Every finding on record at Ivy Woods Healthcare Center.

Based on medical record review, staff interview, and review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual), the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate. This affected four (#52, #103, #46, and #92) of 19 residents reviewed for accuracy of the MDS assessment. The facility census was 89.Findings included:1. Review of the medical record revealed the facility admitted Resident #52 on 08/22/2025. Diagnosis included essential hypertension (high blood pressure). Review of Resident #52's Smoking assessment dated [DATE] revealed the resident used three to five cigarettes daily, was aware of the risks, and was independent for smoking. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2025, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Section J1300 of the admission MDS revealed code 0 and indicated Resident #52 currently used no tobacco. During an interview on 01/15/2026 at 1:30 P.M., the Executive Director (ED) reported the facility followed the RAI manual. During an interview on 01/16/2026 at 10:13 A.M., the MDS Licensed Practical Nurse (LPN) #10 revealed her process for completing the MDS was to review the admission paperwork, hospital paperwork, health history, and the in-house provider's documentation. The MDS LPN #10 stated she then completed and reviewed the MDS prior to a registered nurse signing the assessment as complete. The MDS LPN #10 stated she had missed Resident #52's smoking assessment and question J1300 was incorrectly coded. During an interview on 01/16/2026 at 1:37 P.M., the Director of Nursing (DON) said she was not familiar with all steps of the MDS completion process, but she would expect the MDS to be coded accurately and the RAI manual to be followed. Review of the RAI manual dated 10/2025 section J1300 Current Tobacco Use revealed Steps for Assessment l. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions - Code 0, no: if there are no indications the resident used any form or tobacco. - Code 1, yes: if the resident or any other source indicates the resident used tobacco in some form during the look-back period. 2. Review of the medical record revealed the facility admitted Resident #103 on 10/28/2025. Diagnoses included severe protein-calorie malnutrition and pressure ulcer of unspecified site and unspecified stage. Review of Resident #103's Wound Assessment Report dated 10/30/2025 revealed the resident admitted to the facility with partial thickness abrasions to the mid back, left shoulder, right inner knee, and left lower back; a Stage 1 (intact skin, with non-blanchable redness) pressure ulcer injury to the left lateral foot; a Stage 2 (shallow open wound) pressure ulcer injury to the left great toe; a Stage 4 (full-thickness tissue loss with exposed muscle, tendon, or bone) pressure ulcer injury to the left buttocks; and a deep tissue injury (DTI, injury to deep tissues under intact skin often at the bone-muscle interface) pressure ulcer injury to the left heel, the left ankle, and the right posterior ankle. Review of the admission MDS, with an Assessment Reference Date (ARD) of 11/05/2025, revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of five, which indicated the resident had severe cognitive impairment. Section M0300B1 indicated Resident #103 had one Stage 2 pressure ulcer, and Section M0300B2 indicated the Stage 2 pressure ulcer was not present on admission. The MDS also indicated one Stage 4 and three Unstageable Deep Tissue Injuries were present on admission/entry or reentry. During an interview on 01/16/2026 at 10:13 A.M., MDS LPN #10 revealed her process for completing the MDS was to review the admission paperwork, hospital paperwork, health history, and the in-house provider's documentation. The MDS LPN #10 stated she then completed and reviewed the MDS prior to a registered nurse signing the assessment as complete. The MDS LPN #10 reviewed section M of Resident 103's MDS and stated that the coding for the number of Stage 2 pressure ulcers present upon admission was coded incorrectly. During an interview on 01/16/2026 at 1:37 P.M., the Director of Nursing (DON) stated that she was not familiar with all steps of the MDS completion process, but she expected the MDS to be coded accurately and the RAI manual to be followed. Review of the RAI manual, dated 10/2025, Section M0300B2: Stage 2 Pressure Ulcers, revealed Coding Instructions for M0300B2- M0300B1- Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is 2. – Enter 0 if no Stage 2 pressure ulcers are present and skip to M0300C, Stage 3. M0300B2 – Enter the number of these Stage 2 pressure ulcers that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, enter the number of Stage 2 pressure ulcers that were acquired during the hospitalization (i.e.[ id est, that is], the Stage 2 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital). Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission/entry or reentry. 3. Review of the medical record revealed the facility admitted Resident #46 on 09/01/2025. Diagnosis included chronic kidney disease, Stage 4 (severe). Review of Resident #46's Care Plan Report included a focus statement initiated 09/18/2025, indicated the resident was on dialysis therapy. Interventions included Day/time: Tuesday Thursday Saturday 6:00 AM along with the dialysis center's address, phone number, transportation details, and Resident #46's dialysis access site on the right upper chest. Review of a 5-day MDS, with an Assessment Reference Date (ARD) of 09/21/2025, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Section O0110J1 Dialysis and O0110J2 Hemodialysis revealed no check marks and indicated Resident #46 did not have dialysis or hemodialysis on admission, while a resident, or at discharge. Review of a nurse practitioner's Progress Note dated 09/22/2025 revealed diagnoses included dependence of renal dialysis. During an interview on 01/16/2026 at 10:13 A.M., the MDS LPN #10 stated she reviewed information and diagnoses when a resident was admitted , set up the entry in the system, initiated the admission assessment, reviewed the payer source, built a profile, and entered information for the care plan based on verified records. The MDS LPN #10 stated she checked her information and, because she was an LPN, the regional resident assessment coordinator signed off on the MDS, indicating that the MDS was complete. The MDS LPN #10 stated Resident #46 was not on dialysis initially but went to the hospital and returned to the facility on dialysis. The MDS LPN #10 stated the hospital set up dialysis and transportation, and the facility followed the hospital's instructions. The MDS LPN #10 stated dialysis was not captured on the MDS because she did not have dialysis run sheets to verify treatment. During an interview on 01/16/2026 at 1:37 P.M., the Director of Nursing (DON) stated she did not know much about MDSs but expected the assessments to be accurate and the RAI manual to be followed. Review of the RAI manual, dated 10/2025, section O0110J1, Dialysis revealed, Code peritoneal [uses the lining of the abdominal cavity as a natural filter blood] or renal dialysis [uses a dialyzer machine to filter blood] which occurs at the nursing home or at another facility, record treatments of hemofiltration [removal of wastes by filtration of blood across a membrane], Slow Continuous Ultrafiltration (SCUF) [filtration through a semipermeable membrane allowing only the passage of small molecules], Continuous Arteriovenous Hemofiltration (CAVH) [filtration powered by the patient's arterial pressure], and Continuous Ambulatory Peritoneal Dialysis (CAPD) [dialysis through the abdomen] in this item. The manual also indicated, O0110J2, Hemodialysis – Check when the dialysis was hemodialysis. 4. Review of the medical record revealed the facility admitted Resident #92 on 07/04/2025. Diagnoses included depression, bipolar disorder, and anxiety disorder. Review of Resident #92's Notice of Preadmission Screening and Resident Review (PASRR) Level II Outcome dated 07/07/2025 revealed the resident had serious mental illness and recommended specialized services. Review of a modified admission MDS, with an Assessment Reference Date (ARD) of 07/11/2025, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Section A1500. Preadmission Screening and Resident Review (PASRR) revealed the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was answered, 0. No. On 01/14/2026 at 1:55 P.M., the Executive Director (ED) stated the facility did not have a policy for completing the MDS and followed the RAI manual. During an interview on 01/16/2026 at 10:13 A.M., the MDS LPN #10 stated she reviewed information and diagnoses when a resident was admitted , set up the entry in the system, initiated the admission assessment, reviewed the payer source, built a profile, and entered information for the care plan based on verified records. The MDS LPN #10 stated she checked her information and because she was an LPN, the regional resident assessment coordinator signed off on the MDS, indicating the MDS was complete. The MDS LPN #10 stated that the Social Services Department was responsible for completing the PASRR section of the MDS. During an interview on 01/16/2026 at 10:44 A.M., the Social Services Designee (SSD) #11 stated she completed the PASRR section of the MDS. The SSD #11 stated Resident #92 had a Level II PASRR, and it should have been captured on the MDS. The SSD #11 stated Resident #92's MDS was not accurate because she checked the wrong box and needed to re-submit the MDS. During an interview on 01/16/2026 at 2:03 PM, the ED stated she expected the MDS assessments to be accurate and the RAI manual to be followed. Review of the RAI manual dated 10/2025 section A1500 Preadmission Screening and Resident Review (PASRR) and Steps for Assessment revealed, 3. Review the PASRR report provided by the State if Level II screening was required. Coding Instructions – Code 0, no: and skip to A1550, Conditions Related to ID/DD [Intellectual and Developmental Disability] Status, if any of the following apply: - PASRR Level I screening did not result in a referral for Level II screening, or – Level II screening determined that the resident does not have a serious MI [Mental Illness] and/or ID/DD or related conditions, or – PASRR screening is not required because the resident was admitted from a hospital after requiring acute inpatient care, is receiving services for the condition for which they received care in the hospital, and the attending physician has certified before admission that the resident likely to require less than 30 days of nursing home care. – Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition.

Based on medical record review and staff and resident interview, the facility failed to provide documentation of informed consent prior to the administration of psychotropic medications. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 89.Findings included:Review of the medical record indicated the facility admitted Resident #17 on 06/07/2025. Diagnosis included major depressive disorder (recurrent, mild).Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2025, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received an antidepressant during the seven-day look-back period. Review of Resident #17's Care Plan included a focus area, initiated 06/07/2025, that indicated the resident was at risk for altered mood and behavior related to depression and anxiety. Interventions directed staff to monitor mood and behavior changes, administer medications as ordered, and provide emotional support and reassurance.Review of the Resident #17's physician order recap report dated for the timeframe from 06/01/2025 through 01/31/2026 included the following medication:- sertraline (an antidepressant) 25 milligrams (mg) one tablet by mouth one time a day, ordered 06/08/2025 and ended 06/24/2025;- sertraline 25 mg two tablets one time a day, started 06/25/2025 with no end date; and - trazodone (an antidepressant) 50 mg one-half tablet at night as needed, ordered 12/12/2025. Review of Resident #17's Medication Administration Record (MAR) dated 01/2026 revealed staff documented the resident was receiving sertraline and trazodone according to the physician orders.Review of Resident #17's record revealed no evidence of informed consent or documentation of discussion of risks, benefits, and alternatives with the resident or their representative prior to initiation or continuation of those medications.During an interview on 01/15/2026 at 10:58 AM, the Medical Records Coordinator (MRC) #14 stated she was unsure where the original consent for Resident #17's psychotropic medications was located and would have to get back with the surveyor.During an interview on 01/15/2026 at 1:20 P.M., the Regional Director of Clinical Operations (RDCO) #12 stated she was unsure where the original consent for Resident #17's psychotropic medication was located and would have to get back with the surveyor.During an interview on 01/15/2026 at 3:48 P.M., Licensed Practical Nurse (LPN) #03 stated she did not know about the consents for psychotropic medications and was unsure who was responsible but thought the provider obtained them. During an interview on 01/16/2026 at 11:45 A.M., Resident #17 stated they did not recall staff reviewing the resident's medications last month and was unsure what medications the resident took.During an interview on 01/16/2026 at 12:12 P.M., the Medical Director (MD) stated the psychiatric nurse practitioner (NP) typically reviewed psychotropic medications and discussed risks and benefits with the resident or responsible party prior to administration. The MD stated it should be documented in psychiatric NP's notes, and they were not sure why it was not there.During an interview on 01/16/2026 at 12:55 P.M., the Clinical Manager Registered Nurse (CMRN) #13 stated the psychiatric NP reviewed the medications and did the risk/benefit discussion with the resident prior to ordering the medication. The CMRN #13 stated she was unsure who would obtain consent if not the psychiatric NP. During an interview on 01/16/2026 at 1:32 P.M., the Director of Nursing (DON) stated the consent could be obtained by the nurse or admission staff, but she was unsure where it was documented. The DON confirmed psychotropic medications such as trazodone required consent and stated the psychiatric NP usually ordered all psychotropic medications. The DON stated the nurse who received the order should have obtained consent prior to ordering the medication from the pharmacy and administering the medication. During an interview on 01/16/2026 at 11:04 AM, the Executive Director (ED) stated the facility did not have a policy specific to psychotropic medications.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the comprehensive care plans included the use of bed rails. This affected two (#20 and #43) of two sampled residents reviewed for bed rail use. The facility census was 89. Findings included:1. Review of the medical record revealed the facility admitted Resident #43 on 01/29/2022. Diagnoses included unspecified convulsions, acute respiratory failure with hypoxia, and unspecified dementia without behavioral disturbance.Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2025, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required setup or clean-up assistance with rolling left and right in bed, sitting on the side of the bed and lying back down, standing, and transfers. The MDS also specified that bed rails were not used as a restraint.Review of Resident #43's physician order summary report with active orders as of 01/13/2026, included an order, dated 10/12/2021, for bilateral grab bars to the bed to enhance mobility and transfers, every shift.Review of Resident #43's Informed Consent Installation of Bed Rail or Assist Bar Not Used as a Restraint, dated 12/15/2023, recommended both right and left bedrails (position bars) were requested by the resident and recommended to promote independence with bed mobility and transfers. The document was signed by Resident #43 on 12/15/2023 but was not signed by a nurse.Review of Resident #43's January 2026 Treatment Administration Record (TAR) revealed grab bars to bed to enhance mobility and transfers every shift. Review of Resident #43's Care Plan Report, revised 09/03/2025, did not include the use of side rails or assistive grab bars.Observations on 01/12/2026 at 10:03 A.M., on 01/13/2026 at 9:45 A.M., on 01/14/2026 at 2:15 P.M., and on 01/15/2026 at 8:55 A.M. revealed Resident #43's bed with two bed canes (assistive bars to provide support) attached at the top of the bed. During an interview on 01/15/2026 at 9:25 A.M., the MDS Licensed Practical Nurse (LPN) #10 stated that if a resident had bed rails, it should be included on the resident's care plan and should include the reason for the bed rails. The MDS LPN #10 stated she must have missed the bed rails when she updated the care plan with the last assessment. During an interview on 01/15/2026 at 10:14 AM, the Divisional Director of Clinical Operations (DDCO)#15 stated use of bed rails should be included on the care plan. During an interview on 01/15/2026 at 3:48 P.M., LPN #03 stated the use of bed rails should be included on the care plan.During an interview on 01/16/2026 at 11:30 A.M., LPN #04 stated she thought bed rails should be care planned.During an interview on 01/16/2026 at 12:55 P.M., the Clinical Manager Registered Nurse (CMRN) #13 verified Resident #43 had orders for grab bars. The CMRN #13 stated the use of grab bars should be included on the care plan.During an interview on 01/16/2026 at 1:32 P.M., the Director of Nursing (DON) stated that the use of bed rails should be included on the care plan. 2. Review of the medical record revealed the facility admitted Resident #20 on 09/12/2008 and readmitted the resident on 11/23/2018. Diagnoses included hypertensive heart disease with heart failure, hemiplegia and hemiparesis following cerebral infarction (a stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD), vascular dementia, and epilepsy.Review of the MDS, with an Assessment Reference Date (ARD) of 11/20/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with rolling left to right in bed, partial/moderate assistance with standing and transferring, and supervision or touching assistance with sitting on the side of the bed and lying on the bed. The MDS also specified that bed rails were not used as a restraint.Review of Resident #20's physician order summary report with active orders as of 01/13/2026, revealed an order dated 06/04/2025 for bilateral grab bars to the bed to enhance resident mobility and repositioning every shift for safety.Review of Resident #20's Informed Consent Installation of Bed Rail or Assist Bar Not Used as a Restraint dated 12/15/2023 recommended both right and left bed rail position bars to promote independence with bed mobility and transfers. The consent was signed by the resident representative and two nurses on 12/15/2023.Review of Resident #20's Care Plan Report revised 11/26/2025 did not include the use of side rails or assistive grab bars.Observations on 01/12/2026 at 10:19 A.M., on 01/13/2026 at 2:12 P.M., on 01/14/2026 at 9:43 A.M., and on 01/15/2026 at 11:55 A.M. revealed Resident #20's bed with two bed canes positioned at the top of the bed. During an interview on 01/15/2026 at 9:25 A.M., the MDS LPN #10 stated that if a resident had bed rails, it should be included on the resident's care plan and should include the reason for the bed rails. The MDS LPN #10 stated she must have missed the bed rails when she updated the care plan with the last assessment. During an interview on 01/15/2026 at 10:14 AM, the DDCO#15 stated use of bed rails should be included on the care plan. During an interview on 01/15/2026 at 3:48 PM, LPN #03 stated that the use of bed rails should be included on the care plan.During an interview on 01/16/2026 at 11:30 AM, LPN #04 stated she thought bed rails should be care planned.During an interview on 01/16/2026 at 12:55 PM, the CMRN #13 verified Resident #20 had orders for grab bars. The CMRN stated that the use of grab bars should be included on the care plan.During an interview on 01/16/2026 at 1:32 PM, the Director of Nursing (DON) stated that the use of bed rails should be included on the care plan.Review of a facility policy titled, Plan of Care Overview, undated indicated The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to the [sic] their daily routines and goals to potentially return to a community setting.Review of a facility policy titled, Safe Use of Bed Rails, dated 02/27/2023, indicated Definitions: Bed rails: are adjustable metal or rigid plastic bars that attach to the bed. The policy also indicated, Examples of bed rails include but are not limited to: side rails, bed side rails, and safety rails; grab bars and assist bars. The policy also indicated, Documentation: a. Physician order is required b. Completion of Bed Safety Evaluation c. Consent obtained for bed rail use d. Education provided to the resident or, if applicable, resident representative and e. Care Plan for the use/need for bed rails.

