21 at 2:30 P.M. of LPN #561 revealed Resident #57 wandered a lot and often needed re-directed from entering other resident rooms. LPN #561 stated it would really help to have more STNA's assigned to the secured unit to assist with monitoring the residents, especially the wanderers, to be proactive and prevent problems before they occur. LPN #561 further stated Resident #57 entered Resident #27's room uninvited a few days ago and Resident #27 was very upset and screamed at her to get out. Review of the facility policy titled, Alzheimer's/Dementia Unit Protocol, dated 03/2005 included the Alzheimer's/Dementia Program includes a comprehensive set of standards, policies, and practices designed specifically to establish a unit within the facility that is a safe and therapeutic service provider for residents with Alzheimer's, dementia and related disorders. Ensuring a safe residential environment through implementation of permanent changes to the facility's physical plant as well as day-to-day safety considerations by all facility associates.

Based on interview and record review, the facility failed to ensure physical abuse allegations were accurately and timely reported within the required two hour time frame to the State Agency. This affected one resident (Resident #57) out of one resident reviewed for reporting of physical abuse. Findings include: Review of Resident #57's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment, dated 07/06/21, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment revealed Resident #57 was a one person physical assist and needed extensive assistance with locomotion and walking in corridor. The assessment revealed Resident #57 was not steady but able to stabilize without staff assistance for walking. Review of Resident #57's care plan, dated 06/04/20, revealed the resident experienced alteration in behavior as evidenced by wandering the halls on the unit, wandering in and out of other resident rooms, and takes items belonging to others at times. Interventions, dated 06/04/20, included distraction and redirection as needed and an intervention, dated 07/03/20, included staff to monitor location on the unit to provide cueing to discourage wandering into other resident rooms, and assist with movement to common area or assist with finding her own room. Review of Resident #57's progress notes on 04/09/21 at 6:39 P.M. revealed Licensed Practical Nurse (LPN) #564 heard yelling coming from the hallway. When she arrived at the location of yelling, State tested Nursing Assistant (STNA) #599 was re-directing Resident #57 out of Resident #48's room. STNA #599 stated Resident #48 slapped Resident #57 on the left side of the face. The left side of Resident #57's face was observed to be red with no swelling and the skin was intact. A small red spot on Resident #57's back was also noted. Review of Resident #57's shower sheet dated 04/12/21 revealed resident had a red area on her left cheek and right upper back. Review of the Self Reported Incident (SRI) # 9 created 04/12/21 at 10:13 A.M. by Administrator #602 (three days after the incident) included in the Summary of Incident Section, on 04/09/21 at approximately 6:20 P.M., Resident #48 made contact with Resident #57, and the residents were separated. Resident #57 was assessed and no new skin abnormalities were noted including no swelling, redness, bruises, scratches or abrasions were noted. The SRI inaccurately reported Resident #57's injuries. Review of the facility Employee Education and Training Document, dated 04/12/21 revealed LPN #564 was educated on the Abuse Policy due to LPN #564 failed to notify the Abuse Coordinator within a timely manner of an alleged abuse incident. Review of STNA #599's witness statement revealed on 04/09/21 at 6:20 P.M. she was walking in the hallway and heard a resident yell don't hit her and by the time she arrived to the scene of yelling she observed Resident #48 smack Resident #57 in the face and yelled get out of my room. STNA #599 separated the residents, re-directed Resident #57 away from Resident #48 and reported the incident to LPN #564. Interview on 07/29/21 at 3:20 P.M. with Administrator #606 and the Director of Nursing revealed although Resident #57's progress note and shower sheet identified the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/30/21 at 8:45 A.M. of LPN #564 confirmed Resident #57 was slapped by Resident #48 and the left side of her face had a red mark. LPN #564 stated the residents were immediately separated, Resident #57 was re-directed away from Resident #48's room and a stop sign barrier was placed on Resident #48's door. Attempt to contact STNA #599 on 07/29/21 at 2:00 P.M. was unsuccessful due to STNA #599 no longer working in the facility. 2. Review of Resident #57's progress notes on 05/31/21 at 9:45 A.M. included staff heard a resident yell get out of my room. A loud thud was heard and Resident #57 was observed on the floor, lying on her back in front of Resident #40's room. Resident #57 stated he hit me. Resident #40 and #57 were separated. Resident #57 was assessed and her pupils were pinpoint and fixed, she was unable to express pain, swelling was noted to the back of her head, and her upper back and left cheek were red. A pillow was placed under Resident #57's head and she was kept still. Certified Nurse Practitioner (CNP) #600 was notified, local Fire and Police Department staff arrived to the facility and Resident #57 was transported to the local hospital by Emergency Medical Services (EMS). Review of Resident #57's Incident/Accident Body Assessment, dated 05/31/21, revealed redness to left cheek, right upper back redness, and swelling to the back of her head. Review of the facility SRI # 9 created on 05/31/21 at 11:23 A.M. by Administrator #602 included in the Summary of Incident Section on 05/31/21 at 9:45 A.M. there was a resident to resident altercation between Resident #40 and Resident #57. No contact was witnessed by facility staff. Resident #57 was assessed and no new noted skin abnormalities were observed including no swelling, redness, bruises, scratches, or abrasions. Resident #40 was placed on one to one supervision. Staff working on the unit had no relevant findings. The SRI inaccurately reported Resident #57's injuries. Interview on 07/28/21 at 1:22 P.M. of STNA #573 revealed on 05/31/21 she was working on the secured unit and she heard a loud noise like something hitting something really hard, heard a scream, and Resident #40 yelled get out of my room. STNA #573 observed Resident #57 sitting on the floor and Resident #40 standing in the doorway. STNA #573 asked Resident #40 if he pushed Resident #57 and he stated he did not want anyone in his room. STNA #573 stated she observed a bump on the back of Resident #57's head and redness under her neck between her shoulder blades. STNA #573 stated she reported the incident to LPN #541 and staff from the local Police and Fire Departments arrived to the facility and Resident #57 was taken to the hospital by EMS. Interview on 07/28/21 at 2:54 P.M. of Certified Occupational Therapy Assistant (COTA) #603 revealed she was working with another resident on the secured nursing unit on 05/31/21 when she heard yelling and the words get out of my room, and saw Resident #57 fly backward and lose her balance. COTA #603 stated Resident #57 fell on her butt, and her head went back and hit the door frame. At the same time she saw Resident #40 standing in the doorway to his room. LPN #541 arrived on scene and assessed Resident #57. Interview on 07/29/21 at 3:20 P.M. with Administrator #606 and the Director of Nursing revealed although Resident #57's Incident/Accident Body Assessment identified the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16 included it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made to the Administrator or designee of the facility and to other officials, including the State Survey Agency, in accordance with State law.

