Every finding on record at Jennings Hall

Based on record review, observation, interview and facility policy review, the facility failed to ensure Resident #74 was treated with respect and dignity. This affected one resident (#74) out of three residents reviewed for respect and dignity. The facility census was 168. Findings include:Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, peripheral autonomic neuropathy, anxiety disorder, abnormalities of gait and mobility, dysphagia, insomnia, muscle weakness, essential tremor, and foot drop. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment revealed Resident #74 a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Interview on 10/16/25 at 11:51 A.M. with Resident #74's responsible party revealed that during review of video camera footage placed in Resident 74's room, she observed staff telling Resident #74 she was fat. Resident #74's responsible party reported the incident to the facility's administration for further investigation. Observation on 10/21/25 at 11:20 A.M. of video submission dated 08/08/25 with the Administrator, the Chief Nursing Officer and Director of Nursing (DON) #303 revealed Care Partner (CP) #495 was alone in Resident #74's room and stated, Are you alright Big Mama? Interview on 10/21/25 at 11:55 A.M. with DON #303 revealed CP #495 was counseled in the past not to use derogatory terms when caring for Resident #74. Interview on 10/21/25 at 1:20 P.M., Resident #74 stated she felt sometimes staff could be mean to her. Interview on 10/21/25 at 1:23 P.M. with CP #495 revealed she made a statement to Resident #74 that she was thick but did not have an offensive intention. CP #495 stated DON #303 counseled her not to use terms that would offend a resident. Interview on 10/21/25 at 2:13 P.M. with DON #303 revealed CP #495 had used the term Big Mama to Resident #74, and Resident #74 felt offended with the term and felt disrespected. Review of a facility document dated 05/19/25 revealed CP #495 was disciplined and counseled not to use verbally abusive language to residents prior to the 08/08/25 incident. Review of the facility policy titled Residents' Rights, dated 06/12/18, revealed residents would be free from discrimination and reprisal from the facility in exercising their rights. This deficiency represents non-compliance investigated under Complaint Number 2642861.

Based on record review, interview and review of the facility policy, the facility failed to ensure admission paperwork was signed as required. This affected one resident (#74) of three residents reviewed for admission. The facility census was 168. Findings include:Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, peripheral autonomic neuropathy, anxiety disorder, abnormalities of gait and mobility, dysphagia, insomnia, muscle weakness, essential tremor, foot drop. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment revealed Resident #74 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Interview on 10/16/25 at 11:00 A.M. with Resident #74's responsible party revealed she was concerned because the facility had called her stating they did not have Resident #74's admission paperwork, and she was told she needed to fill out the admission paperwork again. Review of the admission packet provided by the Administrator on 10/20/25 for new admission residents, revealed the admission Agreement, assignment of benefits, authorization of representative, resident personal funds, suite hold and leave of absence, authorization for professional services, special financial Power of Attorney (POA), release of information to the facility and from the facility, information consent form, photo consent form, mail authorization form, contact information form, and organizational practices. The Administrator was unable to produce a signed copy of Resident #74's admission Agreement. On 10/20/25 at 9:37 A.M. an interview with the Administrator verified Resident #74's admission paperwork was not signed and should be completed at the time of admission. The Administrator stated when the facility performed audits of admission Agreements, they discovered Resident #74 did not have a signed admission Agreement. The facility had reached out to Resident #74's responsible party inquiring if she had a copy of the admission Agreement. The Administrator stated Resident #74's admission Agreement was not lost; it was not done. Interview on 10/20/25 at 4:04 P.M. with Resident #74's responsible party revealed the facility had contacted her to sign the facility admission Agreement because the facility admissions coordinator did not generate the document for her. Review of the facility's policy titled Admissions, dated 03/24/16, revealed and admission team met periodically as needed. Completed applications were reviewed to determine if the facility could properly serve the applicant. An application was deemed completed and ready for review by the admission team when it contained the completed admission application including completed financial disclosure, a completed pre-admission physical or medical transfer and copies of applicant's social security card, Medicare card and copies of all secondary medical insurance. This deficiency represents non-compliance investigated under Complaint Number 2642861.