Based on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to assess the use of bed rails for two (#20 and #43) of two residents sampled for use of bed rails. In addition, the facility failed to ensure bed rails were maintained. This affected one (#43) of two residents sampled for bed rails. The facility census was 89.Findings included:1. Review of the medical record revealed the facility admitted Resident #43 on 01/29/2022. Diagnoses included unspecified convulsions, acute respiratory failure with hypoxia, and unspecified dementia without behavioral disturbance.Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2025, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required setup or clean-up assistance with rolling left and right in bed, sitting on the side of the bed and lying back down, standing, and transfers. The MDS also specified that bed rails were not used as a restraint.Review of Resident #43's physician order summary report with active orders as of 01/13/2026, included an order, dated 10/12/2021, for bilateral grab bars to the bed to enhance mobility and transfers, every shift.An observation on 01/12/2026 at 10:03 A.M. revealed Resident #43 lying in bed with two bed canes attached at the top of the bed. The observation revealed the left bed cane was loose and leaning outward away from the mattress.An observation on 01/13/2026 at 9:45 A.M. revealed Resident #43's bed canes remained in place, and the left cane continued to be loose and leaned outward. An observation on 01/14/2026 at 2:15 P.M. revealed the left bed cane continued to be loose and leaned outward, creating a gap between the cane and the mattress.An observation and interview on 01/15/2026 at 8:55 A.M. revealed the left bed cane remained loose and leaned outward. Resident #43 was observed lying in bed and stated they did not use the bars and tried not to use the loose one.Review of Resident #43's Bed Safety Evaluation dated 12/06/2025 indicated the resident was capable of decision-making; was capable of using their call light; had not demonstrated poor bed mobility or difficulty sitting on the side of the bed; was able to transfer independently from bed; was not receiving medication that would require increased safety precautions; had no current medical symptoms that would require use of a bed mobility device; and no device was currently in use. The Bed Safety Evaluation did not mention any type of side rails.Review of Resident #43's Informed Consent Installation of Bed Rail or Assist Bar Not Used as a Restraint dated 12/15/2023 recommended both right and left bedrails (position bars) were requested by the resident and recommended to promote independence with bed mobility and transfers. The document was signed Resident #43 but was not signed by a nurse.Review of Resident #43's Treatment Administration Record (TAR) dated 01/2026 revealed grab bars to bed to enhance mobility and transfers every shift. Resident #43's record did not include an assessment for the use of side rails, positioning/grab bars, or canes; the risk to the resident of side rail use; or side rail alternatives that were attempted and the reasons for their failure. During an interview on 01/15/2026 at 10:00 A.M., Certified Nursing Assistant (CNA) #01 stated Resident #43 used their bed cane when standing and transferring, and she thought it was beneficial. CNA #01 stated she did not realize the bed cane was loose, and, if she had, she would have submitted a work order and notified the maintenance department. During a concurrent observation and interview on 01/15/2026 at 2:10 P.M. upon entering Resident #43's room, the Director of Plant Maintenance (DPM) #16 noted the loose bed cane and stated a work order needed to be done to tighten the rail, but he had not received one. During an interview on 01/15/2026 at 3:48 P.M., Licensed Practical Nurse (LPN) #03 stated they completed bed safety evaluations every quarter but did not realize the form did not address bed rails. LPN #03 stated Resident #43 used their bars for standing and positioning, LPN #03 stated they were not aware Resident #43's bar was loose and a work order should have been submitted. During an interview on 01/16/2026 at 1:32 P.M., the Director of Nursing (DON) stated that therapy usually did the assessment for bedrails and then therapy staff would bring the assessment to her. The DON verified the Bed Safety Evaluation did not include an assessment for the use of positioning bars. The DON stated Resident #43's positioning bars were used for repositioning. 2. Review of the medical record revealed the facility admitted Resident #20 on 09/12/2008 and readmitted the resident on 11/23/2018. Diagnoses included hypertensive heart disease with heart failure, hemiplegia and hemiparesis following cerebral infarction (a stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD), vascular dementia, and epilepsy.Review of the MDS, with an Assessment Reference Date (ARD) of 11/20/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with rolling left to right in bed, partial/moderate assistance with standing and transferring, and supervision or touching assistance with sitting on the side of the bed and lying on the bed. The MDS also specified that bed rails were not used as a restraint.Review of Resident #20's physician order summary report with active orders as of 01/13/2026, revealed an order dated 06/04/2025 for bilateral grab bars to the bed to enhance resident mobility and repositioning every shift for safety.An observation on 01/12/2026 at 10:19 A.M. revealed Resident #20 was not in the room, the resident's bed was positioned at a normal height, and two bed canes were at the top of the bed. An observation on 01/13/2026 at 2:12 P.M. revealed Resident #20 was not in the room, two bed canes were positioned at the top of the bed, and the bed canes were not loose. An observation on 01/14/2026 at 9:43 A.M. revealed Resident #20 was not in the room, two bed canes were positioned at the top of the bed, and the bed canes were not loose.An observation on 01/15/2026 at 11:55 A.M. revealed Resident #20 was not in the room, two bed canes were positioned at the top of the bed, and the bed canes were not loose. Review of Resident #20's Bed Safety Evaluation dated 12/04/2025 indicated the resident was not capable of decision-making; was not capable of using their call light; demonstrated poor bed mobility; was able to transfer independently from bed; was not receiving medication that would require increased safety precautions; had a medical symptom of left-sided weakness that required a bed mobility device; a low bed was currently being used; and the resident had not expressed a desire for an assistive device on their bed. The Bed Safety Evaluation did not mention any type of side rails.Review of Resident #20's Informed Consent Installation of Bed Rail or Assist Bar Not Used as a Restraint dated 12/15/2023 recommended both right and left bed rail position bars to promote independence with bed mobility and transfers. The consent was signed by the resident representative and two nurses on 12/15/2023.Review of Resident #20's nursing progress notes dated from January 2025 through January 2026 revealed no mention of grab bars, bed canes, bed bars, side rails, or similar devices.Resident #20's medical record did not include an assessment for the use of side rails, positioning/grab bars, or canes; the risk to the resident of side rail use; or side rail alternatives that were attempted and the reasons for their failure.During an interview on 01/15/2026 at 9:15 A.M., the Regional Director of Clinical Operations (RDCO) #12 stated they were reviewing the bed safety evaluations and trying to locate specific evaluations for bed rails.During an interview on 01/15/2026 at 10:00 A.M., CNA #01 stated Resident #20 used their bed canes to assist with bed mobility and benefited from the canes being there.During an interview on 01/15/2026 at 3:48 P.M., LPN #03 stated they completed bed safety evaluations every quarter but did not realize the form did not address bed rails. LPN #03 stated Resident #20 used their bars for bed mobility. During an interview on 01/16/2026 at 1:32 P.M., the DON stated therapy usually did the assessment for bed rails and then therapy staff would bring the assessment to her. The DON verified the Bed Safety Evaluation did not include an assessment for the use of positioning bars. The DON stated Resident #20's positioning bars were used for repositioning. During an interview on 01/17/2026 at 9:54 A.M., the Regional Director of Therapy (RDT) #17 stated nursing staff completed the bed safety evaluation on admission and referred to the therapy department if there were concerns. The RDT #17 stated the therapy department did not do routine reassessments unless there was a change in condition. She was not aware the bed safety evaluation form did not address bed rails.Review of a facility policy titled, Safe Use of Bed Rails, dated 02/27/2023, indicated Bed rails are adjustable metal or rigid plastic bars that attach to the bed. The policy also indicated, Examples of bed rails include but are not limited to: side rails, bed side rails, and safety rails; grab bars and assist bars. The policy also indicated, Policy: It is the policy of this facility to provide resident centered care that meets the safety, psychosocial, physical, and emotional needs, and concerns of the residents. [Corporate Name] prohibits the use of bed rails as a restraint. The facility will assess the residents' cognition and therapeutic need of the bed rail to assist the resident in reaching their highest potential of independence. A physician order is required to implement the use of bed rails. The policy also indicated, Procedure: 1. Assessment of residents with bed rails include: a. Level of independence with bed mobility b. Review of prior interventions and outcomes prior to the initiation of bed rails c. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms should be evaluated prior to initiation. The policy also indicated, 3. Monitoring a. Bed Safety Evaluation is completed upon admission, quarterly, and as needed such as a significant change in condition. The policy also indicated, 6. Documentation a. Physician order is required b. Completion of Bed Safety Evaluation c. Consent obtained for bed rail use d. Education provided to the resident or, if applicable, resident representative e. Care Plan for the use/need for bed rails.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the medication error rate was less than five percent. There were two medication errors out of 26 opportunities for error with a calculated medication error rate of 7.69 percent. This affected one (#01) of five residents reviewed during medication administration. The facility census was 89. Findings included:Review of the medical record indicated the facility admitted Resident #01 on 02/18/2020. Diagnoses included hemiplegia following cerebral infarction, chronic obstructive pulmonary disease (COPD), vascular dementia, and constipation.Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2025, revealed Resident #01 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment.Review of Resident #01's Physician Order Summary Report, with active orders as of 01/13/2026, revealed an order dated 12/23/2025 for ascorbic acid (vitamin C) oral tablet 250 milligrams (mg) give one tablet by mouth two times a day for supplement give with iron tablet and an order dated 04/24/2025 for senna (a laxative) oral capsule 8.6 mg, give one capsule by mouth two times a day for constipation.A medication administration observation on 01/13/2026 at 9:36 A.M., revealed Licensed Practical Nurse (LPN) #06 administered vitamin C 500 mg, one tablet and Senna Plus (docusate, a stool softener, and senna) 50/8.6 mg one tablet to Resident #01 instead of the ordered doses of ascorbic acid 250 mg and senna 8.6 mg.During an interview on 01/13/2026 at 3:17 P.M., LPN #06 stated the medication administration process was to check the resident's name, birthday, and identification band for the right patient, right dose, and right route. LPN #06 stated she compared the medication in the drawer to the computer system, which served as the medication administration record (MAR). LPN #06 stated the medication drawer contained stock supply. LPN #06 stated Resident #01 was administered Vitamin C 500 mg, and the facility had a couple of different senna medications in the medication cart. After reviewing the physician's orders, LPN #06 stated Resident #01 had an order for ascorbic acid 250 mg two times a day and acknowledged 500 mg was not the correct dose. LPN #06 provided the surveyor with the Senna Plus bottle and stated that it was the medication she administered that morning. After checking the physician's order, LPN #06 stated senna 8.6 mg was Resident #01's routine order.During an interview on 01/14/2026 at 7:19 A.M., the Director of Nursing (DON) stated the nurse should look at the MAR, check the resident, and check the medication to ensure it was correct. The DON stated she expected nurses to administer medications as the physician ordered because nurses did not have a license to prescribe medications. The DON stated she expected the medication error rate to be less than 5 percent and would prefer zero percent.Review of a facility policy titled, Medication Administration, undated indicated a. Administer medication only as prescribed by the provider. The policy also indicated f. Observe the five rights in giving each medication: i. the right resident ii. the right time iii. the right medicine iv. the right dose v. the right route.