Based on medical record review, staff interview, and facility policy review, the facility failed to to provide adequate, timely, and thorough care regarding Resident #2's change in condition. This affected one (Resident #2) of three residents reviewed for changes in condition. Findings Include: Review of Resident #2 medical records revealed she was admitted on [DATE] and discharged to the hospital on 03/16/21. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was five, which indicated she had a severe cognitive impairment. Review of Resident #2's progress note dated 03/13/21, revealed Licensed Practical Nurse (LPN) #101 noticed swelling to the left side of Resident #2 face/cheek area. There was also redness and swelling noted to the inside of her mouth, along the gum line. LPN #101 contacted the nurse practitioner to explain what she observed and her thoughts that it could be a dental issue/abscess. The nurse practitioner ordered an antibiotic, antiseptic mouthwash, and to follow up with a dental appointment at first available time for the potential dental issues/abscess. LPN #101 also contacted Resident #2 family to inform them of the change in condition and to get dental preferences for a dental appointment on Monday, 03/15/21. Review of Resident #2's progress note dated 03/14/21 revealed the resident's swelling to left cheek decreased when resident lies tat and increased throughout day and the nurse practitioner was updated. Review of Reesident #2's medical record from 03/13/21 to 03/16/21 revealed the facility did not schedule a dental appointment or change the course of dental treatment originally made. Resident #2 continued to be given antibiotics for a possible dental/tooth infection. Resident #2's progress note dated 03/16/21 revealed the resident's daughter was called concerning the resident's face discoloration and the resident was being sent to the emergency department for suspected mouth abnormalities behind teeth. There was no indication of discoloration to the residents face prior to 03/16/21. Interview with Director of Nursing (DON) and LPN #101 on 04/24/21 from 12:20 P.M. to 2:45 P.M. revealed if there is a significant change in a resident's condition, they will fully assess the situation, make a determinate on care, notify the physician/nurse practitioner and family/representative, and document what they did/will do. They will document this in the electronic medical records. LPN #101 revealed the resident had discoloration with potential bruising to her face on 03/13/21 when the swelling was first identified. DON confirmed there was no evidence the resident's discoloration to her face on 03/13/21 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she spoke with the nurse practitioner about this, so they decided not to make the dental appointment and make an appointment with ENT. LPN #101 confirmed there was no evidence the change of Resident #2's treatment was discussed with the nurse practitioner. DON and LPN #101 confirmed Resident #2 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . They confirmed the facility did not set up a dental or ENT appointment for Resident #2. Review of facility Change of Condition policy (dated April 2013) revealed a change of condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a.) a life-threatening condition, b.) a significant alteration in treatment, or c.) a significant change in the resident's clinical condition or status. Significant changes in resident's clinical condition or status include improvement or decline in the following: improvement or deterioration in overall condition and emergence of unstable condition or disease. The unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification. This deficiency substantiates Complaint Number OH 621.

Based on medical record review, staff interview, and facility policy review, the facility failed to notify the resident's representatives when there was a significant change in condition or care. This affected one (Resident #2) of three residents reviewed for a change in condition. Findings Include: Review of Resident #2 medical records revealed she was admitted on [DATE] and discharged to the hospital on 03/16/21. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was five, which indicated she had a severe cognitive impairment. Review of Resident #2's progress note dated 03/13/21, revealed Licensed Practical Nurse (LPN) #101 noticed swelling to the left side of Resident #2 face/cheek area. There was also redness and swelling noted to the inside of her mouth, along the gum line. LPN #101 contacted the nurse practitioner to explain what she observed and her thoughts that it could be a dental issue/abscess. The nurse practitioner ordered an antibiotic, antiseptic mouthwash, and to follow up with a dental appointment at first available time for the potential dental issues/abscess. LPN #101 also contacted Resident #2 family to inform them of the change in condition and to get dental preferences for a dental appointment on Monday, 03/15/21. Review of Resident #2's progress note dated 03/14/21 revealed the resident's swelling to left cheek decreased when resident lies flat and increased throughout day, and the nurse practitioner was updated. Review of Reesident #2's medical record from 03/13/21 to 03/16/21 revealed the facility did not schedule a dental appointment or change the course of dental treatment originally made. Resident #2 continued to be given antibiotics for a possible dental/tooth infection. Resident #2's progress note dated 03/16/21 revealed the resident's daughter was called concerning the resident's face discoloration and the resident was being sent to the emergency department for suspected mouth abnormalities behind teeth. There was no indication of discoloration to the residents face prior to 03/16/21. Interview with Director of Nursing (DON) and LPN #101 on 04/24/21 from 12:20 P.M. to 2:45 P.M. revealed if there is a significant change in a resident's condition, they will fully assess the situation, make a determinate on care, notify the physician/nurse practitioner and family/representative, and document what they did/will do. They will document this in the electronic medical records. DON and LPN #101 confirmed there was no documentation regarding the thought that Resident #2 issues might be ENT related, and that they were going to look at that as a possibility. They also confirmed there was no documentation to support Resident #2 family was notified about this addition/change in course of medical treatment. LPN #101 confirmed she spoke with the nurse practitioner about Resident #2 issue being ENT related since the swelling and discoloration would go away when she laid down, but return when she was upright. LPN #101 stated she could not confirm if she discussed the ENT appointment or the decision not to move forward with the dental appointment with Resident #2 family. Review of facility Change of Condition policy (dated April 2013) revealed a change of condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a.) a life-threatening condition, b.) a significant alteration in treatment, or c.) a significant change in the resident's clinical condition or status. Significant changes in resident's clinical condition or status include improvement or decline in the following: improvement or deterioration in overall condition and emergence of unstable condition or disease. The unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification. This deficiency substantiates Complaint Number OH 621.