Based on record review, observation, interview and facility policy review, the facility failed to ensure staff provided Resident #74 with the appropriate level of assistance to ensure a safe transfer and bed mobility. This affected one resident (#74) of three residents reviewed or transfers and bed mobility and had the potential to affect 60 residents (#15, #109, #95, #66, #82, #157, #78, #165, #162, #153, #87, #154, #124, #123, #143, #53, #42, #116, #27, #29, #49, #69, #125, #32, #93, #47, #25, #110, #104, #155, #89, #108, #99, #40, #112, #51, #14, #16, #57, #37, #71, #128, #76, #34, #120, #161, #156, #13, #60, #94, #115, #113, #126, #160, #15, #115, #113, #126, #160, and #24) identified by the facility as dependent on staff for transfers from bed to chair and 20 residents (#66, #82, #122, #153, #157, #165, #51, #104, #156, #15, #63, #113, #115, #126, #160, #32, #125, #150, #27, and #80) residents identified by the facility as dependent on staff to roll left and right in bed. The facility census was 168. Findings include:Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, heart failure, atrial fibrillation, hypertension, peripheral autonomic neuropathy, anxiety disorder, abnormalities of gait and mobility, dysphagia, insomnia, muscle weakness, tremor, and foot drop. Review of the care plan initiated on 05/15/25 revealed Resident #74 was at risk for falls related to deconditioning, gait and balance problems and tremors. Goals included Resident #74 would be free from falls, Resident #74 would be free from minor injury, and Resident #74 would not sustain serious injury. Interventions included anticipating the needs of Resident #74, Resident #74 needed prompt response to all requests for assistance, encouraging Resident #74 to participate in activities that promote exercise for physical strengthening and improved mobility, and physical therapy (PT) to evaluate and treat as ordered and as needed. Review of the health status note dated 06/07/25 at 10:50 A.M. written by Registered Nurse (RN) #308 revealed Resident #74 stated her arm was extended too far in the Hoyer (mechanical) lift last night. The care partner stated Resident #74's arm was not extended, and Resident #74 complained of pain to that left arm. RN #308 assessed Resident #74's skin, and if the pain did not get better, RN #308 would call the doctor. Review of the health status note dated 06/08/25 at 8:38 A.M. written by RN #308 revealed Resident #74 stated her shoulder hurt. RN #308 reported the pain to the nurse practitioner (NP). Review of the PT discharge summary electronically signed on 06/09/25 at 4:11 P.M., revealed the dates of service were 05/13/25 to 06/09/25. Resident #74's highest practical level was achieved. Resident #74 was baseline dependent on staff to roll from lying back to left and right and PT did not attempt to assist using log rolling techniques due to medical conditions or safety concerns. Resident #74's discharge mobility consisted of dependent on staff for chair to bed or chair transfers. PT recommendation consisted of mechanical sling lift bed to wheelchair transfers. Review of the physician visit note dated 06/12/25 written by NP #583 revealed Resident #74 was seen as a follow up for left shoulder pain. Pain was present in the left humerus. Resident #74 stated she was in pain since they Hoyered her. Pain was present for the last five days. There was no improvement with pain. The incident occurred more than two days ago, and the left shoulder was affected. The pain severity of five on a zero to ten pain scale, ten being the worst pain. The pain was moderate and had been intermittent since the injury. Resident #74 had no other injuries or history of shoulder surgery. The plan was a left humerus x-ray per order. Review of physician visit note dated 06/13/25 at 1:30 P.M. written by NP #583, revealed an x-ray was completed and unremarkable. The results were reviewed with Resident #74 and her daughter. A lidocaine patch (pain relieving patch) was ordered, and Resident #74 was given Tylenol (analgesic) for pain. Review of the occupational therapy (OT) discharge summary electronically signed on 06/26/25 at 9:22 A.M., revealed the dates of service were 05/12/25 to 06/19/25. Resident #74's goal was met on 06/19/25 to increase ability to tolerate ceiling lift transfers with no complaints of pain or discomfort. Resident #74's baseline was trialed with various slings to increase comfort during transfers. The discharge summary revealed Resident #74 tolerated a full sling during transfers. Review of the health status note dated 08/08/25 at 1:53 P.M. written by RN #308 revealed Resident #74 