Based on medical record review, staff interview, review of the Long Term Care Pharmacist Recommendation, and policy review, the facility failed to ensure discontinuation of physician orders were transcribed in the medical record. This affected one (#32) of five residents reviewed for Medication Regimen Review (MRR). The facility census was 89.Findings included:Review of the medical record revealed the facility admitted Resident #32 on 07/18/2025. Diagnosis included vascular dementia, unspecified severity with other behavioral disturbance.Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2025, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment.Review of Resident #32's Long Term Care Pharmacist Recommendation dated 12/18/2025 revealed under Issues/Concerns: The resident had the following active orders: Folic acid (vitamin B-9) 1 mg daily, a multivitamin, Thiamine (vitamin B1) 100 mg daily, and cholecalciferol (vitamin D3) 1000 units daily. Recommendations: To reduce medication burden and reduce the risk of adverse effects, please evaluate the above medication for discontinuation. The section Physician/Prescriber Response revealed on 01/02/2026 the Medical Director responded to discontinue all medications listed by the pharmacy consultant.Review of Resident #32's Physician Order Summary Report with active orders as of 01/12/2026 revealed an order Thiamine Mononitrate (a synthetic vitamin B1) oral tablet 100 mg give 1 tablet by mouth one time a day for supplement, started 07/19/2025.Review of Resident #32's Medication Administration Record dated 01/2026 revealed the transcription of an order for thiamine mononitrate oral tablet 100 milligram (mg), give one tablet by mouth one time a day for supplement, started 07/19/2025 at 7:00 AM with no end date indicated.During an interview on 01/16/2026 at 11:35 A.M., the Medical Director (MD) stated pharmacy reviews were completed once monthly or more as needed by the pharmacist. The MD stated the pharmacist emailed the MRR and recommendations to the Director of Nursing (DON). The MD stated they reviewed the MRR and any recommendations made. The MD stated it was their expectation for the DON to follow the recommendations and update the resident's orders. The MD verified their signature and date on Resident #32's Long Term Care Pharmacist Recommendation form and stated it was their direction to discontinue all the medications the pharmacist had recommended. The MD stated it was their expectation for the staff to discontinue those medications and contact them if clarification was needed.During an interview on 01/16/2026 at 4:07 P.M., the DON stated pharmacy recommendations were completed monthly, and they received the MRR in an email from the pharmacist. The DON stated they had the MD review the MRRs and recommendations. The DON stated they took the recommendations and changed the orders as needed in the system. The DON verified Resident #32's MRR recommendation to show the physician's response was to discontinue the medications listed. The DON verified on Resident #32's MAR the thiamine was not discontinued and was still being administered to the resident. The DON stated they were responsible for updating the orders from the MD, and they must have been pulled away at the time they updated the resident's orders and did not finish.During an interview on 01/17/2026 at 8:34 A.M., the Executive Director stated the DON was responsible to make sure the MRRs were completed, accurate, and updated in the residents' orders.Review of a facility policy titled, Medication Regimen Review, undated revealed Procedure: a. The consultant Pharmacist shall conduct a monthly medication regimen review for each resident in the facility. The policy also indicated, 3. Irregularity Reports. A. The Director of Nursing (DON) or designee will be responsible for addressing all medication irregularity reports with the medical practitioner in a manner that meets the needs of the resident. The consultant Pharmacist must provide the DON the report of Non-urgent irregularities within 72 hours of their last scheduled consultation visit for the month or sooner. Urgent or Clinically Significant Medication Irregularity is communicated the day it is observed.

Based on medical record review, observation, staff interview, review of staff training transcripts, and facility policy review, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn for one (#05) of two residents sampled for Enhanced Barrier Precautions (EBP). In addition the facility failed to clean and store nebulizer equipment after use. This affected two (#17 and #20) of four residents sampled for infection control. The facility census was 89.Findings included:1. Review of the medical record revealed the facility admitted Resident #05 on 11/18/2024. Diagnoses included gastrostomy status, systemic lupus erythematosus, and other paralytic syndrome following cerebral infarction. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2025, revealed Resident #05 had a Brief Interview for Mental Status (BIMS) score of six, which indicated the resident had severe cognitive impairment. Review of Resident #05's Care Plan Report included a focus area dated 12/23/2024 indicating the resident required Enhanced Barrier Precautions (EBP) for an indwelling medical device, a gastrostomy tube (G-tube, a tube inserted through the abdomen to the stomach for feeding or drainage). Interventions directed staff to utilize appropriate Personal Protective Equipment (PPE) during high contact care (dressing, bathing/showering, transferring in room or therapy gym, providing hygiene, changing linens, changing briefs, or assisting with toileting), initiated 04/16/2025; to provide education to the resident and resident representative as appropriate, initiated 04/16/2025; and the resident was not isolated to their room and could move about the facility freely, initiated 04/16/2025. Review of Resident #05's Physician Order Summary Report dated 01/2026, contained an order, dated 04/16/2025, for enhanced barrier precautions related to enteral (involving passing through the intestine) When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift for EBP. Review of Licensed Practical Nurse (LPN) #06's training transcript dated 01/15/2026 at 2:36 P.M., revealed completed training for EBP with a grade of 100 percent on 12/30/2025, 01/03/2025, 04/15/2024, and 08/23/2023. An observation on 01/12/2026 at 11:44 A.M. revealed an EBP sign on Resident #05's door. The EBP sign read, Stop. Enhanced Barrier Precautions, everyone must clean their hands, including before entering and when leaving the room, providers and staff must also: wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. An observation on 01/13/2026 at 8:20 A.M. revealed LPN #06 wore a mask as they entered Resident #05's room to discontinue the resident's continuous tube feeding. The observation revealed LPN #06 washed their hands, donned gloves, but did not don a gown. The observation revealed LPN #06 flushed the residents' G-tube, stopped the residents' feeding pump, disconnected the feeding tube from the G-tube, checked the placement of the residents' G-tube, and replaced the cap on the G-tube port. The observation revealed LPN #06 removed their gloves and washed their hands. During an interview on 01/13/2026 at 8:34 A.M., LPN #06 stated they only wore a gown if bodily fluids or drainage were present. LPN #06 stated staff did not wear gowns to hook up or disconnect a resident's feeding tube or to give medications through a resident's feeding tube. LPN #06 stated they received training for EBP recently. LPN #06 stated they did not realize a gown should have been worn when G-tube care was performed. During an interview on 01/16/2026 at 11:35 A.M., the Medical Director (MD) stated they expected staff to utilize a mask, gloves, and a gown with any resident on EBP. The MD stated that the importance of EBP was to prevent cross contamination and keep the resident free from unnecessary infection. During an interview on 01/16/2026 at 4:07 P.M., the Director of Nursing (DON) stated residents with a feeding tube required staff to use EBP. The DON stated staff were expected to wear gloves, a gown, and a mask for all residents on EBP. The DON stated residents on EBP were identified by a sign on their door that indicated what should be worn in the resident's room when providing high-contact care. During an interview on 01/17/2026 at 8:34 A.M., the Executive Director (ED) stated staff were expected to utilize all PPE for residents identified as needing EBP, and they expected staff to utilize a gown, gloves, and a mask when in the resident's room. The ED stated it was her expectation that staff utilize EBP when providing any type of care for Resident #05. Review of a facility policy titled, Enhanced Barrier Precautions, undated revealed PPE required - gowns and gloves. The policy also indicated, EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines including PICC [Peripherally Inserted Central Catheter], urinary catheters, feeding tubes, and tracheostomies. A peripheral IV [intravenous] line is not considered an indwelling medical device for the purpose of EBP. 2. Review of the medical record revealed the facility admitted Resident #20 on 09/12/2018 and readmitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. Review of Resident #20's Care Plan Report included a focus statement initiated 09/12/2018 for COPD that indicated the resident was at risk for shortness of breath and respiratory complications. Interventions directed staff to administer medications per provider order, initiated 09/12/2018; observe for shortness of breath, initiated 09/12/2018; and elevate the head of the bed as needed, initiated 09/12/2018. Review of Resident #20's Physician Order Summary Report dated 01/13/2026 revealed an active order started 09/22/2024 for albuterol sulfate (a bronchodilator) inhalation nebulization solution 1.25 mg/3 ml (milligrams/milliliter), 1.25 mg inhaled orally by nebulizer every six hours as needed. An observation on 01/12/2026 at 10:19 A.M. revealed Resident #20's nebulizer machine on the nightstand with the mask and medication cannister still connected, not rinsed, or stored in a bag, with dried debris visible on the mask. The observation revealed another used mask was on Resident #20's nightstand, not in a bag. An observation on 01/13/2026 at 2:12 P.M. revealed Resident #20's nebulizer machine remained on the nightstand with the mask and medication cannister on top, not bagged, with dried debris inside the mask. Observations on 01/14/2026 at 9:43 A.M. and 01/15/2026 at 11:55 A.M. revealed Resident #20's same mask in the same condition, on the nightstand, not bagged, with dried debris inside the mask. During an interview on 01/15/2026 at 3:48 P.M., Licensed Practical Nurse (LPN) #03 stated nebulizers should be rinsed and stored in a plastic bag when not in use, and, if no longer needed, the machine should be disinfected and the tubing/mask discarded. During an interview on 01/16/2026 at 11:30 A.M., LPN #04 verified the nebulizer equipment in Resident #20's room was not stored appropriately, and there was no bag to store it in. During an interview on 01/16/2026 at 12:55 P.M., the Clinical Manager Registered Nurse (CMRN) #13 stated nebulizers should be cleaned, dried, and stored in a bag after each use. The CMRN #13 stated that if discontinued, the nebulizer equipment should be removed, cleaned, and stored in the oxygen room. During an interview on 01/16/2026 at 1:32 P.M., the DON stated nebulizers should be cleaned and dried and placed in a bag after each use. The DON stated that the nebulizer machine should be removed and disinfected when the treatment was discontinued. 3. Review of the medical record revealed the facility admitted Resident #17 on 06/07/2025. Diagnoses included COPD and congestive heart failure. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2025, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #17's Care Plan Report included a focus area revised 07/02/2025 that indicated the resident had COPD with shortness of breath while lying flat. Interventions directed staff to elevate the head of the bed as needed to prevent shortness of breath while lying flat, revised 07/02/2025; monitor vitals (measurements including body temperature, heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions), initiated 06/07/2025; and observe for signs and symptoms of COPD, initiated 06/07/2025. Review of Resident #17's Physician Order Recap Report dated for the timeframe from 06/01/2025 through 01/31/2026, revealed an order for ipratropium-albuterol (bronchodilators) solution 0.5-2.5 (3) mg/3ml (milligrams/milliliter), one vial inhaled orally three times a day for wheezing for five days, started on 12/29/2025 and ended on 01/03/2026. Review of Resident #17's Medication Administration Records (MARs) dated 12/2025 and 01/2026 revealed ipratropium-albuterol was administered from 12/29/2025 through 01/03/2026. An observation on 01/12/2026 at 9:59 A.M. revealed Resident #17's nebulizer machine on the nightstand with the mouthpiece and medication cannister still connected and not stored in a bag. An observation on 01/13/2026 at 2:11 P.M. revealed Resident #17's nebulizer machine remained on the nightstand with the mouthpiece touching the surface and not bagged. An observation on 01/14/2026 at 9:45 A.M. revealed the same condition, Resident #17's nebulizer machine on the nightstand with the mouthpiece touching the surface and not bagged. An observation on 01/15/2026 at 11:55 A.M. revealed the same condition, Resident #17's nebulizer machine on the nightstand with the mouthpiece touching the surface and not bagged. An observation on 01/16/2026 at 9:39 A.M. revealed Resident #17's mouthpiece and cannister were stored in a plastic trash bag. During an interview on 01/15/2026 at 3:48 P.M., LPN #03 stated nebulizers should be rinsed and stored in a plastic bag when not in use, and, if no longer needed, the machine should be disinfected and the tubing/mask discarded. During an interview on 01/16/2026 at 11:30 A.M., LPN #04 stated that if a resident only used the nebulizer for a short time and the order was discontinued, the machine should be removed and cleaned, and the tubing and mask thrown away. During an interview on 01/16/2026 at 12:55 P.M., the CMRN #13 stated nebulizers should be cleaned, dried, and stored in a bag after each use. The CMRN #13 stated that if discontinued, the nebulizer equipment should be removed, cleaned, and stored in the oxygen room. The CMRN #13 stated equipment was changed every seven days. During an interview on 01/16/2026 at 1:32 P.M., the DON stated nebulizers should be cleaned and dried and placed in a bag after each use. The DON stated that the nebulizer machine should be removed and disinfected when the treatment was discontinued. Review of a facility policy titled, Nebulizer [a medical treatment device that converts liquid medication into a mist or aerosol, allowing for direct inhalation into the lungs] Treatments, undated indicated, Rinse the nebulizer with sterile water and allow it to air dry. Alternatively, discard it after therapy if applicable.

Based on record review, observation, staff interview, and policy review, the facility failed to follow proper techniques while providing incontinence care. The affected one (#16) of the three residents reviewed for incontinence. The facility census was 90. Findings include: Review of the medical record for Resident #16 revealed the resident was admitted on [DATE]. Diagnosis included diabetes, dementia, anxiety, and dysphagia. Review of Resident #16's care plan dated 07/19/22, revealed the resident had bladder/bowel incontinence. Interventions included checking resident for incontinence, and wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had moderate cognitive deficits and required extensive assistance with all activities of daily living (ADLs). Observation of incontinence care for Resident #16 on 06/24/24 at 3:41 P.M. with State Testing Nursing Assistant (STNA) #20 revealed the resident was observed to be incontinent of urine and stool as STNA #20 removed the resident's incontinent brief. During care, STNA #20 was observed to clean the resident from back to front with stool. Interview at the same time with STNA #20 verified she wiped Resident #16 the wrong way, but it stated it was too hard to do the correct way. Review of the 2018 facility policy titled Perineal Care Male/Female, revealed to wash perineal area wiping from front to back and wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. This deficiency represents non-compliance investigated under Complaint Number OH00154279.