Based on observations, record review, interviews, policy review, and Centers for Disease Control COVID-19 guidelines, revealed the facility failed to ensure proper infection control practices were followed throughout the facility during medication pass, and for COVID-19 prevention. This had the potential to affect all 66 of 66 residents residing at the facility. Findings include: 1. Review of Resident #46 medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 03/22/21 at 9:05 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #205 dropped one of Resident #46's medications on the medication cart, picked it up with her ungloved hand, and placed it in the medication cup. She then walked into the residents room and administered the medication. Interview on 03/22/21 at 9:30 A.M. with LPN #205 verified that she dropped the medication, picked it up, and administered the medication to the resident. Review of the facility policy, General Guidelines for Medication Administration dated 08/07/21 stated the procedure for medication administration included pouring the the correct number of tablets or capsules into the medication cup, and to never touch any of the medications with your fingers. 2. Review of Resident #12's medical record revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 03/22/21 at 9:30 A.M. revealed Resident #12 walking outside of his room in the dinning area with his family. The resident was observed to be without any Personal Protective Equipment (PPE), including a mask. Observation on 03/22/21 at 2:10 P.M. revealed an isolation cart to be sitting on the outside of Resident #12's room, and signs indicating the resident was on contact isolation precautions. Observation on 03/22/21 at 2:13 P.M. revealed Speech Therapist #210 walked Resident #12 down the hall into the therapy department. Speech Therapist #210 was observed with out a gown or gloves and Resident #12 was observed without any PPE. Interview on 03/22/21 with the Director of Nursing confirmed Resident #12 was on contact isolation due to being a new admission and should not have left his room. She further confirmed Resident #12 and Speech Therapist #210 did not have proper PPE on. Review of the facility document titled Infection Control Policy/Procedure Manual revised 11/28/17, revealed the facility had a policy in place to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the policy revealed staff were to utilize gloves, gowns, facemask, appropriate mouth, nose, and eye protection. Review of the facility document titled Inservice dated 01/13/21, 02/18/21, and 10/19/20, revealed the facility staff had ongoing in-service training related to infection control. Review of the Inservice record revealed staff were educated on the hand washing protocol, donning, and doffing, personal protective equipment (PPE), and isolation (contact/droplet). Review of the Centers for Disease Control COVID-19 guidance at the time of the survey titled, Interim Infection Prevention and Control Recommendations to Prevent [DIAGNOSES REDACTED]-CoV-2 Spread in Nursing Homes revealed residents, if tolerated, should wear a well-fitting form of source control upon arrival and throughout their stay in the facility. Residents may remove their source control when in their rooms but should put it back on when around others and whenever they leave their room, including when in common areas or when outside of the facility. The guidance continues that residents in quarantine should be placed in a single-person room and should shelter-in-place at their current location while being monitored for evidence of [DIAGNOSES REDACTED]-CoV-2 infection. Health Care Personnel (HCP) should wear an N95 or higher-level respirator, eye protection (including goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. 3. Observation on 03/21/21 at 7:50 A.M. near the facility entrance, revealed State tested Nurse Assistant (STNA) #200 was standing near a nursing cart. STNA #200 was observed standing with no face mask positioned on her face. Interview on 03/21/21 at 8:00 A.M. with STNA #200 revealed that all staff were required to wear a face mask upon entry into the building. Interview with STNA #200 revealed she worked the 1st floor unit. STNA #200 confirmed she was not wearing her face mask. Review of the facility document titled Infection Control Policy/Procedure Manual revised 11/28/17, revealed the facility had a policy in place to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the policy revealed staff were to utilize gloves, gowns, facemask, appropriate mouth, nose, and eye protection. Review of the facility document titled Inservice dated 01/13/21, 02/18/21, and 10/19/20, revealed the facility staff had ongoing in-service training related to infection control. Review of the Inservice record revealed staff were educated on the hand washing protocol, donning, and doffing, personal protective equipment (PPE), and isolation (contact/droplet). Review of the Centers for Disease Control COVID-19 guidance at the time of the survey, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. This deficiency substantiates Complaint Number OH 899.

Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure personal protective equipment (PPE) was donned for Resident #12, who was on droplet precautions, and hand hygiene was consistently implemented to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 66 residents of the facility. Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment was currently in progress. Review of physician's orders [REDACTED].#12 was on contact and droplet isolation precautions. Staff was to wear PPE upon entering the room. The resident was to remain in the room during this time. Observation on 10/07/20 at 10:05 A.M. revealed that Certified Occupational Therapist Assistant (COTA) #100 and Physical Therapist (PTA) #101 were in Resident #12's room providing therapy. Neither COTA #100 or PTA #101 had a gown or goggles on while giving care to Resident #12. The room was clearly marked to See Nurse, PPE was well stocked in a bin outside the room, and a sign was posted to demonstrate donning and doffing of PPE for droplet precautions. PTA #101 left the room pushing a wheelchair without washing her hands. Interview on 10/07/20 at 10:08 A.M. with PTA #101 verified that she did not wear proper PPE and did not wash her hands or use hand sanitizer when she exited the room. COTA #100 stated she did not know that PPE was needed while providing care for Resident #12. Interview on 10/07/20 at 11:35 A.M. with Therapy Program Director #103 revealed staff training is facility based. Review of the in-service completed on 10/05/20 showed that COTA #100 was in-serviced on PPE and hand washing, and PTA #101 was in-serviced on 08/10/20. Review of the facility's policy titled, Standard and Transmission-based Precautions, dated 11/28/17, revealed the facility will use the category of transmission-based precautions will determine the type of PPE to be used. Review of the facility's policy titled, Hand Hygiene, dated 11/28/17, revealed staff will perform hand hygiene before and after contact with a resident. Review of CMS policy memo QSO-20-14-NH revised 3/13/20 titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. Review of the Centers for Disease Control and Prevention (CDC) training titled, Hand Hygiene in Nursing Homes, dated 02/25/19 revealed hand hygiene was an element of standard precautions. It was an important Infection Prevention Control (IPC) practice for breaking the chain of infection. Hand hygiene protects both residents and staff. Hand hygiene was a simple and effective method for preventing the spread of pathogens by direct and indirect contact. The hands of staff members may become transiently contaminated with pathogens after touching a resident or surfaces in their environment. Staff members can transfer those pathogens to themselves and they can also transfer those pathogens to other residents or surfaces. Performing hand hygiene removes pathogens and protects both staff and residents. Since staff cannot tell whether their hands have been contaminated with a pathogen, hand hygiene should be consistently performed. Review of the World Health Organization (WHO) Hand Hygiene brochure titled Hand Hygiene: Why, How, and When?, revised August 2009, revealed hands are the main pathways of germ transmission during health care and hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. The brochure further revealed hand hygiene is indicated after touching any object or furniture when leaving the patient surroundings to protect the health-care environment against germ spread. This deficiency substantiates Complaint Number OH 132.