reported she was smashed on the left side of the face while being turned in bed this morning. The care partner reported her glasses touched Resident #74's face, but Resident #74 now stated it felt like she was hit with a bowling ball in the face. No redness or bruising were noted. Reported to the Director of Nursing (DON) and NP. The NP assessed Resident #74 resulting in no new skin issues. (There was only one staff member in the room at the time of the incident). Review of the physician visit note dated 08/08/25 at 10:27 P.M. written by NP #583 revealed Resident #74 stated her left side of the face collided with the care partners face and glasses during her incontinence care. No injury was noticed. Resident #74 denied pain. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #74 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #74 was dependent on staff for feeding, toilet hygiene, and bathing, and required maximum assistance to roll left and right in bed, and transfer from bed to chair. Review of the PT evaluation dated 09/17/25 revealed Resident #74 was at baseline status and did not need continued PT. Baseline consisted of not attempting to roll left and right in bed due to medical condition or safety concern. Resident #74 was unable to complete sit to stand and stand to sit transfers with one-person maximum assistance. Resident #74 was dependent on mobility in bed and dependent on staff for chair to bed transfers. Observation on 10/16/25 at 10:30 A.M. revealed Senior Care Partner #362, Care Partner #418 and the DON were present in the room for the transfer of Resident #60's transfer from the recliner to the bed. Two staff members (Senior Care Partner #362 and Care Partner #418) performed the task together. Interview on 10/16/25 at 10:30 A.M. with Senior Care Partner #362 and Care Partner #418 revealed they always performed a ceiling lift on residents with two staff members. Interview on 10/16/25 at 11:20 A.M. with Licensed Practical Nurse (LPN) #491 revealed two staff members were to be in the room to assist with ceiling lifts for resident safety. This would prevent accidents from happening like equipment malfunction. Interview on 10/16/25 at 11:25 P.M. with Senior Care Partner #379 revealed two nurses or aides must be in the room for ceiling lifts to prevent resident falls. Interview on 10/16/25 at 11:51 A.M. with Resident #74's responsible party stated she viewed camera recordings in Resident #74's room, which revealed, on 06/06/25 in the evening an aide transferred Resident #74 from the recliner to the bed. Resident #74's arm appeared to be stretched and repeatedly stretched during the transfer, and the resident cried throughout the incident. Interview on 10/16/25 at 1:53 P.M. with the DON revealed at the previous facility Resident #74 transferred from suggested two care takers in Resident #74's room were needed for all care. The facility made sure two care givers were available for Resident #74 bathing, ceiling lifts and rolling in bed. The facility utilizes two types of slings, the hygiene sling and body sling, for use during the ceiling lift. When Resident #74's shoulder was in pain (note from 06/07/25) the aide used a hygiene lift that was too tight that caused Resident #74 pain. There was only one aide in the room during this lift. Interview on 10/16/25 at 3:15 P.M. with Care Partner #421 revealed two care takers must be present in a resident's room when the ceiling lift was used because this placed a resident at high risk for falls. Interview on 10/16/25 at 3:20 P.M. with Resident #74 revealed one staff member was present to use the ceiling lift and she hurt her shoulder (note dated 06/07/25) because the straps kept hurting her. She stated she just wanted to get out of the lift. Resident #74 also stated an aide hit her head with her head (note dated 08/08/25) because the bed went up and down. It was horrible. Interview on 10/20/25 at 11:14 A.M. with Director or Therapy #587 revealed if a resident was dependent on staff for mobility, two staff members were needed to assist for mobility. Resident #74 was dependent on staff for chair-to-bed transfers to ensure resident and staff safety. Observation on 10/20/25 at 4:01 P.M. of Resident #74 revealed she was lying on her back in bed and was not able to turn left or right in bed. Interview on 10/21/25 at 11:30 A.M. with NP #583 revealed Resident #74 required a high level of care, and it would be best for two staff members to care for Resident #74 because Resident #74 was dependent on staff for all mobility and activities of daily living. NP #583 stated Resident #74 was injured in the sling (note dated 