Based on record review, staff interview, facility fall investigation review, and facility policy review, the facility failed to ensure appropriate care was provided to a resident to avoid a preventable fall and the facility failed provided to thoroughly investigate a resident's fall and implement interventions to prevent a similar incident. This affected one (#10) out of three residents (#10,#84, #85) reviewed for falls. The facility census was 85. Findings Include: Review of medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia malignant neoplasm of rectum, diabetes mellitus, hypertension, aphasia, insomnia, and epilepsy. Review of physician's orders dated 08/22/23 for Resident #10, revealed the resident was to be transferred via Hoyer lift for all transfers. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 10/01/23 for Resident #10, revealed the resident had severely impaired cognition. The assessment revealed Resident #10 required extensive assistance of two staff members with bed mobility and transfers. Review of the Plan of Care dated updated on 06/05/23 for Resident #10, revealed the resident had an activities of daily living (ADLs) self-care performance deficit and required assistance with ADLs due to dementia, hemiplegia, and contractures and weakness on the right side. The resident was dependent on two or more staff members for bed mobility and transfers. Review of the nurse's progress notes dated 10/24/23 at 5:20 A.M. for Resident #10 and authored by Licensed Practical Nurse (LPN) #274, revealed the resident was being assisted up by staff when the staff pulled resident, and he rolled past the staff member and rolled onto the floor on his left side parallel to the bed. The resident was assessed with no injuries and was assisted back into bed by three staff members and with the use of a gait belt. A call was made to the physician to report fall with no injuries. Review of the Situation Assessment Background Recommendation (SBAR) summary dated 10/24/23 at 5:55 A.M. for Resident #10 and authored by LPN #274, revealed resident had a change in condition related to a fall. The nursing recommendations indicated the resident should be a two-person transfer/assist. Review of a post fall evaluation/notification dated 10/24/23 at 7:30 A.M. and authored by Registered Nurse (RN)/Unit Manager (UM) #252, revealed the resident had a witnessed fall with no injuries. The resident was not transferred to the hospital, the physician and responsible party was notified and resident had no pain. Review of Fall Risk Observation Tool dated 10/24/23 at 3:37 P.M. for Resident #10, revealed the resident was a fall risk and required a total mechanical lift for all transfers due to unable to bear weight, unable to cooperate, limited in movement and heavy or obese. Review of an Interdisciplinary Team (IDT) note dated 10/24/23 at 3:41 P.M. authored by RN/UM #252, revealed Resident #10 had a witnessed fall on 10/24/23. Resident #10 was being provided care by CNA #246 when the resident was moved over too far causing CNA #246 to lower him to the floor in room. The root cause of the incident was poor judgement of surface area on mattress and the interventions included an Occupational Therapy (OT) assessment. Review of incident log dated 10/24/24 at 5:40 P.M., revealed Resident #10 had a fall and lowered to the ground by staff member. Review of the fall investigation revealed a document titled Telephone Interview 10/24/23 and authored by Director of Nursing (DON). The statement indicated Certified Nursing Assistant (CNA) #246 reported she was taking care of Resident #10 and during the morning rounds, she had to change the resident's sheets. CNA #246 reported that while the resident was on his left side (the resident's strong side), the resident started sliding out of the bed and onto the floor. CNA #246 reported she assisted the resident to the floor to prevent the resident from hitting his head. A second unknown STNA entered the room and CNA #246 left to get the nurse. CNA #246 reported after the nurse assessed the resident, the three staff members assisted the resident back in the bed. The investigation revealed no documented evidence of the resident's fall being thoroughly investigated and the appropriate interventions being implemented to prevent a similar incident. Review of the nurse's progress notes dated 10/26/23 at 2:04 P.M. for Resident #10, revealed the resident was noted with signs and symptoms of pain and swelling to the right knee. Resident #10 was assessed by Nurse Practitioner (NP) #501 and ordered an Xray of the resident's right knee and leg due to pain and swelling. Review of the nurse's progress notes on 10/27/23 at 6:50 P.M., revealed the x-ray revealed no acute fractures, dislocations were noted, and the surrounding soft tissues were normal, and results reviewed with physician. No new orders and resident's brother was updated. Interview on 11/07/23 at 4:01 P.M. with Nurse Practitioner (NP) #501 revealed she assessed Resident #10 on 10/26/23 which was two days after the fall. NP #501 stated the staff reported Resident #10 had low food intake and reports of pain in his right leg. NP #501 stated the right leg looked swollen and Resident #10 grimaced and pulled leg back when the right leg was touched. NP #501 stated the resident had an as needed (PRN) order for Tylenol (pain) in place and she ordered an order for an x-ray of the right knee. NP #501 confirmed she was not aware the staff failed to provide pain medication for Resident #10 at any time after his fall. Interview on 11/08/23 at 12:30 P.M. with the DON and Regional Clinical Nurse (RCN) #500 indicated Resident #10 had a witnessed fall and the facility determined the root cause analysis was poor judgement of the surface of the mattress while the staff was turning Resident #10. The DON and RCN #500 stated they were unable to say what this meant, and since RN/UM #252 wrote the root cause analysis, she could explain it better. The DON stated the facility does not get a statement from the on-duty nurses when a resident falls because the facility utilized the nurse's progress notes as the nurse's statement. The DON confirmed Resident #10's nursing progress notes revealed a third caregiver who assisted Resident #10 off the floor after the fall on 10/24/23, however the facility did not attempt to identify that staff member or obtain a witness statement from them. RCN #500 confirmed Resident #10 was dependent on two staff members for bed mobility and transfers. The DON verified CNA #246 was providing personal care to Resident #10 by herself when the resident fell out of his bed onto the floor on 10/24/23. Interview on 11/08/23 at 12:35 P.M. with the RN/UM # 252, revealed Resident #10's fall was due to poor judgement of the surface of the mattress while CNA #246 attempted to turn Resident #10 in the bed. RN/UM #252 stated CNA # 246 did not utilize the correct judgement of where Resident #10 was on the mattress during care, and this is why he rolled out of bed onto the floor. Interview on 11/08/23 at 8:01 A.M. with CNA# 246, revealed she provided personal care to Resident #10 and attempted to change his sheet on 10/24/23 when she rolled Resident #10 onto his weaker side, and he kept going and fell on to the floor. CNA #246 indicated she rolled the resident away from her and she was on the opposite side of the bed when Resident #10 fell on to the floor. CNA #246 confirmed she was the only staff member present during the incident. CNA#246 stated she got the nurse and another CNA, and they placed Resident #10 back into bed after lifting him from the floor. CNA #246 indicated the facility staff did not utilize a gait belt to get Resident #10 back into the bed. Review of the facility policy titled, Fall Prevention and Management, dated 06/01/22, revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs. The policy stated fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage resident's care if a fall occurs. Further review of the policy revealed an investigation should include witness statements by having staff write a statement. The policy stated the fall interventions should be added to the care plan. This deficiency represents non-compliance investigated under Complaint Numbers OH00148209.

Based on record review, staff interview, review of facility fall investigation, review of facility policy, the facility failed to timely and adequately address a resident's complaints of pain following a fall. This affected one (#10) out of three residents reviewed for pain. The facility census was 85. Findings Include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia malignant neoplasm of rectum, diabetes mellitus, hypertension, aphasia, insomnia, and epilepsy. Review of the physician's orders dated 12/17/21 for Resident #10, revealed the resident was to be monitored for pain twice day (each shift) and Tylenol (pain relief) 650 milligrams (mgs) every four hours as needed (PRN) for pain. On 08/22/23, an order for the resident to be transferred via Hoyer lift for all transfers. On 10/26/23, an order for the resident to have an x-ray completed on his right knee and leg due to pain and swelling. Review of the plan of care dated updated on 06/05/23 for Resident #10, revealed the resident had a risk for falls related to hemiplegia, an activities of daily living (ADLs) self-care performance deficit and was dependent on staff for ADLs due to dementia, hemiplegia, and contractures and weakness on the right side. The resident was dependent on two or more staff members for bed mobility and transfers. The care plan updated on 07/26/22, revealed Resident #10 had acute and chronic pain related to hemiplegia. Interventions included complete pain assessment with significant change and PRN, provide medications per orders and monitor for signs and symptoms of side effects and evaluated the effectiveness of medication. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 10/01/23 for Resident #10, revealed the resident had severely impaired cognition. The assessment revealed Resident #10 required extensive assistance of two staff members with bed mobility and transfers. Review of the nurse's progress notes dated 10/24/23 at 5:20 A.M. for Resident #10 and authored by Licensed Practical Nurse (LPN) #274, revealed the resident was being assisted up by staff when the staff pulled resident, and he rolled past the staff member and rolled onto the floor on his left side parallel to the bed. The resident was assessed with no injuries and was assisted back into bed by three staff members and with the use of a gait belt. A call was made to the physician to report the fall with no injuries. Review of the Situation Assessment Background Recommendation (SBAR) summary dated 10/24/23 at 5:55 A.M. for Resident #10 and authored by LPN #274, revealed resident had a change in condition related to a fall. The nursing recommendations indicated the resident should be a two-person transfer/assist. Review of the post fall evaluation/notification dated 10/24/23 at 7:30 A.M. and authored by Registered Nurse (RN)/Unit Manager (UM) #252 revealed the resident had a witnessed fall with no injuries. The resident was not transferred to the hospital, the physician and responsible party were notified, and resident had no pain. Review of an Interdisciplinary Team (IDT) note dated 10/24/23 at 3:41 P.M. authored by RN/UM #252, revealed Resident #10 had a witnessed fall on 10/24/23. Resident #10 was being provided care by CNA#246 when the resident was moved over too far causing CNA #246 to lower him to the floor in room. The root cause of the incident was poor judgement of surface area on mattress and the interventions included an Occupational Therapy (OT) assessment. Review of the incident log dated 10/24/24 at 5:40 P.M., revealed Resident #10 had a fall and lowered to the ground by staff member. Review of the fall investigation revealed a document titled Telephone Interview 10/24/23 from Certified Nursing Assistant (CNA) #246 and authored by Director of Nursing (DON). CNA #246 reported she was taking care of Resident #10 and during the morning rounds, she had to change the resident's sheets. CNA #246 reported that while the resident was on his left side (the resident's strong side), the resident started sliding out of the bed and onto the floor. CNA #246 reported she assisted the resident to the floor to prevent the resident from hitting his head. A second unknown STNA entered the room and CNA #246 left to get the nurse. CNA #246 reported after the nurse assessed the resident, the three staff members assisted the resident back in the bed. The investigation revealed no documented evidence of the resident's fall being thoroughly investigated and the appropriate interventions being implemented to prevent a similar incident. Review of the SBAR summary dated 10/26/23 at 2:27 P.M. for Resident #10 revealed the resident had a change in condition. The resident had decreased and/or unable to eat and /or drink adequate amounts of food or fluids and other change in conditions. The summary indicated the Nurse Practitioner (NP) was in the facility and assessed the resident. The resident was assessed to have pain and an x-ray of his right knee and leg was ordered. Review of the nurse's progress notes on 10/27/23 at 6:50 P.M. revealed the x-ray revealed no acute fractures, dislocations, and the surrounding soft tissues were normal, and results reviewed with physician. No new orders and resident's brother was updated. Interview on 11/07/23 at 4:01 P.M. with Nurse Practitioner (NP) #501 revealed she assessed Resident #10 on 10/26/23 which was two days after the fall. NP #501 stated the staff reported Resident #10 had low food intake and reports of pain in his right leg. NP #501 stated the resident's right leg was swollen and the resident grimaced and pulled his leg back when the right leg was touched. NP #501 stated the resident already had a PRN order for Tylenol in place and she ordered an order for an x-ray of the right knee. NP #501 confirmed she was not aware the staff failed to provide any pain medications to Resident #10 after his fall. Review of the October and November 2023 Medication Administration Records (MARs) for Resident #10, revealed no documented evidence the resident was administered any of his PRN ordered Tylenol when the resident complained of pain. Review of the October and November 2023 Treatment Administration Records (TARs) for Resident #10, revealed the monitoring of resident's pain was recorded each shift; however, there were no assessments of the resident's pain to include any non-pharmacological interventions completed, pain intensity, pain location, the duration of the pain, and any aggravating or alleviating factors. Interview on 11/07/23 at 12:37 P.M. with the Director of Nursing (DON) confirmed Resident #10 had a witnessed fall on 10/24/23 when a staff member rolled the resident out of bed and onto the floor while performing personal care. The DON confirmed Resident #10 was recorded as having pain on 10/26/23 and Resident #10 did not receive any of his PRN pain medications. The DON stated the facility staff would have given Resident #10 pain medications if he had pain, however, Resident #10 did not have pain. The DON confirmed the nurse documented Resident #10 had signs and symptoms of pain on 10/26/23 two days after his fall. The DON stated that was because Resident #10's family visited on 10/26/23 and reported Resident #10 had pain. The DON indicated no one questioned the family regarding the reason they thought Resident #10 had pain and no staff assessed the resident for pain. The DON stated Resident #10 was assessed by the NP on 10/26/23 as having pain and swelling to his right leg and the NP ordered an x-ray. The DON indicated the nursing staff monitored Resident #10 for pain twice daily by looking for signs of pain such as grimacing and other non-verbal indicators due to Resident #10 being nonverbal. The DON verified there was no documented evidence that the resident's pain was assessed to include any non-pharmacological interventions completed, pain intensity, pain location, the duration, and aggravating or alleviating factors. Interview on 11/08/23 at 8:01 A.M. with CNA# 246, revealed she provided personal care to Resident #10 and attempted to change his sheet on 10/24/23 when she rolled Resident #10 onto his weaker side, and he kept going and fell on to the floor. CNA #246 indicated she rolled the resident away from her and she was on the opposite side of the bed when Resident #10 fell on to the floor. CNA #246 confirmed she was the only staff member present during the incident. CNA#246 stated she got the nurse and another CNA, and they placed Resident #10 back into bed after lifting him from the floor. CNA #246 indicated the facility staff did not utilize a gait belt to get Resident #10 back into the bed. Review of the facility policy titled, Pain Management Assessment, undated, revealed it was the policy of the facility to provide resident centered care that meets psychosocial, physical, and emotional needs of the residents. Further review of the policy revealed the clinician must accept the resident's report of pain. Review of the facility policy titled, Fall Prevention Management, dated 06/01/22, revealed the facility manages a Residents care after a fall. The policy stated after a Resident has a fall, the resident should be assessed for pain. This deficiency represents non-compliance investigated under Complaint Number OH00147503 and is an example of continued noncompliance from the survey dated 10/05/23.