Based on observation, interview and record review the facility failed to ensure staff washed/sanitized their hands after providing personal care and removing dining trays from isolation resident rooms. This affected two (Residents #66 and #18) of six residents who were in isolation. The facility census was 70 residents. Findings include: On 07/22/2020 at 9:42 A.M. during infection control observations on the first floor, a stop sign was observed on the door frame of room [ROOM NUMBER] which stated see a nurse before entering. There was also a small three drawer plastic dresser containing personal protective equipment outside of the door. Registered Nurse (RN) #50 was observed in room [ROOM NUMBER] taking the blood pressure of Resident #66. RN #50 asked the surveyor if she needed help with something. The surveyor asked her what infection Resident #66 had which required the sign and the personal protective equipment, and RN #50 explained yesterday was her first day and that she was unfamiliar with the residents but would check the computer. While waiting for the [DIAGNOSES REDACTED].M. the surveyor observed State tested Nursing Assistant (STNA) #40, going into room [ROOM NUMBER] and removing Resident #66's breakfast tray. The STNA exited the room and placed the tray on the cart then began to go into room [ROOM NUMBER], where Resident #18 resided and also had a sign on the door frame that stated see a nurse before entering. There was also had a small three drawer plastic dresser containing person protective equipment placed outside of the door. Before STNA #40 entered the room, the surveyor stopped her and asked her to sanitize her hands. The STNA then used hand sanitizer that she had in her pocket before proceeding into room [ROOM NUMBER]. RN #50 then said that it looked as if Resident #66 had [MEDICAL CONDITION]. RN #50 then began going through cart, and the surveyor asked her if she sanitized her hands after taking the blood pressure of Resident #66. RN #50 said there was no sanitizer in the resident's room, but she had sanitizer on her cart, however she did not sanitize her hands. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Physician orders [REDACTED].#66 for signs and symptoms of COVID-19 infection, such as fever and poor oxygenation, or unusual symptoms for the resident such as dry cough, tiredness, aches/pains, sore throat, other symptoms of respiratory infection, diarrhea, other symptoms of GI infection, [MEDICAL CONDITION], headache, loss of taste or smell, rash on skin, and discoloration of fingers or toes. Progress notes dated 07/04/2020 indicated Resident #66 had bilateral [MEDICAL CONDITION] requiring an antibiotic, [MEDICATION NAME]. Review of Resident #18's medical record revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. of fingers or toes. Review of the Infection Control Policy and Procedure dated 11/28/2017 included Hand Hygiene Protocol that stated: a. All staff shall perform hand hygiene their when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall perform hand hygiene before and after performing resident care procedures and per our facility's established hand hygiene procedure. Both RN #50 and STNA #40 had gone into a room designated as requiring isolation and did not wash or sanitize their hands upon exiting the room after providing resident care services and removing meal trays from the resident's bedside table.

Based on interview, observation and record review, the facility did not ensure there was an adequate amount of staff to monitor cognitively impaired residents or that there was enough staff to provide resident care needs including toileting and answering of call lights timely. This affected four residents (Resident #5, #6, #9, and #20) of seven residents reviewed for adequate staffing to meet the needs of the residents. The facility census was 70. Findings include: 1. Review of closed medical record for Resident #20 revealed an admission date of [DATE] and discharge date of [DATE]. Her [DIAGNOSES REDACTED]. Review of the undated care plan for Resident #20 revealed she was at risk for injuries related to falls due to impaired mobility, impaired cognition, dementia and anxiety. Interventions included Broda chair (reclining chair on four wheels) for sitting balance and positioning, have commonly used items within easy reach, and provide assistance with transfers. Review of the undated care plan for Resident #20 revealed she was at risk for alteration in mood and behavior related to anxiety. Interventions included attempt to identify triggers for behavior, decrease stimulation as needed, distraction and redirection as needed and offer reassurance as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition. She required extensive assist of one person with bed mobility, and she was totally dependent of two staff for transfers and toileting. Review of the nursing note for Resident #20 dated 01/29/20 at 6:13 P.M. authored by Registered Nurse (RN) #[AGE]4 revealed she was alerted to the dining room by Licensed Practical Nurse (LPN) #[AGE]2. Resident #20 was observed on the floor on her right side. Resident #20's skin assessment noted a hematoma (occurs when blood leaks from a large blood vessel) to her right forehead and laceration a to the bridge of her nose. Interview on 02/12/20 at 9:23 A.M. and at 3:05 P.M. with LPN #[AGE]2 revealed she was the nurse on duty on 01/29/20 at approximately 5:50 P.M. when Resident #20 fell from her Broda chair. She revealed she was about 25 feet from the dining room standing by the medication cart. She revealed she was unable to visually see the dining room from where she was standing. She revealed Resident #3 alerted her to come look in the dining room. She stated she went to the dining room and observed Resident #20 lying on the floor next to her Broda chair. She revealed other residents were in the dining room, but they were sitting at the tables finishing their dinner, and she did not see any residents agitated. She stated there was not any staff in the dining room at the time of the incident. She revealed Resident #20 was lying on her affected side and had a cut to her nose and bump on her head. She indicated on 01/29/20 at the time Resident #20 fell they only had two State tested Nurse Aides (STNA's) and two nurses on the unit. She revealed the unit usually had about 45 residents, and most the residents had severe dementia and required extensive assistance and monitoring as the residents did not have safety awareness. She revealed two STNA's and two nurses on the 200 hall (secured unit) was not enough staff to safely monitor the residents. Interview on 02/12/20 at 9:35 A.M. with RN #[AGE]4 revealed Resident #20 had a tendency to push herself away from the dining room table when she was done eating and that was how staff knew she was done. Interview on 02/12/20 at 2:58 P.M. with STNA #[AGE]7 revealed she was the STNA assigned to Resident #20 on 1/29/20 at 5:50 P.M. She revealed there were only two STNA's and two nurses assigned to the unit at the time Resident #20 fell . She stated she was in the dining room and Resident #20 had scooted to the front of her Broda chair a couple times during dinner, and she had to reposition her back into the Broda chair. She stated she did not know why she was scooting herself to the edge of the chair. She revealed she was the only staff in the dining room as the other STNA was in the other dining room, and she needed to transport other residents back to their room as the residents finished dinner. She revealed she left the dining room unattended to assist other residents back to their rooms and provide care. She revealed two STNA's and two nurses was not enough staff to adequately monitor the residents on the 200 unit (secured unit) as the residents required extensive assist as well as they had severe cognitive deficits and required increased monitoring. Interview on 02/12/20 at 3:22 P.M. with STNA #[AGE]8 revealed she worked the secured unit (200-hall), and with a census of approximately 45 residents it was not possible to ensure proper monitoring of the residents when there were only two STNA's and two nurses as almost all the residents had severe cognitive impairment and often wandered into other resident's rooms, were at risk for falls, and required extensive assistance with their care needs. She revealed they often had two STNA's and two nurses and felt it was unsafe. Interview on 0[DATE] at 9:24 A.M. with the Director of Nursing verified the 200 hall was a secured unit for individuals with dementia and cognitive impairments and had a census of approximately 45 residents. She revealed 40 of the residents on the unit had a [DIAGNOSES REDACTED]. She verified on 1/29/20 at 5:50 P.M., at the time of Resident #20's fall, there were only two STNA's and two nurses on the unit assigned. 