06/07/25), and Resident #74 complained of pain. Resident #74 also stated an aide's face collided with her face when an aide turned her (note dated 08/08/25). The previous facility had suggested two staff members for all Resident #74's care. Observation and interview on 10/21/25 at 1:00 P.M. with Administrator Resident#584, the Administrator, Chief Nursing Officer, and the DON viewed a video dated 06/06/25 at 7:05 P.M. that revealed Resident #74 was observed to be sitting in a recliner with one aide in the room that performed the ceiling lift. The aide raised the ceiling lift with straps attached to the sling and ceiling lift and resident positioned in the sling. Resident #74's right hand was over the sling in a bent position. Resident #74's left arm was observed to be extended straight up between the sling strap and the ceiling lift. Resident #74's arm extended up as the ceiling lift rose up toward the ceiling. Resident #74's left arm remained extended until the aide lowered the resident to the bed. Resident #74's face was noted to be in distress during the transfer. After the aide replaced the ceiling lift in the charger, the aide asked Resident #74, Which arm is it? the aide touched Resident #74's left arm and ask if it was this one. Resident #74 stated, yes. Resident #74 was observed to moan in pain when the sling was removed and during the lift. Resident #74 stated it was because of the Hoyer lift. The DON #stated the aide used the hygiene sling during the lift, and it was not the whole-body sling and verified both arms should be bent outside the sling, not extended. Observation and interview on 10/21/25 at 1:15 P.M. with Administrator Resident #584, the Administrator, Chief Nursing Officer and the DON revealed a video dated 08/08/25 at 6:13 A.M. revealed one aide was providing peri-care to Resident #74 alone in Resident #74's room. When the aide rolled Resident #74 to the right-side edge of the bed, the bed dropped down. The aide grabbed Resident #74's body and bumped Resident #74's head. The aide stated I'm sorry three times and asked Resident #74 if she was bleeding. The aide stated, this bed went down , I didn't want you to fall, I tried to catch you because I felt the bed going down. Resident #74 was observed to lay in bed with her hand holding her head. The DON stated two staff members should roll Resident #74 in bed because Resident #74 was dependent on care. Interview on 10/21/25 at 1:23 P.M. with Care Partner #495 revealed on 08/08/25 she was changing Resident #74 when she heard the bed click. Care Provider #495 was concerned that Resident #74 was going to fall, so she grabbed the resident; her glasses hit Resident #74 in the face. Care Provider #495 stated two staff members were needed for ceiling lifts and to turn Resident #74. (There was only one staff member in the room at the time of the incident). Review of the facility policy titled Ceiling Lifts, dated February 2006, revealed the ceiling lift would be used for any resident who displayed the functional need and met the criteria for use. The ceiling lift would be used according to product guidelines, and the appropriate number of staff members would be used. This deficiency represents non-compliance investigated under Complaint Number 2642861.

Based on record review, observation and interview, the facility failed to ensure medications were secured until consumed by residents. This affected one resident (#87) of 25 residents (#28, #42, #52, #53, #56, #64, #75, #84, #87, #114, #116, #117, #122, #124, #127, #132, #139, #142, #146, #153, #154, #162, #165, #166, and #167) residing on the Main Level [NAME] Unit. The facility census was 168. Findings include:Review of the medical record for Resident #87 revealed an admission date of 12/12/24 with diagnoses including type two diabetes mellitus, primary generalized osteoarthritis, and chronic diastolic heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had intact cognition. Interview on 10/16/25 at 9:11 A.M. noted Resident #87 sitting at a table in the dining room. Interview with the resident revealed no concerns; however, further observations revealed a medication cup sitting on the table filled with 19 medications. No medications were controlled medications. Interview on 10/16/25 at 9:13 A.M., the Director of Nursing (DON) observed the medication cup filled with medications. The DON then stated, this is wrong to have the medications sitting on the table without staff. The facility was unable to provide a policy related to ensuring medications were consumed by residents. This deficiency represents non-compliance investigated under Complaint Number 2642861.