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide pain management interventions in accordance with the resident's care plan. This resulted in Actual Harm to Resident #139 who had traumatic burn wounds to her bilateral lower extremities and was not medicated for pain prior to wound care which resulted in the resident exhibiting signs of severe pain. This affected one resident (#139) of three residents reviewed for pain management. The facility census was 90 residents. Findings include: Review of the medical record for Resident #139 revealed an admitted [DATE] with diagnoses of cellulitis and open wounds of the lower legs. Review of an admission nursing progress note for Resident #139 dated 09/29/23, revealed the resident was alert and oriented and was able to make her needs known. Review of the care plan for Resident #139 dated 09/29/23, revealed the resident had complaints of acute/chronic pain and/or was at risk for pain. Interventions included the following: administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice/heat, music therapy, relaxation techniques, imagery), complete a pain assessment on admission/re-admission, quarterly, significant change, and as needed, and follow the physician orders for complaint of pain. Review of the physician's orders for Resident #139 dated 09/29/23, revealed the resident was ordered to receive Tylenol 650 milligrams (mg) every six hours as needed (PRN) for pain. Resident #139 had no other pain medications ordered. Review of the physician's orders for Resident #139 dated 09/30/23, revealed the resident was ordered to have wounds to lower extremities cleansed with normal saline and patted dry, Santyl applied to wounds, Dakin's-soaked gauze applied, and wrapped with Kerlix gauze once daily. Review of the progress note for Resident #139 dated 10/03/23 and authored by nurse practitioner (NP) #104, revealed the resident had burn wounds to her lower legs related to a motorcycle accident. The left lower leg was a full thickness wound which measured 16 centimeters (cm) in length by 9 cm in width by 0.2 cm in depth. The wound contained slough tissue and had a scant amount of serosanguinous drainage. The right lower leg was a full thickness wound which measured 16 cm in length by 9 cm in width by 0.2 cm in depth. The wound contained slough tissue and had a scant amount of serosanguinous drainage. The resident's wound pain at rest was seven on a scale of one to 10 (zero being no pain and 10 being the worst pain.) NP #104 recommended the resident should receive pain medication prior to dressing changes as the wounds were quite tender with dressing removal. The primary provider should order and manage the pain medications. Observation of wound care on 10/03/23 at 12:55 P.M. per Registered Nurse (RN) #06 and NP #104 revealed as the nurse was removing the ace wrap covering the dressings to Resident #139's lower legs, she asked the resident if she was having any pain to her legs and the resident said the pain was a seven out of 10. Resident #139 confirmed she had not received any pain medication on 10/03/23. RN #06 told the resident she would try to be gentle. As RN #06 began removing the gauze from the old dressing it was stuck to the resident's skin and the resident cried out in pain and began cursing. The resident apologized for cursing but said when the nurse made contact with the wounds the pain increased to 10 out of 10 scale. As RN #06 continued the various steps in the dressing change such as cleansing the wound, applying Santyl, and applying the Dakin's gauze, the resident continued to curse and express extreme discomfort. NP #104 measured the resident's wounds after RN #06 removed the old dressings. Interview with RN #06 on 10/03/23 at 1:15 P.M., confirmed Resident #139 had not received any pain medication prior to the dressing change and the resident had Tylenol ordered for pain PRN. Interview with NP #104 on 10/03/23 at 1:17 P.M., confirmed this was the first time she had seen Resident #139's wounds, and she was going to recommend that resident receive pain medication prior to dressing changes and that the resident might need a stronger medication than Tylenol as the wounds were full thickness burn wounds, and resident showed signs of severe pain during the procedure. Interview with Resident #139 on 10/03/23 at 1:20 P.M., confirmed when she had her wound dressings changed in the hospital, they always gave her a pain pill before her dressing change to her legs and she did not know why they did not offer that in the facility. Resident #139 apologized again to the surveyor for cursing during the dressing change but said she could not help herself because it hurt so badly. Review of the October 2023 Medication Administration Record (MAR) for Resident #139 revealed the resident had not been administered any Tylenol on 10/03/23. Review of the undated facility policy titled Pain Management and Assessment revealed the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the resident's comprehensive care plan, and the resident's choices, related to pain management. There was no objective test that could measure pain, and the clinician must accept the resident's report of pain. Factors such as activities, care, or treatment could precipitate or exacerbate pain.

Based on record review and staff interview, the facility failed to have the Medical Director in attendance at the Quality Assurance and Performance Improvement (QAPI) meetings. This had potential to affect all 90 residents who resided in the facility. Findings include: Review of the QAPI quarterly meetings sign-in sheets dated 10/22/22, 01/15/23, 04/19/23 and 08/09/23, revealed no documented evidence the Medical Director attended the meetings. Interview with the Administrator on 10/05/23 at 2:32 P.M. verified the Medical Director did not attend the QAPI meetings on 10/22/22, 01/15/23, 04/19/23 and 08/09/23. The Administrator reported the Medical Director was required to attend all the QAPI Meetings as part of the required attendees.

Based on record review, observations, staff interviews, review of resident's diet lists, and review of facility policy, the facility failed to provide menus as planned by a Registered Dietitian (RD). This affected 13 Residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69, and #06) of the 13 residents observed in the main dining room. The facility also failed to provide appropriate substitutions to residents. This affected four residents (70, # 53, #38 and #07) of the four residents identified by the facility as receiving puree diets. The facility census was 90. Findings Include: 1. Observation of the initial dining service in the main dining room on 10/04/23 from 12:00 P.M. through 12:30 P.M. revealed all 13 residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) received a four ounce (one-half cup) serving of salad. Review of the menu spreadsheet dated 10/04/23 revealed residents on regular diet, 2-gram sodium diet, carbohydrate-controlled diet and dysphagia advanced diets were ordered to receive eight ounces (one cup) of salad during the lunch meal service. Review of a facility document titled Resident Diet Listing revealed residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) were listed as being ordered to receive eight ounces (one cup) of salad. Observation and interview on 10/04/23 at 12:30 P.M with Diet Manger, (DM) #55 verified the salad portion served to the 13 residents in the dining room was a four-ounce serving of salad and should have been an eight-ounce portion. The DM #55 stated the serving bowl used for the residents in the dining was a four-ounce bowl instead of an eight-ounce bowl. 2. Observation of the lunch tray line service on 10/04/23 from 12:00 P.M. through 12:30 P.M revealed residents (#70, # 53, #38 and #07) received pudding. The facility identified four residents (#70, # 53, #38 and #07) who were ordered to receive puree consistency diets. Review of the menu spreadsheet dated 10/04/23, revealed the four residents on puree diets should have received puree mandarin oranges. Review of the substitution log dated 10/04/23 revealed no entry of a substitution for puree mandarin oranges. Interview on 10/04/23 at 12:30 P.M. with DM #55, verified the residents with a puree order received pudding instead of the planned menu of puree mandarin oranges. DM #55 verified the mandarin oranges should have been prepared as per the puree mandarin orange recipe. DM #55 verified the puree mandarin orange recipe was not available for the cook to prepare. DM #55 stated the substitution had not been approved by the RD or recorded on the substitution log. Interview with RD #110 on 10/05/23 at 10:4 A.M., verified all meals are to be provided as listed on the menu and all substitutions were to be approved by the RD and must be listed on the substitution log. RD #110 verified she had not been contacted on 10/04/23 regarding a substitution of pudding for the mandarin oranges. RD #110 stated the puree mandarin oranges should have been prepared for the residents receiving puree diets and stated the pudding was not a like substitution for mandarin oranges. Review of the undated facility policy titled Menus revealed menus will be served as written, and the RD approves the menus. A substitution log would be maintained.

Based on record review, observation and staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 89 residents who received food from the kitchen. The facility census was 90. Findings include: 1. Observations of the kitchen on 10/02/23 from 9:05 A.M. through 12:30 P.M. revealed the following: a. There was a trash can under the preparation (prep) sink that had no lid and was full of food debris and trash. b. The 100-A, 100-B, 200-A, and 200-B unit meal delivery carts were noted to have a large buildup of brownish food debris in the corners and sticky substances on the interior cart racks where meal trays were being stored during delivery. During lunch meal service, staff were observed placing the resident's food tray in the dirty carts and the trays being delivered were observed touching the soiled areas of the food carts racks. c. Numerous ceiling tiles directly above the stove were soiled with brownish substances which appeared to be from splatters. d. Two air vents above the dish machine area where clean dishes had exited the dishwasher were noted to have a build-up of black fuzz around the vents and on the ceiling. e. There was a three-foot-long area of black, wet substance consistent with the appearance of mold along the dish machine dish rack table and the caulking seal was missing along the strip. f. There was a large build-up of brownish looking substance on the pipes and along the floor under the three- compartment sink. g. An unsecured electrical wire was hanging from the ceiling and identified by the kitchen staff as being the main electrical power source for the steam table had dark fuzzy substance on the cord and hanging from the cord. The electric cord was hanging directly over one side of the steam table where lunch was being served from. Interview with Dietary Manager (DM) #55 on 10/05/23 at 11:50 A.M., verified the observations of the kitchen on 10/02/23. The DM #55 stated the Cleaning Schedule form was to be completed by staff daily and once a week for areas of delivery carts cleaning, dishwasher area, floors, and sinks. The DM #55 was unable to show documentation of any cleaning records or when the kitchen areas were last cleaned. 2. Observation of the 200-unit refrigerator on 10/05/23 at 12:00 P.M. revealed a sign posted on the exterior part of the refrigerator which noted the refrigerator was only for the residents use and all resident foods were to be labeled and dated, and foods were to be discarded after seven days. Observation of the refrigerator included a container of food unlabeled and undated, unrecognizable food dated 09/27/23, food appeared to be some type of meat unlabeled and undated, two resident named foods undated, and an opened 64-ounce juice container undated and a pizza box containing pizza unlabeled and undated. Interview at the same time with Licensed Practical Nurse, (LPN) #33, verified the resident refrigerator was only to be used by residents and indicated all foods must be labeled and dated. LPN #33 verified the contents of the refrigerator. LPN #33 indicated the refrigerator was used for all 89 residents who received from the kitchen. Review of the undated facility policy titled Environment, the Dining Service Director will ensure the kitchen is maintained in a clean and sanitary manner including floors, ceilings, sanitizing equipment, and food contact surfaces. The Director will ensure a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All trash will be contained in cover containers. Review of the undated facility policy titled Storage of Resident Food, revealed refrigerators will be monitored daily and containers will be dated, and food discarded when no longer safe.

Based on observation and interview, the facility failed to maintain essential kitchen equipment in a safe and sanitary condition. This affected all 89 residents who received meals from the kitchen. The facility total census was 90. Findings include: Observation of the kitchen on 10/04/23 at 12:00 P.M., revealed the steam table had electrical wires in three sections hanging two inches below the back covering. There was an on/off switch inside the lower cabinet and all four temperature control knobs were missing. The steam team table had a brownish, sticky substance covering most of the steam table. Continued observation revealed the renal diet ravioli appeared to be dry and sticking to the steam table pan. Interview with Cook #64 on 10/04/23 at 12:45 P.M. verified food dries out quickly on the steam table as the temperature knobs are not available to control the steam temperature. She verified the ravioli was dry and stuck to the pan, making it less palatable. Interview with the Diet Manager (DM) #55 on 10/04/23 at 12:50 P.M. verified the hanging wires should not be exposed and should be up under the steam table panel. The DM #55 stated the control knobs had been missing for years and an on/off switch was installed. The on/off switch had the steam table on high temperature at all times or turned off. There were no controls to permit warming of the food at various temperatures. The DM #55 verified the steam table had baked on, non-cleanable substance and it was so old, it could not be cleaned. There were no manufacture directions available to review the replacement of the control knobs or cleaning instructions. DM #55 indicated there was no facility policy for maintaining essential kitchen equipment.

Based on record review, observation, resident interview, and review of facility policy and documents the facility failed to ensure residents were treated with dignity and respect. This affected two residents (#28 and #81) of the 18 residents sampled. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) During a random observation on 10/02/23 at 9:49 A.M., revealed Housekeeper #105 passed by Resident #28's door and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M. confirmed Housekeeper #105 routinely addressed him in this manner, and he felt it was disrespectful. Resident #28 confirmed he usually responded to Housekeeper #105 in a joking manner and called her dark and lovely whenever she called him light skin. Resident #28 confirmed he had been dealing with people making comments about his skin color since childhood and he had just given up on trying to get people to stop talking to him this way. Resident #28 confirmed he wanted to be called by his first name or by mister followed by his surname and he did not want staff or anyone to make remarks about his skin color. Interview with Housekeeper #105 on 10/02/23 at 9:59 A.M. confirmed she had called out, Hey, light skin, to Resident #28 as she passed by his room. Housekeeper #105 confirmed she usually referred to Resident #28 in this manner, and she presumed it didn't bother him, because he would often respond by calling her dark and lovely. Interview with the Administrator on 10/02/23 at 10:10 A.M. confirmed she was not aware Housekeeper #105 referred to Resident #28 by anything other than his name. Administrator confirmed Resident #28 had not reported any concerns regarding Housekeeper #105. Surveyor relayed to the Administrator the observation of the interaction between Housekeeper #105 and Resident #28 and the interviews obtained both with resident and employee. Administrator confirmed Housekeeper #105's conduct did not sound appropriate and she would address the concern immediately. Review of facility document titled Professionalism In-Service for Housekeeper #105 presented by Corporate Housekeeping Supervisor (CHS) #106 dated 10/02/23 revealed Housekeeper #105 had signed the document which defined unprofessional behavior as discourteous, racist, rude, uncouth communication. Employees were expected to communicate with residents in a respectful manner. Interview with CHS #106 on 10/03/23 at 12:26 P.M. confirmed Housekeeper #105 told her she usually called Resident #28 light skin and he would often respond by calling her dark and lovely. CHS #106 confirmed she gave Housekeeper #105 an in-service on professionalism on 10/02/23. Review of the facility policy titled Resident Rights revealed residents will be treated with dignity and respect. Staff will speak respectfully to residents. 2. Review of the medical record for Resident #81 revealed an admitted [DATE] with diagnoses including atherosclerosis, cocaine use, hypertension (HTN), malignant neoplasm of the esophagus, dysphagia, and anemia. Review of the MDS assessment for Resident #81 dated 09/15/23, revealed the resident was cognitively intact and required supervision and set up help of one staff with ADLs. Review of the facility document titled Concern Form dated 09/18/23 for Resident #81, revealed the resident was upset that his clothing was marked with permanent marker and his last name showed through his lighter items of clothing. Further review of the concern form revealed the items would be replaced by the facility, but the resident expressed he wanted identical items, and the facility was unable to find the same items. Observation on 10/02/23 at 12:38 P.M. revealed Resident #81 had seven shirts hanging in his closet, and the resident's last name could be read through the clothing. Interview with Resident #81 on 10/02/23 at 12:38 P.M., confirmed the facility staff took his clothes down to the laundry and wrote his last name in each article of clothing using a black permanent marker. Resident #81 confirmed he was embarrassed to wear the seven lighter-colored shirts because his name showed through, and he thought it looked undignified. Interview with Laundry Supervisor (LS) #103 on 10/03/23 at 2:56 P.M., confirmed the laundry aides had written Resident #81's name on all of his clothing upon admission with a permanent marker and the name was visible on the lighter colored items. LS #103 confirmed he had heard Resident #81 was upset that his name showed through his clothing. Review of the facility policy titled Personal Clothing dated 06/2016 revealed all clothing must be labeled in a manner that is both practical and respects the dignity of the resident.