2. Review of the medical record for Resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS 3.0 assessment dated [DATE] revealed she had intact cognition. She required extensive assist of one person with bed mobility, she was totally dependent of two people to assist with transfers and was totally dependent of one person assist with toileting. She was always incontinent of bowel and bladder. Review of facility form titled, Resident *Family * Staff Concern Form, dated 12/24/19, revealed Resident #6 had a concern on [DATE] with the frequency of rounds, offering of snacks and ice water and the cleanliness of the floor she resided on. The form indicated Resident #6 was interviewed, and an in-service was provided to the staff on 12/24/19. The form indicated on 12/24/19, in the resident response section, Resident #6 was informed an in-service was being provided to staff, and Resident #6 was satisfied at this time. There was no additional documentation as follow-up after 12/24/19. Interview on 02/12/20 at 12:25 P.M. with Resident #6 revealed she was the Resident Council President. She verified she filed a concern on 12/24/19 as they were not doing rounds as she would lay in urine for prolonged period. She revealed she rang her call light, but staff took over an hour at times to answer her call light. She revealed the facility had stated they were educating the staff but that was the only intervention. She revealed the issue continued as she still was not changed timely as she rings her light when she needs changed, but it took over an hour at times for staff to answer her call light. She revealed she had brought up the concern to the Administrator several times that the issue was not resolved, but she does not do anything about it. Observation on 02/12/20 at 3:12 P.M. revealed Resident #6's call light to her room was activated. Observation revealed the call light was answered by STNA #[AGE]8 on 02/12/20 at 3:31 P.M. (19 minutes). Interview on 02/12/20 at 3:34 P.M. with STNA #[AGE]8 verified she did not know how long Resident #6's call light had been alarming. She stated they were unable to answer call lights timely at times due to not enough staff. 3. Review of the medical record for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition. He required extensive assist of one person with bed mobility and toileting. He required extensive assist of two people with transfers. Interview on 02/12/20 at 1:55 P.M. with Resident #9 revealed he had attended several Resident Council meetings and had expressed concern that his call light was not being answered timely as at times it takes staff 30 minutes to an hour to answer his call light. He revealed he had brought this concern up within the last two months at the Resident Council Meeting, and they tell him they were hiring more staff but never stated how they were going to fix the issue. He revealed his call light was still not answered timely as he was still waiting up to an hour for staff to answer it at times. He revealed the facility had not informed him of the follow-up to his concern. 4. Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS 3.0 assessment dated [DATE] revealed she had intact cognition. She required extensive assist of two people with bed mobility, transfers and toileting. She was always continent. Interview on 02/12/20 at 12:02 P.M. with Resident #5 revealed she did not feel there was enough staff as she had to wait a long time, sometimes up to one hour, before staff answered her call light. She stated she cannot go to the bathroom by herself as she needs assistance. She revealed she had been incontinent of urine because staff did not come in time. She revealed that when they come after waiting at times an hour, she then had to wait sometimes the same amount of time to be assisted off of the toilet as she rings when in the bathroom, and it takes them just as long to respond. She revealed it was hard especially on her [MEDICAL TREATMENT] days to have to sit on the toilet waiting for staff to respond as she was always tired after her treatments. She revealed this happened at least a few times a week. Interview on 02/12/20 at 2:55 P.M. with STNA #[AGE]6 revealed there was not enough staff to meet the needs of the residents. She revealed she was unable to provide adequate monitoring especially on the 200 hall as many residents had severe cognitive impairments and it was hard to monitor when they only had two STNA's for the unit. She revealed she did the best she could, but call lights do not get answered timely because she feels there was not enough staff. Interview on 02/12/20 at 2:58 P.M. with STNA #[AGE]7 revealed when there were only two aides on the 200-unit, she did not feel the residents were monitored safely, and their needs were unable to be met. She revealed many of the residents had dementia, and being on a secured unit required more staff to safely monitor the residents. She revealed call lights were not answered timely on the 100-hall unit or the 200 unit as there just was not enough staff some days. Interview on 02/12/20 at 3:05 P.M. with LPN #[AGE]2 revealed when she had two aides on the 200-unit, it was impossible to monitor the residents as they should be. She revealed almost all the residents had severe cognitive impairments and they are in and out of other's rooms, at risk for falls, and require assistance with their care needs. She revealed they often had two aides, and with two aides call lights cannot get answered timely. Interview on 02/12/20 at 4:19 P.M. with the Administrator revealed she did not have any call light audits or follow-up regarding resident concerns regarding call lights not being answered timely. She verified the expectation was to have call lights answered within five to ten minutes. She verified she did not have any further documentation regarding Resident #6's 12/24/19 concern except the in-service to staff. She did not have any documentation of checking with Resident #6 to see if her concern was resolved after 12/24/19. Review of undated Facility Assessment revealed the facility nurse ratio goal was one nurse to 20 to 35 residents and STNA ratio goal was one STNA to 12 to 20 residents. The facility assessment did not differentiate staffing levels for the 200 unit (secured unit) that had residents with severe cognitive deficits. This deficiency substantiates Master Complaint Number OH 082 and Complaint Number OH [AGE]7.

Based on interview, observation and record review the facility failed to adequately act promptly and resolve Resident Council grievances or concerns. This affected four residents (Residents #4, #6, #8 and #9) of seven residents reviewed for grievances/ concerns. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. She required extensive assist of one person with bed mobility, she was totally dependent of two people to assist with transfers and was totally dependent of one person to assist with toileting. She was always incontinent of bowel and bladder. Review of facility form titled, Resident *Family * Staff Concern Form dated 12/24/19 revealed Resident #6 had a concern on [DATE] with the frequency of rounds, offering of snacks and ice water and the cleanliness of the floor she resided on. The form indicated Resident #6 was interviewed and an in-service was provided to the staff on 12/24/19. The form indicated on 12/24/19, in the resident response section, Resident #6 was informed an in-service was being provided to staff, and Resident #6 was satisfied at this time. There was no additional documentation as follow-up after 12/24/19. Interview on 2/12/20 at 12:25 P.M. with Resident #6 revealed she was the Resident Council President. She revealed she did not feel her concerns, or the concerns of residents who attended Resident Council were addressed promptly or that the concerns were resolved. She revealed every Resident Council meeting the residents brought up concerns regarding not enough staff to meet their needs as well as call lights not being answered timely, especially having to wait over an hour at times. She verified she filed a concern on 12/24/19 as they were not doing rounds as she would lay in urine for prolonged periods of time. She revealed she rang her call light, but staff took over an hour at times to answer her call light. She revealed the facility had stated they were educating the staff but that was the only intervention. She revealed the issue continued as she still was not changed timely. She stated she rings her light when she needs changed, but it takes sometimes over an hour to answer her call light. She revealed she had brought up the concern to the Administrator several times, but she does not do anything about it. She revealed Resident #4 had brought up in a couple Resident Council meetings that she was unable to make her bed and needed help as she felt she may fall. Resident #6 stated this issue continues as she had spoken to Resident #4 after the Resident Council meetings, and Resident #4 stated she was still not getting assistance in making her bed. Resident #6 revealed Resident #8 had brought up a concern that he needed a wash cloth and towel to wash up every morning as he had to go looking