Based on observation, interview and facility policy review, the facility failed to ensure food was prepared and served under sanitary conditions. This affected all 164 residents receiving meals from the kitchen, as the facility identified five residents (#10, #13, #38, #71 and #359) who did not consume meals by mouth. The facility census was 169. Findings include: Observation on 09/09/24 at 10:13 A.M. with Dietary Manager (DM) #642 during the initial kitchen tour revealed DM #642 had a full facial beard from ear to ear approximately one-inch long hair growth and was not wearing a beard net while working in the kitchen. DM #642 confirmed he was not wearing a beard net and should have been. Observation on 09/09/24 at 10:35 A.M. of DM #642 testing the level of quaternary sanitizer with a test strip for the three compartment sink revealed when he dipped the strip into the sanitizer water the strip did not change color. DM #642 confirmed the test strip did not change color so there was not an appropriate amount of sanitizer in the water to sanitize dishes. DM #642 was unable to provide evidence of the past month chemical testing logs. Observation on 09/10/24 at 3:56 P.M. of DM #642 revealed he continued to have a full facial beard approximately one inch in hair length and was not wearing a beard net while working in the kitchen. Dietary Manager #64 confirmed he did not have a beard net on. Observation on 09/11/24 at 12:35 P.M. of [NAME] #707 serving the resident lunch meal revealed he reached to get something out of the cabinet behind him using his gloved hand and then proceeded to use the same gloved hand to grab a handful of lettuce out of the lettuce container for a resident taco salad meal. Interview at the time of the observation with [NAME] #707 confirmed he used his gloved hand to open the cabinet door behind him to reach for an item out of the cabinet and then proceeded to grab lettuce for the resident meal and had not washed his hands or changed gloves in between time. [NAME] #707 confirmed he did not have a serving utensil for the lettuce and went back to the kitchen to get one. [NAME] #707 returned with the appropriate size serving spoon for the lettuce at 12:45 P.M. and meal service resumed. Interview on 09/11/24 at 1:05 P.M. with Dietitian #724 confirmed [NAME] #707 should have used a serving spoon to prevent any chance of sanitation concern and should not have used his hands. Review of the facility policy dated May 2018 called Culinary Services revealed culinary services will function according to the regulations established by the Ohio Department of Health. Interview on 09/12/24 at 1:12 P.M. with the Administrator confirmed the facility policy called; Culinary Services did not address specifics about hand washing procedures for the kitchen or when hair and beard nets were needed and stated they were unable to find a policy that addressed those concerns.

Based on record review and interview, the facility failed to ensure comprehensive discharge assessments were completed at discharge. This affected two (Resident's #27 and #162) of 38 residents reviewed. The facility census was 169. Findings include 1. Review of Resident #27's medical record revealed a 03/15/24 admitted with diagnoses including hyperlipidemia, dementia and malnutrition. Review of the Minimum Data Set (MDS) 3.0 Assessments revealed an Admission MDS was completed 03/28/24. There was no evidence of a subsequent MDS. Review of the nurse notes included the resident discharged home with family 04/16/24. Interview 09/12/24 at 10:05 A.M. with Licensed Practical Nurse (LPN) #659 verified the facility failed to submit a discharge MDS Assessment. LPN #659 included it was human error. On 09/12/24 at 4:07 P.M. the Administrator emailed the facility did not have a discharge MDS policy. 2. Review of Resident #162's medical record revealed a 12/18/22 admission with diagnoses including renal insufficiency, dementia, and arthritis. Review of the MDS 3.0 Assessments revealed a Quarterly MDS was completed 04/04/24. There was no evidence of a subsequent MDS. Review of the nurse notes included the resident discharged home with family 04/16/24. Interview 09/12/24 at 10:05 A.M. with Licensed Practical Nurse (LPN) #659 verified the facility failed do submit a discharge MDS Assessment. LPN #659 included it was human error.