Based on record review, observation, resident interview, and staff interview the facility failed to ensure residents had appropriate bedding and mobility devices to accommodate resident needs. This affected one resident (#140) of 18 residents sampled. The facility census was 90 residents. Findings include: Review of the medical record for Resident #140 revealed an admitted [DATE] with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute respiratory failure (ARF) with hypoxia. Review of the admission weight record for Resident #140 dated 09/29/23 revealed the resident weighed 350 pounds and was 71 inches tall. Review of an admission note for Resident #140 dated 09/29/23, revealed the resident had bilateral wounds to the lower extremities and his legs were wrapped. Review of a nurse progress note for Resident #140 dated 09/30/23, revealed the resident was up in a wheelchair, and he required assistance of two staff to transfer from bed to chair. Observation of Resident #140 on 10/02/23 at 9:50 A.M., revealed the resident was lying in bed with a standard sized mattress. The bed did not appear to be large enough to accommodate the resident's height and weight. There was a bariatric wheelchair without footrests in the resident's room. Interview with Resident #140 on 10/03/23 at 9:50 A.M. confirmed he was admitted on [DATE] from the hospital and he required a bariatric bed. Resident #140 confirmed the bed provided by the facility was too small and was very uncomfortable for him. Resident #140 confirmed the facility staff told him they had ordered a bariatric bed for him, but it hadn't arrived yet. Resident #140 confirmed he had wounds to both lower extremities and he wanted to be able to use the wheelchair for long distances such as going to the smoke area or the dining room, but the wheelchair didn't have footrests. Resident #140 confirmed he needed footrests when being pushed in the wheelchair due to his lower extremity wounds. Interview with Maintenance Director (MD) #69 on 10/03/23 at 2:51 P.M. confirmed Resident #140 was admitted on [DATE] and the facility did not have a bariatric bed available. MD #69 confirmed the facility ordered a bariatric bed for Resident #140 which had arrived in the afternoon of 10/03/23. MD #69 confirmed the facility had ordered footrests for Resident #140's wheelchair, but they had not arrived yet.

Based on record review, staff interview, and review of the facility policy the facility failed to ensure residents had their advanced directives /code status noted in the medical record. This affected two residents (#28 and #21) of the four residents sampled for advanced directives. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the hospital note for Resident #28 dated 06/17/22 revealed resident's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of the care plan for Resident #28 dated 06/28/22 revealed the resident's code status was DNRCC. Interventions included the following: code status will be established at time of admission/readmission and will be reviewed quarterly and as needed, obtain copies of advanced directives from resident / resident representative to have on file, obtain medical provider order for code status, and obtain the state specific form regarding code status. Review of the physician orders for Resident #28 dated 12/02/22 revealed an order which indicated the resident's code status was Do Not Resuscitate (DNR.) There was no additional information included in the order regarding whether the resident was a DNRCC or DNRCC-Arrest. Observation of Resident #28's paper medical record on 10/02/23 at 1:55 P.M. revealed the record did not contain a copy of his advanced directives, or the state of Ohio DNR form signed by the physician to indicate whether residents was a DNRCC or DNRCC-Arrest. Interview on 10/02/23 at 1:55 P.M. with Licensed Practical Nurse (LPN) #115 confirmed Resident #28's electronic medical record indicated he was a DNR, but the record did not indicate if he was a DNRCC or DNRCC-Arrest. LPN #115 confirmed Resident #28's hard medical chart did not include a copy of his advanced directives, the state of Ohio DNR form signed by the physician to indicate whether residents was a DNRCC or DNRCC-Arrest. Interview on 10/02/23 at 2:38 P.M. with Social Worker (SW) #43 confirmed the facility could not locate the advanced directives and the state of Ohio form for Resident #28 but his hospital note dated 06/17/22 indicated the resident was a DNRCC-Arrest. SW #43 confirmed the facility needed to get clarification from the resident and the physician regarding resident's correct code status. 44083 2. Review of the medical record for Resident #21 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: encephalopathy, rhabdomyolysis, pressure right heel, right hip, atrial fibrillation, disease, and schizoaffective disorder. Review of the code status documents dated 08/01/23 for Resident #21 and provided by Social Service Designee, (SSD) #43, revealed the document was signed on 08/01/23 by the physician and the code status was a DNRCC. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13. Review of the care plan dated 09/11/23 for Resident #21, revealed there was a DNR code status and no further specific orders regarding the code status. Interventions included to be the code status to be reviewed quarterly and as needed and to obtain medical order for code status. Review of the physician orders dated 08/02/23 for Resident #21, revealed a code status order of DNR and no other specific direction for the code status. Interview on 10/05/23 at 2:30 P.M. with SSD #43 verified Resident #21's code status order did not have the complete code status needed for staff to reference during an emergency. The signed code status was not available in the electronic medical chart for staff reference. Review of the undated facility policy titled Advanced Directives revealed each resident should have an advanced directive; copies will be made and placed on the hard chart medical record as well as communicated to the staff.

Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure staff honored the residents' right to privacy by failing to knock prior to entering the resident's room and the resident's bathroom. This affected two residents (#09 and #140) of 18 residents sampled. The facility census was 90 residents. Findings include: Review of the medical record for Resident #09 revealed an admitted [DATE] with a diagnosis of peripheral vascular disease (PVD), diabetes mellitus (DM), alcoholic cirrhosis of the liver, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #09 dated 08/16/23 revealed the resident was cognitively intact and required limited assistance of one staff with activities of daily living. Review of the medical record for Resident #140 revealed an admitted [DATE] with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute respiratory failure (ARF) with hypoxia. Interview on 10/03/23 at 9:50 A.M. of Resident #140 confirmed staff did not always knock prior to entering his room especially if the door was open. Observation on 10/03/23 at 9:54 A.M. revealed State tested Nursing Assistant (STNA) #17 entered Resident #140's room without knocking and walked to the other side of the room and retrieved a bag of linen off the nightstand of Resident #140's roommate who was not in the room. Surveyor was standing in the room interviewing Resident #140 when STNA #17 entered the room. The door to the room was open per the resident's preference. Surveyor questioned STNA #17 regarding why she didn't knock prior to entering, and STNA #17 walked back to the door and knocked on it. Then STNA #17 opened the door of Resident #140's bathroom without knocking. Resident #140's room shared a bathroom with the adjoining room which was Resident #09's room. Resident #09 had his pants down and was sitting on the commode when STNA #17 opened the bathroom door without knocking. STNA #17 shut the bathroom door without saying anything and then asked Resident #140 if she could get his weight later. Resident #140 said yes. STNA #17 then exited Resident #140's room. Interview on 10/03/23 at 10:00 A.M. of STNA #17 confirmed she did not knock prior to entering Resident #140's room and wait to be invited into the room nor did she knock prior to opening the bathroom door to Resident #140's room. STNA #17 confirmed Resident #09 was sitting on the commode with his pants down when she opened the bathroom door without knocking. Review of the facility policy titled Resident Rights undated revealed staff will knock before entering a resident's room.