for staff to receive them and at times had to wait a long time for staff to get him these items. Resident #6 revealed she had spoken to Resident #4 and he had stated he was still not getting a wash cloth or towel brought to him, and he still had to go track staff down every morning. She revealed she had informed the Administrator several times that concerns of Resident Council and other concerns were not being addressed. She revealed she had the Administrator come to her room recently to discuss the concerns not being met. She revealed the Administrator came to her room and as she was talking the Administrator was looking at her phone making her feel that she was not really listening to any of the concerns. She revealed she was never shown the Resident Council meeting minutes after a meeting, so had no idea if they put the concerns they brought up in the minutes, and she was never informed of how an issue was going to be addressed. She revealed she felt Resident Council was not useful at this facility as management did not listen to their concerns. Observation on 02/12/20 at 3:12 P.M. revealed Resident #6's call light to room was activated. Observation revealed the call light was answered by State tested Nurse Aide (STNA) #[AGE]8 on 02/12/20 at 3:31 P.M. (19 minutes). Interview on 02/12/20 at 3:34 P.M. with STNA #[AGE]8 verified she did not know how long Resident #6's call light was going alarming. She revealed at times they were unable to answer call lights timely due to not having enough staff. 2. Review of the medical record for Resident #4 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the care plan dated 02/09/17 revealed Resident #4 had a self-care deficit related to mobility impairments. Interventions included provide assistance with activities of daily living as needed based on resident needs and abilities. Review of the Resident Council Meeting Minutes dated 11/25/19 revealed Resident #4 currently makes her own bed and would like a STNA to start doing it daily because she was beginning to feel unsteady moving around the bed. Review of the Resident Council Meeting Follow-Up Reports revealed there was no follow-up report for Resident #4's concerns made at the Resident Council Meeting on 11/25/19. Review of the Resident Council Meeting Minutes dated [DATE] revealed Resident #4 continued to feel that STNAs were not making her bed often enough. The minutes revealed the Director of Nursing would remind staff that she can no longer make her own bed. Review of the physician orders [REDACTED].#4 had an order to encourage the patient to use her call light when in need of assistance with transfers and a reminder in her room to call for assistance with transfers. Review of Resident #4's quarterly MDS 3.0 assessment dated [DATE] revealed she had intact cognition. She required limited assist with bed mobility and transfers. She was unable to ambulate. Interview on 02/12/20 at 11:55 A.M. with Resident #4 revealed she had brought up in Resident Council about needing assistance in making her bed as she gets unsteady when she tried to do it. She revealed she had asked several times as she revealed she does not like a messy bed. She revealed they still do not make her bed about four to five times a week as she revealed she still had to do it even though she was afraid she may fall. Interview and observation on 02/12/20 at 1:43 P.M. revealed Resident #4 was sitting up in her wheelchair in her room and her bed was unmade. Resident #4 revealed staff had not made her bed all day, and she knew staff would not come and make her bed this late in the day. 3. Review of the medical record for Resident #8 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #8's care plan dated 07/15/19 revealed he may require assistance with activities of daily living related to cognitive impairment and disease process. Interventions included he needed assistance with bathing. Review of the Resident Council Meeting Minutes dated 11/25/19 revealed a concern was brought up regarding residents who required minimal assistance wanted towels and wash clothes offered to them daily as they had to go up to the nurses' desk to request a towel every day. Review of Resident Council Meeting Follow-Up Report revealed there was not a follow-up for the concerns brought up at 11/25/19 Resident Council Meeting regarding towels and wash clothes. Review of Resident Council Meeting Minutes dated 12/30/19 revealed a concern was brought up in November 2019 regarding residents who required minimal assistance would like towels and wash cloths offered to them daily as they are currently having to request towels at the nurse's desk. A resident at the meeting had revealed it had improved. Review of Resident #8's quarterly MDS 3.0 dated 12/31/19 revealed his cognition was not assessed. He required supervision with set-up help with personal hygiene and bathing. Interview on 02/12/20 at 1:51 P.M. with Resident #8 revealed he had brought up a concern in Resident Council regarding it was frustrating in the morning as he liked to wash up every morning but needed a towel and wash cloth. He revealed he had to go out to the nursing station and track down a staff to get a towel and wash cloth which sometimes took a long time as staff were busy. He revealed he just asked if he could get a towel and wash cloth dropped off in the morning, so he did not have to track down staff. He revealed a couple times a week he still had to track down staff to try to get a towel and wash cloth. 4. Review of the medical record for Resident #9 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition. He required extensive assist of one person with bed mobility and toileting. He required extensive assist of two people with transfers. Interview on 02/12/20 at 1:55 P.M. with Resident #9 revealed he had attended several Resident Council meetings and had expressed concern about his call light not being answered timely as at times it took staff 30 minutes to an hour to answer his call light. He revealed he had expressed this concern the last two months at the Resident Council Meeting, and they only tell him they were hiring more staff but never stated how they were going to fix the issue. He revealed his call light still was not answered timely as he still was waiting up to an hour for staff to answer his call light at times. He revealed staff had not informed him of the follow-up to his concern. Interview on 02/12/20 at 4:19 P.M. with the Administrator revealed she was aware of Resident #8's concern requesting a towel and wash cloth every morning. She revealed she did not feel it should be the expectation or was a regulation that required a facility to just freely hand out linens as linens have come up missing. She revealed the facility had wet wipes he could use as well. She verified she did not have any documentation regarding this concern being discussed with Resident #8 or any follow-up or interventions put in place regarding his preference to have a wash cloth and towel every morning. She revealed Resident #4 requested her bed be made per staff, and the Resident Council Meeting minutes had no documentation on how this was being addressed. She verified she did not have any call light audits or follow-up regarding resident concerns regarding call lights not being answered timely. She verified the expectation was to have call lights answered within five to ten minutes. She verified she did not have any further documentation regarding Resident #6's 12/24/19 concern except the in-service to staff. She did not have any documentation related to checking with Resident #6 to see if her concern was resolved after 12/24/19. Interview on 0[DATE] at 9:42 A.M. with Activities Director #[AGE]9 revealed she wrote up the minutes after the Resident Council Meeting and did not have the Resident Council President review the minutes. She did not update the Resident Council President as to the follow-up to the concerns until the next meeting as at that time they went over how the concern was addressed. She verified Resident #4 had brought up concerns regarding staff not assisting in making her bed, and she verified Resident #9 had requested towel and washcloths every morning to assist in washing up. Review of facility policy labeled, Resident Council, dated March revealed the purpose of the forum was for residents to voice their concerns. The policy revealed the Resident's Council was intended to promote resident interest and provide a forum for the residents to voice their opinions, concerns, and suggestions in the day to day operation of the facility. The policy revealed the Activities Director or Social worker would assist in the coordination of the council meeting to assure that the needs of the residents were adequately serviced. The policy did not reveal how the facility would follow up on issues or concerns brought up by residents and monitor how concerns were resolved. This deficiency substantiates Master Complaint Number OH 082 and Complaint Number OH [AGE]7.

Based on interview and record review, the facility did not ensure neurological checks were completed per protocol for Resident #20 after she sustained a fall hitting her head. This affected one resident (Resident #20) of three residents reviewed for change in condition. The facility census was 70. Findings include: Review of the closed medical record for Resident #20 revealed an admission date of [DATE] and discharge date of [DATE]. Her [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition. She required extensive assist of one person with bed mobility, and she was totally dependent of two staff with transfers and toileting. Review of nursing note for Resident #20 dated 01/29/20 at 6:13 P.M. authored by Registered Nurse (RN) #604 revealed she was alerted to the dining room by another nurse. Resident #20 was noted on the floor on her right side. She was assessed on the floor. Resident #20's skin assessment noted a hematoma (occurs when blood leaks from a large blood vessel) to her right forehead and a laceration to the bridge of her nose. RN #604 applied a treatment. Resident #20's range of motion was at baseline without rotation of her hips, and her legs were equal in length. Resident #20 displayed no pain or discomfort. RN #604 initiated neurological checks, notified Resident #20's daughter and her physician. Review of nursing note for Resident #20 dated 01/29/20 at 8:30 P.M. revealed Resident #20's family was at her bedside and requested they wanted her Primary Care Physician (PCP) #605 contacted to order x-rays to check Resident #20 for a concussion. PCP #605 ordered facial x-rays but then the family requested Resident #20 to be sent to the hospital. Resident #20 was sent to the hospital. Review of facility form labeled, Skin Grid Non-Pressure V2 dated 01/29/20 authored by RN #604 revealed Resident #20 had a hematoma to her right forehead that measured four centimeters in length and four centimeters in width. Review of facility form labeled, Neurological Assessment Flowsheet for Resident #20 revealed the instruction on the top of the form was to complete neurological checks after each fall with suspected head injury. The neurological checks were to be completed every 15 minutes for four times, then every 30 minutes for four times, then every hour for four times, then every four hours for four times, and then every eight hours for four times. Review of the Neurological Checks revealed they were completed on 1/29/20 at 5:50 P.M., 1/29/20 at 6:05 P.M., 01/29/20 at 6:20 P.M., 01/29/20 at 6:35 P.M. but then not again until 01/29/20 at 7:30 P.M. (55 minutes later). The neurological checks completed on 01/29/20 at 7:30 P.M., 01/29/20 at 8:00 P.M., and on 01/29/20 at 8:30 P.M. revealed the nurse did not assess Resident #20's right or left pupil response as the documentation was blank. The neurological check completed on 01/29/20 at 8:00 P.M. did not have a pulse rate documented as being completed. Interview on 02/12/20 at 12:10 P.M. with the Director of Nursing verified neurological checks for Resident #20 were not completed accurately per their facility protocol as Licensed Practical Nurse (LPN) #610 should have completed her neurological checks on 1/29/20 at 7:05 P.M. (30 minutes after the previous neurological check) not at 7:30 P.M. (55 minutes after the previous neurological check). She also verified there was no documentation per the neurological assessment flowsheet or the nurses notes as to LPN #610 assessing Resident #20's pupil response on 1/29/29 at 7:30 P.M., at 8:00 P.M. and at 8:30 P.M. She also verified a pulse rate was not documented as being completed for Resident #20 on 01/29/20 at 8:00 P.M. per protocol. Interview on 02/12/20 at 1:50 P.M. with Primary Care Physician (PCP) #605 revealed she was notified of Resident #20's fall that sustained a trauma to her head on 01/29/20. She revealed she was aware the nurses were completing neurological checks per the facility protocol. She verified checking a resident's pupil response was an important assessment to be completed during the neurological checks. Review of facility policy labeled, Assessment: Neurological Checks, dated (MONTH) 2006, revealed the purpose of neurological checks was to promptly recognize and accurately interpret changes in level of consciousness and other neurological symptoms after a fall with suspected head injury. Neurological checks (cranial checks) included checking a resident's level of consciousness, a resident's ability to move, a resident's pupil response, and a resident's vital signs. The policy indicated pupil responses were checked for the shape, size, and equality of the pupil as the third cranial nerve was responsible for the [MEDICATION NAME] of the pupil. The policy indicated when pressure increases the nerve would become compressed and the result of the pupil response would be decreased briskness of reaction, dilation, and eventual fixation of the pupil. The policy indicated if there was increased pressure on the medulla (part of the brain that makes up the brainstem) the resident's pulse rate would decrease. The neurological checks were to be completed after an incident every 15 minutes for four times, then every 30 minutes for four times, then everyone hour for four times, then every four hours for four times, and then every eight hours for 24 hours. The nurse was to ensure the neurological checks were charted accurately and report any noticeable changes immediately. This deficiency substantiates Master Complaint Number OH 082 and Complaint Number OH 837.

Based on interview and record review, the facility failed to ensure adequate monitoring with sufficient amount of staff to prevent Resident #20's fall from her Broda chair (a reclining chair on four wheels). This affected one resident (Resident #20) of three residents reviewed for accidents. The facility census was 70. Findings included: Review of the closed medical record for Resident #20 revealed an admission date of [DATE] and discharge date of [DATE]. Her [DIAGNOSES REDACTED]. Review of the undated care plan for Resident #20 revealed she was at risk for injuries related to falls due to impaired mobility, impaired cognition, dementia and anxiety. Interventions included Broda chair for sitting balance and positioning, have commonly used items within easy reach, and provide assistance with transfers. Review of the undated care plan for Resident #20 revealed she was at risk for alteration in mood and behavior related to anxiety. Interventions included attempt to identify triggers for behavior, decrease stimulation as needed, distraction and redirection as needed, and offer reassurance as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition. She required extensive assist of one person with bed mobility, and she was totally dependent of two staff with transfers and toileting. Review of the nursing note for Resident #20 dated 01/29/20 at 6:13 P.M. authored by Registered Nurse (RN) #604 revealed she was alerted to the dining room by Licensed Practical Nurse (LPN) #602. Resident #20 was noted on the floor on her right side. She was assessed on the floor. Resident #20's skin assessment noted a hematoma (occurs when blood leaks from a large blood vessel) to her right forehead and a laceration to the bridge of her nose. RN #604 applied a treatment. Resident #20's range of motion was at baseline without rotation of her hips, and her legs were equal in length. Resident #20 displayed no pain or discomfort. RN #604 initiated neurological checks, notified Resident #20's daughter and her physician. Review of the nursing note for Resident #20 dated 01/29/20 at 8:30 P.M. revealed her family was at her bedside, and they requested her Primary Care Physician (PCP) #605 be contacted to order x-rays to check if Resident #20 had a concussion. PCP #605 ordered facial x-rays, but then the family requested Resident #20 to be sent to the hospital. Resident #20 was sent to the hospital. Review of Self- Reported Incident (SRI) with tracking # 4 and discovery date of 01/31/20 revealed the Police Department called to inquire about Resident #20's recent fall. The police department was looking into possible allegation of physical contact made to Resident #20 due to extensive bruising to her face. The SRI revealed on 01/29/20 at 5:50 P.M. Resident #20 fell out of her Broda chair in the dining room on the memory care unit. A resident had alerted the nurse to Resident #20 being on the floor. LPN #602 immediately responded and observed Resident #20 lying on the floor