Based on record review, observation, resident interview, and staff interview the facility failed to ensure resident room furnishings were in good repair and properly functional. This affected two residents (#18 and #06) of 18 residents sampled. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #81 revealed an admitted [DATE] with diagnoses including atherosclerotic, cocaine use, hypertension (HTN), malignant neoplasm of the esophagus, dysphagia, and anemia. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #81 dated 09/15/23 revealed the resident was cognitively intact and required supervision and set up help of one staff with activities of daily living (ADLs.) Observation of Resident #81's room on 10/03/23 at 12:41 P.M. revealed the resident's foot board was broken and had a jagged edge exposed approximately one foot in length. Resident #81's closet door had a hole in it which measured approximately three inches in diameter and the electrical outlet in the resident's bathroom was non-functional. Interview of Resident #81 on 10/03/23 at 12:41 P.M., confirmed the foot board was broken when he was admitted , and the hole was in the closet door upon admission. Resident #81 confirmed the electrical outlet had not been working since he was admitted , and he was unable to use his electric razor in the bathroom in front of the mirror. Observation of Resident #81's room on 10/03/23 at 1:28 P.M. with Maintenance Director (MD) #69, confirmed he had not received any recent work orders for Resident #81's room. MD #69 confirmed Resident #81's foot board had a jagged edge exposed and should be replaced. MD #69 confirmed the hole in Resident #81's closet door should be repaired. MD #69 confirmed Resident #81's outlet was nonfunctional and should be repaired. 2. Review of the medical record for Resident #06 revealed an admitted [DATE] with a diagnosis of dementia without behavioral disturbance. Review of the MDS assessment for Resident #06 dated 07/12/23, revealed the resident was cognitively intact and required supervision with ADLs. Observation of Resident #06's room on 10/03/23 at 7:23 A.M. with Licensed Practical Nurse (LPN) #56, revealed the cover of resident's mattress was peeling and had multiple tears in it. Interview with Resident #06 on 10/03/23 at 7:23 A.M., confirmed she had the same mattress for years and it had multiple tears in the cover, and there was diffuse peeling observed to the surface of the mattress. Interview with LPN #56 on 10/03/23 at 7:24 A.M., confirmed Resident #06's mattress was peeling and probably should be replaced. Interview with MD #69 on 10/03/23 at 2:51 P.M. confirmed Resident #06's mattress was in a state of disrepair and should be replaced. MD #69 confirmed he had not received any recent work orders regarding Resident #06's mattress.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, review of a self-reported incident (SRI), review of the hospital records, review of the facility investigation, review of personnel files, and policy review, the facility failed to ensure residents were appropriately transferred from the bed to the geriatric chair with a mechanical lift resulting in an avoidable fall. This resulted in Actual Harm when State tested Nurse Aide (STNA) #01 failed to use the mechanical lift pad as directed and failed to ensure there were two staff members present for the transfer with the mechanical lift resulting in Resident #48 falling from the mechanical lift and hitting the left side of her head on the chair and mechanical lift causing bruising to the left side of her face and a subdural hematoma. This affected one resident (#48) of three reviewed for accidents. The census was 48. Findings include: Review of Resident #48's medical record revealed the resident was admitted on [DATE]. Diagnoses included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non dominant side, [CONDITION(S)] following cerebral infarction, [CONDITION(S)] due to excess calories, muscle weakness, [CONDITION(S)], acute [CONDITION(S)] with [CONDITION(S)], asthma, dysphagia oropharyngeal phase, other seizures, abnormal posture, pain in left knee, contracture left hand, [CONDITION(S)] and delusional disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive of two plus person assistance with bed mobility, transfers, and toileting. The resident also required extensive one person physical assist with dressing and eating and total dependence with one person physical assistance with personal hygiene. Review of the fall risk assessment dated [DATE] revealed the resident had fallen one to two times in the past six months and was at high risk for falls. Review of the progress note dated 03/22/21 revealed Licensed Practical Nurse (LPN) #22 was in morning meeting when an STNA alerted her that two STNAs had been getting Resident #48 up from the bed to her geriatric chair when Resident #48 had slipped out of the mechanical lift pad and hit her face on the mechanical lift. Resident #48 was noted to have a bruise on her eye. Upon entering Resident #48's room, Resident #48 was found to be laying on the floor with a pillow under her head. Resident #48 had an evident bruise above her left eye. Vitals were taken and were within normal limits. Range of motion was within normal limits for the resident. Resident #48 was assisted back to her bed using a mechanical lift and two STNAs. Resident #48's physician and power of attorney were notified. Review of the progress note dated 03/22/21 at 8:19 A.M. revealed Resident #48 was admitted to the hospital with a subdural hematoma and would be transferred to another hospital for treatment. Review of Resident #48's progress note dated 03/25/21 at 5:01 P.M. revealed Resident #48 returned to the facility around 4:00 P.M. Resident #48 was evaluated at the hospital for her subdural hematoma which was a result of her fall at the facility. The computerized tomography (CT) scan was negative for anything acute, but the hospital wanted Resident #48 back in a month to do a repeat scan. Resident #48's aspirin and [MEDICATION(S)] were discontinued. Resident #48 continued with a yellowish green bruise to her eye and some smaller bruises of color to her left leg. Resident #48 also has a small three centimeters (cm) by 2 cm open area to her coccyx. This was noted in the discharge papers and was discovered about two days prior. Review of Resident #48's progress note dated 03/26/21 at 2:00 P.M. revealed medical records set up an appointment with the trauma physician for 04/06/21 at 1:30 P.M. Review of Resident #48's progress note dated 03/28/21 at 3:29 A.M. revealed Resident #48 was status post a fall with dark purple bruising to her left eye and face. Review of Resident #48's progress note dated 04/01/21 at 2:23 A.M. revealed Resident #48 was alert and oriented to person. Resident #48 was status post fall with purple bruising to the left eye and side of face. Review of Resident #48's activities of daily living care plan initiated on 07/15/20 revealed Resident #48 required extensive assistance for transfers. Further review of Resident #48's activities of daily living care plan revealed Resident #48's care plan was updated on 04/01/21 to state Resident #48 was dependent with transfers using a mechanical lift with two staff members. Review of Resident #48's fall care plan initiated on 07/15/20 revealed Resident #48 was at risk for falls. Interventions included anticipating and meeting the resident's needs, encourage the resident to use the call light, keep personal items within reach, proactively promote comfort, ongoing evaluation to ensure interventions match current needs and review medications as needed. Review of Resident #48's occupational therapy plan of treatment dated 11/06/20 revealed Resident #48 used a mechanical lift with transfers. Review of Resident #48's hospital record dated 03/25/21 revealed Resident #48 was admitted to the hospital on 03/22/21 with a subdural hemorrhage. Resident #48 was discharged from the hospital on 03/25/21. Review of Resident #48's hospital trauma evaluation history and physical dated 03/22/21 revealed Resident #48 was injured as a result of fall at standing height. Resident #48 was able to relate that staff were attempting to get her up using a lift when she fell landing on her knees and then forward. It was reported Resident #48 had an anterior head strike with at least a brief loss of consciousness. The CT scan at the hospital revealed a subdural hematoma with mass effect but no shift. Resident #48 remained neurologically intact throughout her emergency room stay there. Resident #48 reported left knee pain. She also endorsed upper and lower back pain which she rated as mild. Resident #48 was unable to adequate explain her baseline range of motion of the left shoulder. Resident #48 had a clear contracture of the left hand and appeared to have decreased range of motion of the shoulder but stated she was able to use a walker at her baseline. When questioned as to when she last was able to walk with a walker yesterday. When she asked when she was able to stand from sitting with a less than a lift assistance, she stated she was unsure. Further review of the evaluation revealed Resident #48 had ecchymosis around the left eye with induration and swelling. The ecchymosis had an appearance of evolution exceeding 24 hours. Resident #48 was noted to have small ecchymosis of the lateral aspect of each knee. Review of Resident #48's fall investigation dated 03/22/21 revealed the nurse was in a meeting when an STNA alerted her that two STNAs had been getting the resident up from bed to her geriatric chair when Resident #48 had slipped out of the mechanical lift pad. Resident hit her face on the mechanical lift and had a bruise on her left eye. Resident #48 was unable to describe the incident. Upon entering Resident #48's room, the resident was found to be laying on the floor with a pillow under her head where the STNAs had lowered her to the floor. Resident #48 had an evident bruise above her left eye. Vitals were taken and were within normal limits. Range of motion was within normal limits for the resident. Resident #48 was assisted back to her bed using a mechanical lift and the assistance of two STNAs. Resident #48 listed her to be oriented to person. Review of Resident #48's neurological checks initiated on 03/22/21 at 11:15 A.M. revealed Resident #48's neurological checks were within normal limits. Review of the facility's self reported incident (SRI) dated 03/23/21 at 10:41 A.M. revealed the Administrator was made aware on 03/25/21 of possible inaccuracies surrounding staff statements about a fall that occurred on 03/22/21. Resident #48 sustained a fall on 03/22/21. STNA #01 notified the nurse that the resident was on the floor. As part of the facilities incident management program, all staff working with the resident were interviewed. The two STNAs working that hall, STNA #01 and STNA #02 both stated that they were in the room at the time of the fall. They stated that the resident slipped from the mechanical pad during transfer from bed to geriatric chair. On 3/25/21, STNA #02 provided the Administrator with additional information. STNA #02 stated that she was not in the room at the time of the transfer. STNA #02 stated that STNA #01 came to her after the fall had occurred. On 3/25/21, the Administrator interviewed STNA #01 a second time. STNA #01 confirmed her initial statement. Both STNA #01 and STNA #02 were suspended pending investigation on 03/25/21 when the additional information was provided to the facility. The resident was not able to provide meaningful information when interviewed. The facility re-educated all staff regarding the abuse policy and procedure and cooperating with investigations. The facility re-educated all STNAs regarding mechanical lift transfers and the facility completed competency checks. The facility has initiated an ongoing audit related to mechanical lift transfers as part of the quality assurance program. The facility terminated STNA #02 due to not cooperating with and providing misleading information during the investigation. The facility terminated STNA #01 due to failure to follow the resident's care plan and facility policies and procedures related to transfer with a mechanical lift. Resident #48 was diagnosed with a subdural hematoma during hospital stay. Resident #48 returned the facility and was at her baseline functional and cognitive level. Interview with the Administrator on 04/13/21 at 9:19 A.M. revealed Resident #48 fell from a mechanical mechanical lift and that the resident was not positioned correctly in the lift. The Administrator stated she was initially told that STNA #01 and STNA #02 were in the room at the time of the fall. The Administrator reported that the story later changed and STNA #02 stated she was not in the room at the time of the fall and that STNA #01 was alone in the room when Resident #48 fell from the mechanical lift. The Administrator reported Resident #48 required two person assistance with mechanical lift transfers. The Administrator stated the facility immediately started education on mechanical lifts and all education on the mechanical lifts were completed within 24 hours of the fall. The Administrator also stated that the facility initiated competency evaluations on STNAs and started audits regarding the use of mechanical lifts on 03/23/21. The Administrator reported that Resident #48 was noted with bruising after the fall and was sent to the hospital. The Administrator stated both STNA #01 and STNA #02 were terminated. Observation of Resident #48 on 04/13/21 at 9:50 A.M. revealed Resident #48 had bruised on the left side of her face that was yellow in color. The bruise went from her above her left eye to her cheek. Interview with Resident #48 on 04/13/21 at 9:50 A.M. revealed Resident #48 sustained the bruise to the left side of her face from a fall. Resident #48 was unable to provide any additional information regarding the fall. Telephone interview with STNA #01 on 04/13/21 at 10:12 A.M. revealed she was transferring Resident #48 and she did not have the mechanical lift pad on correctly. STNA #01 stated that the resident slipped out of the mechanical lift and hit her left eye on the mechanical lift and on the chair. STNA #01 reported that STNA #02 was in the room with her at the time of the transfer. STNA #01 stated that STNA #02 stayed with Resident #48 while she got the nurse. STNA #01 stated she no longer worked at the facility. Telephone interview with STNA #02 on 04/13/21 at 10:16 A.M. revealed Resident #48 fell and was dropped by STNA #01 when she was transferring her with a mechanical lift. STNA #02 stated she came into Resident #48's room after the incident and was not in the room at the time of the incident. STNA #02 reported she was unsure if anyone else was in the room with STNA #01 at the time of the fall. STNA #02 stated she made a false statement to protect STNA #01 because STNA #01 was a nervous wreck. STNA #02 stated that Resident #48 had an area to her left eye as a result of the fall. Attempted to interview with LPN #22 by telephone on 04/13/21 at 11:07 A.M. with no answer. Review of LPN #22's undated statement revealed she was at morning meeting at approximately 11:00 A.M. the STNA came to her and said the resident had slipped out of the mechanical lift pad and two STNAs helped her to the floor. The STNA stated she must have hit her face on the mechanical lift but they were really not sure. Resident #48 had a place above the left eye. LPN #22 left the meeting and went to Resident #48's room to find her laying in on the floor flat on her back with a pillow under her head. Resident #48 had the mechanical lift pad underneath her. Resident #48 had an area above her left eye at the eye brown and a quarter size light green bruise on her cheek. Resident #48's vitals were taken and neurological check was completed. Resident #48's eyes were responsive to light and she followed commands to follow a finger with her eyes. Resident #48 was talking and answered questions. Resident #48 stated her only pain was her leg. Resident #48 was given her scheduled medication at that time. LPN #22 continued neurological checks approximately every 15 to 20 minutes. Resident #48 never lost consciousness and never appeared to be in any distress. A call was placed to the on call physician and a message was left to call back but LPN #22 did not get a call back. The Administrator came on the hall and was called to the resident's room to see her. The bruising was continuing to get worse and the decision was made to send Resident #48 to the hospital. Resident #48 was on [MEDICATION(S)]. A call was placed to Resident #48's power of attorney and again to the physician on call. Review of STNA #01's undated statement revealed STNA #01 put Resident #48 on the mechanical lift pad and did not know it was on wrong. STNA #01 went and got help lifting her up on the mechanical lift and Resident #48 slid out and hit her eye on the lift. Staff lowered Resident #48 to the floor and went to get the nurse. STNA #01 reported STNA #02 was her help and she was controlling the lift. STNA #01 reported she was pulling her from the back to put her in the chair. Review of STNA #02's witness statement dated 03/22/21 revealed STNA #02 assisted STNA #01 with transferring Resident #48. When STNA #01 came and asked for help, Resident #48 was already fixed up on the mechanical pad. STNA #02 had not realized what type of pad was under Resident #48. Resident #48 started to slide as they move her towards the chair. STNA #02 was controlling the lift and STNA #01 was behind Resident #48 but Resident #48 slid and went down. STNA #01 and STNA #02 both tried lowering Resident #48 the best they could, but she still hit the floor. Review of the facility's follow up witness statement with STNA #02 dated 03/25/21 at 2:40 P.M. revealed STNA #02 was not in the room with STNA #01 when STNA #01 transferred Resident #48. STNA #01 came out of Resident #48's room and said she needed help. STNA #02 saw Resident #48 on the floor. STNA #01 was frantic. STNA #02 put a pillow under Resident #48's head and told STNA #01 to get a nurse. The nurse came to the room. STNA #01 and STNA #02 used the mechanical lift to transfer the resident back in bed. LPN #22 was there and helped. Review of the personnel file for STNA #01 confirmed the employee hired on 10/29/1998 and was terminated on 03/29/21 with her last working day being 03/22/21. Review of the personnel file for STNA #02 confirmed the employee hired on 10/29/1998 and was terminated on 03/29/21 with her last working day being 03/22/21. Review of the facility policy titled Using a Mechanical Lifting Machine dated July 2017 revealed at least two STNAs were needed to safely move a resident with a mechanical lift. Further review of the policy revealed the staff should measure the resident for the proper sling size and purpose according to the manufacturers instructions. Review of the facility policy titled Using a Mechanical Lift Sling undated revealed staff check the chains and hooks to see that they are properly positioned. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 04/02/21: STNA #01 and STNA #02 were suspended on 03/22/21 and terminated on 03/29/21. On 03/22/21, Resident #48's was sent to the emergency room for evaluation and treatment. On 03/22/21, the Director of Nursing (DON) completed mechanical lift observations of all residents that required mechanical lifts. On 03/23/21 the Administrator completed an in service of all nurses and STNAs on the use of mechanical lifts. On 03/23/21, the facility initiated ongoing monitoring or audits three times a week for four weeks on mechanical lift transfers including the use of two staff members, equipment being used properly, and transfers being executed safely. The audits were completed by the Administrator. As of 04/12/21 there had been no further incidents or concerns identified. On 03/23/21 to 03/25/21, the facility completed competency assessments on all STNAs regarding the use of mechanical lifting machines. The assessments were completed by the Administrator. On 03/29/21, 03/30/21 and on 03/31/21, all staff were educated by the Administrator and the Director of Nursing (DON) on the abuse and neglect policy. On 04/02/21, the facility ordered 10 new mechanical slings. This deficiency substantiates Complaint Number OH 289.