on her right side of her stomach with her right side of her face on the floor. LPN #602 notified Resident #20's nurse (RN #604) who assessed her. Resident #20 had a hematoma to her right forehead and a laceration to the bridge of her nose. RN #604 revealed Resident #20 was pointing to her teddy bear that was on the floor next to her Broda chair. Interview on 02/12/20 at 9:23 [NAME]M. and at 3:05 P.M. with LPN #602 revealed she was the nurse on duty on 01/29/20 at approximately 5:50 P.M. when Resident #20 fell from her Broda chair. She revealed she was about 25 feet from the dining room standing by the medication cart. She revealed she was unable to visually see the dining room from where she was standing. She revealed Resident #3 alerted her to come look in the dining room. She revealed she went to the dining room and observed Resident #20 lying on the floor next to her Broda chair. She revealed other residents were in the dining room, but they were sitting at the tables finishing their dinner, and she did not see any residents agitated. She revealed there was no staff in the dining room at the time of the incident. She revealed Resident #20 was laying on her affected side and had a cut to her nose and a bump on her head. She revealed she alerted RN #604 as she was down the hallway. She revealed they both assessed Resident #20. She revealed on 01/29/20 at the time Resident #20 fell they only had two State tested Nurse Aides (STNA's) and two nurses on the unit. She revealed the unit usually had about 45 residents, and most of the residents had severe dementia and required extensive assistance and monitoring as the residents did not have safety awareness. She revealed two STNA's and two nurses on the 200 hall (secured unit) was not enough staff to safely monitor the residents. Interview on 02/12/20 at 9:35 [NAME]M. with RN #604 revealed Resident #20 had a tendency to push herself away from the dining room table when she was done eating and that was how staff knew she was done. Interview on 02/12/20 at 2:58 P.M. with STNA #607 revealed she was the STNA assigned to Resident #20 on 1/29/20 at 5:50 P.M She revealed there were only two STNA's and two nurses assigned to the unit at the time Resident #20 fell . She revealed she was in the dining room, and Resident #20 had scooted to the front of her Broda chair a couple times during dinner, and she had to reposition her back into the Broda chair. She revealed she did not know why she was scooting herself to the edge of the chair. She revealed she was the only staff in the dining room as the other STNA was in the other dining room, and she needed to transport other residents back to their room as the residents finished dinner. She revealed she left the dining room unattended to assist other residents back to their rooms and provide care. She revealed two STNA's and two nurses were not enough staff to adequately monitor the residents on the 200 unit (secured unit) as the residents required extensive assist as well as they had severe cognitive deficits and required increased monitoring. Interview on 02/12/20 at 3:22 P.M. with STNA #608 revealed she worked the secured unit (200-hall), and with a census of approximately 45 residents. She stated it was not possible to ensure proper monitoring of the residents when there were only two STNA's and two nurses as almost all the residents had severe cognitive impairment and often wandered into other resident's rooms, were at risk for falls, and required extensive assistance with their care needs. She revealed they often had two STNA's and two nurses and felt it was unsafe. Interview on 02/13/20 at 9:24 [NAME]M. with the Director of Nursing verified the 200 hall was a secured unit for individuals with dementia and cognitive impairments and had a census of approximately 45 residents. She revealed 40 of the residents on the unit had a [DIAGNOSES REDACTED]. She verified on 1/29/20 at 5:50 P.M. at the time of Resident #20's fall there was only two STNA's and two nurses on the unit assigned. Review of undated Facility Assessment revealed the facility nurse ratio goal was one nurse to 20 to 35 residents and STNA ratio goal was one STNA to 12 to 20 residents. The facility assessment did not differentiate staffing levels for the 200 unit (secured unit) that had residents with severe cognitive deficits. This deficiency substantiates Master Complaint Number OH 082 and Complaint Number OH 837.

Based on record review and interview, the facility failed to ensure the environment remains as free from accident hazards as possible by ensuring the bathroom floor was dry prior to transferring a resident. This resulted in actual harm to Resident #15 who suffered a fractured fibula and dislocated ankle when she fell in the bathroom. The deficient practice affected one (Resident #15) of three residents reviewed for falls. The facility census was 65. Findings: Record review revealed Resident#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of fthe admission fall risk assessment identified Resident #15 as a high risk for falls and a fall prevention plan of care was developed. Review of the nurses notes and a facility Investigation Report completed by Registered Nurse(RN) #10 dated 10/06/14 revealed State tested Nurse Aide (STNA) #9 told to RN #10 that Resident#15 was lowered to the floor in the bathroom when the resident slid out of her wheelchair. STNA #9 indicated the floor was wet which caused the resident to slide forward striking her left foot on the toilet. RN#10 documented the assessment of Resident#15 after the fall revealed an obvious deformity of the left ankle. The nurses notes and the investigation did not indicate the resident was wearing non-skid footwear or use of a shower mat. RN#10 documented the floor was wet and 911 was called to transport Resident#15 to the hospital. RN#10 documented new fall prevention interventions of a non-skid mat to bathroom floor in front of the shower and to ensure the floor was dry. Interview with the facility Administrator and Director of Nursing on 10/30/14 at 3:40 P.M. revealed Resident#15 ambulated with a walker and one person assist prior to the fall. The Administrator confirmed the bathroom floor was wet when Resident#15 fell on [DATE] and stated staff should always ensure floors are dry prior to transfer of a resident. The Administrator verified Resident#15 suffered a fractured leg bone and dislocated ankle from the fall and now was non-weight bearing on her left leg and required a Hoyer mechanical lift for all transfers. This deficiency substantiates Complaint Number OH 706.

Based on record review and interview, the facility failed to ensure fall prevention measures were in place at all times. This resulted in Actual Harm of a head laceration for Resident #69, one of three residents reviewed for falls. Findings include: Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of fall risk assessments revealed the facility assessed the resident at risk for falls on admission and quarterly and a fall prevention plan of care was developed. The fall care plan included the added intervention on 12/13/13 of alarming self-releasing seatbelt to enable the resident to think before acting out with attention seeking behaviors in which the resident throws self from wheelchair. Review of nurses notes and fall investigation report dated 01/27/14 revealed Resident #69 was found by facility staff on the floor in her room, lying on her left side. The resident's wheelchair was nearby and the seatbelt was not alarming. The resident had a four centimeter (cm) by 0.5 cm laceration to the left side of her head. The physician and family were notified and Resident #69 was sent to the hospital by ambulance, received five staples to close the laceration and returned to the facility the same day. Review of the fall investigation report revealed the facility determined a Hospice state tested nurse aide (STNA) caring for Resident #69 did not apply the self alarming seatbelt prior to leaving the room. Interview with the facility Director of Nursing (DON) on 03/04/14 at 10:30 A.M. confirmed a Hospice STNA had not applied the fall prevention intervention for Resident #69 and the resident fell and sustained a head laceration. The DON confirmed Hospice was in charge of the plan of care for Resident #69 and the Hospice STNA should have been aware of the fall prevention plan of care for Resident #69 and should have applied the seatbelt before leaving the room. This deficiency substantiates Master Complaint Number OH 774.