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) COVID-19 Long Term Care Facility Guidance dated 04/02/20, Nursing Home Guidance from the Centers for Disease Control (CDC), observations, medical record reviews, interviews with staff, residents and the Local Health Department (LHD), review of the facilities COVID-19 line list, review of the facility census, and review of the facility's infection control policies, the facility failed to implement effective and recommended infection control practices to prevent the spread of infectious disease and move COVID-19 positive residents out of rooms with COVID-19 negative residents. With positive and negative residents cohorting, the likelihood exists for serious harm or death related to the spread of the COVID-19 virus. This resulted in Immediate Jeopardy on 10/27/20 when the facility received notification that 11 residents tested positive and two of the newly positive residents remained in their room being shared with a COVID-19 negative resident. The facility also dismantled their COVID-19 unit on this date due to the amount of residents who were positive for COVID-19, the facility had positive and negative residents on the same units and no place to move the residents. The facility also received notification that eight additional residents tested positive on 10/28/20 and one of the eight newly positive residents remained in their room being shared with a COVID-19 negative resident. This has the potential to affect all residents in the facility and specifically affected three residents (Residents #07, #58 and #61) who were residing with COVID-19 positive residents. The facility identified eight residents (#01, #07, #33, #35, #36, #38, #39, #58 and #61) who were negative for COVID-19. Additionally, the facility failed to ensure they posted signage to alert staff which residents were on droplet precautions and failed to ensure staff utilized Personal Protective Equipment (PPE) appropriately. The facility census was 59. On 11/04/20 at 2:27 P.M., the Administrator, Corporate Director of Operations (CDO) #450 and Corporate Infection Preventionist Control Registered Nurse (CIPCRN) #500 were notified Immediate Jeopardy began on 10/27/20 when facility wide testing for COVID-19 was completed and results were received for all staff and residents following a facility outbreak. At that time 11 additional new cases were identified including Residents #04, #05, #08, #30, #31, #34, #40, #59, #60, #63 and #200. Two residents (#58 and #61) that tested negative for COVID-19 remained in rooms with residents who had tested positive. The facility also dismantled their COVID -19 unit on this date due to the amount of residents who were positive for COVID-19, the facility had positve and negative residents on the same units and no place to move the residents. Additional testing on 10/28/20 resulted in eight additional positive cases including Residents #03, #06, #32, #37, #41, #57, #62, and #201. One Resident (#07) that tested negative remained in a room with a resident that tested positive. Additionally, the facility failed to ensure they posted signage to alert staff which residents were on droplet precautions and failed to ensure staff utilized Personal Protective Equipment (PPE) appropriately. The Immediate Jeopardy was removed on 11/05/20 when the facility completed the following corrective actions: · On 11/04/20, Residents #01, #07, #33, #35, #36, #38, #39, #58 and #61 were all retested for COVID-19. The residents who are negative will continue to be assessed and tested per current CDC guidelines. Results were received on 11/05/20 and all nine residents remained negative for COVID-19. · On 11/04/20, the Administrator and Director of Nursing (DON) initiated in-services for all staff including agency staff. They were in-serviced on the facility COVID-19 policy. The in-service training was specific to effective infection control practices, appropriate use of PPE, appropriate cohorting, proper barriers and proper signage indicating which residents which were positive for COVID-19. Education was completed on 11/05/20 at 2:30 P.M. · On 11/04/20, the Medical Director was notified of the Immediate Jeopardy and discussed the concerns with the Interdisciplinary team on this date. · On 11/05/20, room changes were made with COVID negative residents cohorted together and COVID positive residents cohorted together. · On 11/05/20, barriers were rehung to separate the COVID negative residents from the COVID positive residents. Also, signage was rehung to notify staff which residents were COVID positive. · The barriers and the signage will be audited by the DON/designee three times weekly for two weeks, then one time weekly for two weeks then as recommended by the Quality Assurance Performance Improvement (QAPI) committee. · Appropriate use of PPE will be audited by the DON/designee three times weekly for two weeks, then one time weekly for two weeks, then as recommended by QAPI committee. Although the Immediate Jeopardy was removed on 11/05/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20, revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Review of the facility's undated COVID-19 line list revealed 11 Residents (#04, #05, #08, #30, #31, #34, #40, #59, #60, #63 and #200) tested positive on their COVID-19 test that was administered on 10/26/20 and reported on 10/27/20. Review of the facility's undated list of positive residents revealed eight residents (#03, #06, #32, #37, #41 #57, #62, and #201) tested positive for COVID 19 on 10/28/20. The list also indicated nine residents (#01, #07, #33, #35, #36, #38, #39, #58 and #61) remained negative for COVID-19. Review of the facility census dated 10/29/20 revealed eight rooms were vacant including room [ROOM NUMBER], #125, #205, #209, #212, #218, #220 and #222. Observation of the facility on 11/02/20 at 1:00 P.M. and 11/04/20 at 8:00 A.M. revealed Residents #58 and #59 were cohorted in the same room, Residents #60 and #61 were cohorted in the same room and Residents #06 and #07 were cohorted in the same room. The facility also had seven vacant rooms at this time including Rooms #122, #125, #204, #209, #212, #220 and #222. 1. Medical record review revealed Resident #06 was admitted to the facility on [DATE]. Review of Resident #06's progress note dated 10/28/20 revealed Resident #06 tested positive for COVID-19 on her point of care test. Medical record review revealed Resident #07 was admitted to the facility on [DATE]. Review of Resident #07's laboratory test for COVID-19 specimen collected on 10/26/20 and reported on 10/27/20 revealed the resident did not have COVID-19 detected. Review of Resident #07's progress note dated 10/27/20 revealed Resident #07 tested negative for COVID 19 on 10/27/20. 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE]. Review of Resident #58's laboratory test for COVID-19 specimen collected on 10/26/20 and reported on 10/27/20 revealed the resident did not have COVID-19 detected. Review of Resident #58's progress note dated 10/27/20 revealed Resident #58 tested negative for COVID-19. Medical record review revealed Resident #59 was admitted to the facility on [DATE]. Review of Resident #59's laboratory test for COVID-19 specimen collected on 10/26/20 and reported on 10/27/20 revealed the resident was positive for COVID-19. Review of Resident #59's progress note dated 10/27/20 revealed Resident #59 tested positive for COVID-19 on 10/27/20. 3. Medical record review revealed Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's laboratory test for COVID-19 specimen collected on 10/26/20 and reported on 10/27/20 revealed the resident was positive for COVID-19. Review of Resident #60's progress note dated 10/27/20 revealed Resident #60 tested positive for COVID-19. Medical record review revealed Resident #61 was admitted to the facility on [DATE]. Review of Resident #61's laboratory test for COVID-19 specimen collected on 10/26/20 and reported on 10/27/20 revealed the resident did not have COVID-19 detected. Review of Resident #61's progress note dated 10/27/20 revealed Resident #61 tested negative for COVID-19. Observation during the initial tour of the facility on 11/02/20 at 12:29 P.M. revealed State tested Nursing Assistant (STNA) #181 was noted on the 100 hallway passing trays while wearing a gown, gloves and protective eye wear. STNA #181 was observed not to change her PPE in between rooms. STNA #181 was observed to offer a tray to Resident #33 whom was negative for COVID-19 after passing trays to positive residents without changing her gown or gloves. Interview with the DON at the time of the observation verified STNA #181 was passing trays on the 100 Hallway without changing her gloves or gown in between passing trays to residents. Observations on 11/02/20 from 12:29 P.M. to 3:00 P.M. revealed staff were putting used PPE in large biohazard bags that were laying on the floor on both the 100 and 200 hallways. No other biohazard bins were observed. Interview with the DON on 11/02/20 at 12:35 P.M. verified staff were doffing PPE in the biohazard bag in the hallway or in the trash cans in the resident rooms. Interview with CIPCRN #500 on 11/02/20 at 12:40 P.M. verified the facility was using a biohazard bag to doff PPE in the hallway. CIPCRN #500 stated that the facility did not have enough biohazard bins but then was later observed putting out cardboard biohazard bins on 11/02/20 at 3:00 P.M. Observation of the facility on 11/02/20 at 12:39 P.M. revealed no signage on rooms of COVID -19 positive residents on the 200 and 100 hallway including Rooms #103, #121, #205, #206, #208, #210, #211, #213, #214, #215, #216, #219, #221, #223, and #224. There were also no plastic barriers to separate COVID-19 positive and negative rooms. All resident rooms doors on the 100 and 200 hallways were observed open. Interview with the DON on 11/02/20 at 12:40 P.M. verified there was not signage on the rooms of positive residents that resided in Rooms #103, #121, #205, #206, #208, #210, #211, #213, #214, #215, #216, #219, #221, #223, and #224. The DON also verified there were no plastic barriers and that all barriers were taken down after residents tested positive on 10/27/20 and verified all resident doors were open on 11/02/20. Observation of the 200 Hallway on 11/02/20 at 12:49 P.M. revealed STNA #118 passing trays on the 200 Hallway. After passing trays, STNA #118 went into Resident #35's room without changing her gown or gloves and assisted him with eating. Interview with STNA #118 at the time of the observation revealed she was told Resident #35 was negative for COVID-19 and reported she was supposed to change her PPE prior to working with him. Observation on 11/02/20 at 12:53 P.M. revealed Maintenance Director #171 fixing an item on the wall in Resident #18's room and then was observed to go into Resident #19 and Resident #20's room with no gown or gloves. Maintenance Director #171 was observed to have protective glasses on top of his hat on his head. Interview with the DON at the time of the observation verified Maintenance Director #171 was fixing items in Resident #18, #19 and #20's room without protective eye wear, a gown or gloves. The DON verified Resident #18, #19 and #20 were all positive for COVID-19. Interview with agency Licensed Practical Nurse (LPN) #600 on 11/02/20 at 1:30 P.M. revealed the facility was very unorganized regarding their infection control practices because they had positive and negative residents on the same hallway with no barriers. Observation on 11/02/20 from 2:15 P.M. to 2:45 P.M. revealed Housekeeper #158 was observed on the 200 hallway passing clothes from room to room without changing her gown or gloves. Housekeeper #158 was observed wearing a gown, gloves and protective glasses. Housekeeper #158 was observed to go to the 100 hallway and pass clothes from room to room without changing her gown or gloves. Interview on 11/02/20 at 2:45 P.M. with Housekeeper #158 verified she did not change her gown or gloves in between resident rooms. Interview with CDO #450 on 11/02/20 at 3:00 P.M. verified Residents #58 and #59 were cohorted in the same room. Resident #58 was negative for COVID-19 and Resident #59 was positive. Residents #60 and #61 were cohorted in the same room. Resident #60 was positive for COVID-19 and Resident #61 was negative for COVID-19. CDO #450 stated the facility did not have any place to move the positive and negative residents cohorted in the same room despite the facility having multiple vacant rooms. Telephone interview with Local Health Department (LHD) #560 on 11/03/20 at 11:49 A.M. revealed the facility reported that they discussed they were short of space due to the number of positive residents. LHD #560 stated she had been very busy and could not remember exactly what the health department had recommended to the facility. LHD #560 stated she could not remember if the facility told her that they had vacant rooms and reported that she could only make recommendations and assist the facility based on the information they provided. Observation of Resident #58 and #59's room on 11/04/20 from 6:40 A.M. to 8:00 A.M. revealed no signage to indicate Resident #59 was positive for COVID-19. Observation of Resident #60 and #61's room revealed no signage to indicate Resident #61 was positive for COVID-19. Interview with agency LPN #550 on 11/04/20 at 6:40 A.M. revealed all residents in the facility were positive for COVID-19 and she wore a gown and gloves in each resident's room. Observation of PPE carts in the facility on 11/04/20 at 6:45 A.M. revealed there were five PPE carts on the 200 Hallway but only one of the carts had gowns. Further observation of the facility revealed there were seven PPE carts on the 100 Hallway with only one of those carts having gowns. Interview with STNA #139 on 11/04/20 at 7:09 A.M. verified only one out of the seven PPE carts on the 100 hallway had gowns. STNA #139 stated there were minimal supplies in the PPE carts and the PPE was locked up. STNA #139 stated the facility did not have gowns at times. STNA #139 reported she did not know which residents were positive and negative because the facility did not communicate that information to the STNAs. Interview with STNA #140 and STNA #157 on 11/04/20 at 7:15 A.M. revealed STNA #140 did not know which residents were positive and negative for COVID-19 or who was on droplet precautions. STNA #140 asked STNA #157 which residents were positive for COVID-19. STNA #157 told STNA #140 that she also did not know who was positive for COVID-19 but told STNA #140 to wear a new gown and gloves into each room. STNA #157 stated that the facility used to have barriers up, but the barriers were not in the correct place as residents could walk in and out of the COVID unit. Interview with STNA #117 on 11/04/20 at 7:25 A.M. revealed STNA #117 was told that Resident #58 and Resident #61 were negative for COVID-19. STNA #117 stated she was not aware of any other negative residents on the 200 Hallway but stated both Resident #58 and Resident #61 had positive roommates. Interview with STNA #108 on 11/04/20 at 7:28 A.M. revealed she was unaware which residents were positive and negative for COVID-19 or which were on droplet precautions. STNA #108 reported she was treating all residents as if they were positive for COVID-19. Observation on 11/04/20 at 7:45 A.M. revealed Human Resources (HR) #151 was talking to STNA #108 and STNA #117 with her mask below her nose at the 200 nurses' station. Interview with LPN #179 on 11/04/20 at 7:45 A.M. verified HR #151 was talking to STNA #108 and STNA #117 with her mask below her nose. Observation of the facility on 11/04/20 at 7:58 A.M. revealed LPN #194 was standing at her medication cart on the 200 Hallway with her mask below her nose. Further observation of LPN #194 revealed she put the mask back over her nose and later pulled the mask away from her face and held it in place. Interview with LPN #194 at the time of the observation verified her mask was down below her nose and stated her mask did not fit correctly. Observation on 11/04/20 at 8:10 A.M. revealed STNA #108 was observed assisting Resident #39 with putting on a new mask and throwing away his old mask. After assisting Resident #39, STNA #108 was observed to change her gloves and use hand sanitizer but did not change her gown. STNA #108 then proceeded to pass trays to other residents including Resident #27 who tested positive for COVID-19 on 10/28/20 and then to Resident #58 who was negative for COVID-19 without changing her gown or gloves. Interview with STNA #108 on 11/04/20 at 8:22 A.M. verified she did not change her gown in between passing trays to residents on the 200 Hallway. Observations of the 200 Hallway on 11/04/20 at 8:12 A.M. revealed STNA #117 passed trays on the 200 Hallway to positive residents and negative residents including Residents #34, #35 #36 and #39 without changing her gown or gloves. STNA #117 was then observed to go back to Resident #35's room and assist Resident #35 with eating without changing her gown or gloves between passing trays to resident rooms and assisting Resident #35 with eating. Interview with STNA #117 on 11/04/20 at 8:25 A.M. verified she did not change her gloves or gown in between passing meal trays to residents on the 200 Hallway. STNA #117 also confirmed she did not change her gown or gloves in between passing trays to residents on the 200 hallway and assisting Resident #35 with eating. Interview with the Administrator on 11/04/20 at 11:37 A.M. verified Residents #06 and #07 were cohorted in the same room. Resident #06 was positive for COVID-19 and Resident #07 was negative for COVID-19. Interview with STNA #118 on 11/04/20 at 2:45 P.M. revealed the facility currently had a negative resident, Resident #58, in the same room as a positive resident, Resident #59. The facility also had a negative resident, Resident #61, in the same room as positive resident, Resident #60. Review of the facility's Infection Control Guidelines for All Nursing Procedures policy dated August 2012 revealed staff will wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Review of the facility's Infection Prevention and Control Program policy dated August 2016 revealed managing the affected residents, preventing the spread to other residents. The policy also stated important facets of infection prevention include implementing appropriate isolation precautions when necessary and following established general and disease specific guidelines such as those of the CDC. Review of an online resource from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html) dated 09/03/20 revealed the following guidance regarding proper wearing of face coverings: put it over your nose and mouth and secure it under your chin. The article also stated do not touch the mask and to sanitize with disinfectant if the mask is touched. Review of the CDC's article Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID19 Pandemic dated 07/15/20 revealed staff who enter the room of a patient with suspected or confirmed COVID19 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Further review of the article revealed staff should put on a clean isolation gown upon entry into the patient room or area and remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The article also stated staff should put on clean, non-sterile gloves upon entry into the patient room or care area and remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Review of an online resource from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) entitled Responding to COVID19 in nursing homes dated 04/30/20 revealed if a resident is confirmed to have COVID19 regardless of symptoms, they should be transferred to the designated COVID19 care unit. Roommates or residents with COVID19 should be considered exposed and potentially infected and if all possible should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID19 14 days after exposure. Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Further review of the guidance revealed cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents. HCP should use all recommended PPE to care for all residents on affected units including both symptomatic and asymptomatic residents. Further review of the guidance revealed dedicated HCP should be assigned to work only the COVID19 care unit. Review of CMS and CDC's COVID19 Long Term Care Facility Guidance (https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf) dated 04/02/20 revealed full PPE should be worn per CDC guidelines for care of any resident with known or suspected COVID19 per CDC guidance on conservation of PPE. The guidance also reported long term care facilities should separate residents who have COVID19 from residents who are COVID19 negative. Further review of the guidance revealed facilities should use separate staffing teams for COVID19 positive residents to the best of their ability to avoid transmission within long term care facilities. This deficiency substantiates Complaint Number OH 733.