Based on observation, record review, and interview, the facility failed to provide nutritional care and services consistent with Resident #88's assessed needs for eating meals to maintain nutritional status. This affected one resident (#88)of three residents reviewed for nutrition. The census was 169. Findings include: Record review of Resident #88 revealed she was admitted [DATE] and had diagnoses including glaucoma, unspecified visual loss, and unspecified protein-calorie malnutrition. An order dated 09/05/24 called for her to receive a divided dish with meals. Her dietician assessment dated [DATE] revealed she had symptoms of possible swallowing disorder including residual food in the mouth after meals and coughing or choking during meals. Record review of therapy documentation for Resident #88 revealed on 08/21/24 they trialed use of a divided dish to improve her independence with meals. A note on 08/21/24 revealed staff did not provide sufficient cueing for the resident, and a note on 09/02/24 revealed the resident's caregiver did not know she had vision difficulties. The resident demonstrated memory impairment. The divided plate was noted to have a positive impact on her ability to scoop food and locate food items. She was discharged from occupational therapy on 09/02/24 with a recommendation of supervision or touching assistance and a divided dish for all meals. Observation on 09/09/24 at 9:55 A.M. revealed Resident #88 was in bed eating breakfast. Her head was positioned at approximately a 30 degree incline and she had no fluids within reach. The breakfast was served on a normal plate. A sign behind her back noted she was on strict reflux precautions and was to be upright for all meals. Another sign labeled swallowing precautions noted she was to alternate liquids and solids when eating and sit up as close to 90 degrees as possible. She had some small coughing while eating. Interview with Resident #88 on 09/09/24 at 9:55 A.M. revealed she was waiting for something to drink. She said her head of bed should be higher when eating, and independently used the control to raise the head of the bed when the surveyor questioned if she was comfortable. She said it was sometimes hard to get enough to drink. She had poor eyesight and required setup assistance for eating. She denied knowledge of any need for assistive devices such as a divided plate. She did not recall anyone teaching her to sit up for meals or alternate food and liquids to assist swallowing. Observation on 09/09/24 at 10:04 A.M. revealed an aide entered the room and gave Resident #88 a small glass of juice. The resident drank the glass quickly over the course of the surveyor interview and asked the surveyor to get her more to drink. Interview with Registered Nurse #780 on 09/09/24 at 10:17 A.M. confirmed the above findings. Interview with Speech Therapist #793 on 09/10/24 at 10:37 A.M. revealed Resident #88 was referred to her service after weight loss. The resident was to be sitting up at least 45 degrees and ideally 90 degrees during meals. The resident needed setup assistance mostly due to vision problems. Interview with Dietician #724 on 09/10/24 at 2:42 P.M. revealed she was not involved in the decision to place Resident #88 on a divided dish. To her knowledge it was only put in place around 09/09/24, because she did not see the resident using a divided dish until recently.

Based on record review, interview, and policy review the facility failed to obtain weights as ordered by the physician and according to the policy for Resident #164. This affected one resident (#164) of three residents review for weight loss. The facility census was 163. Findings include: Review of the closed medical record for Resident #164 revealed an admitted [DATE]. Diagnoses included arthritis, anemia, anorexia, stage four chronic kidney disease, and dysphagia. Resident #164 expired on [DATE] at the facility. Review of the Minimum Data Set (MDS) assessment for Resident #164 dated [DATE] revealed the resident was moderately cognitively impaired. She had an impairment to both sides of her body on the upper and lower halves, required substantial or maximum assistance for eating, oral hygiene, personal hygiene, toileting, showering or bathing, and upper body dressing. She was totally dependent on staff for lower body dressing. The resident had no swallowing disorders or dental issues. She had weight loss of 5% or more in the last month or 10% or more in the last six months and was on a mechanically altered diet. She received hospice services. Review of the plan of care dated [DATE] for Resident #164 revealed the resident had the potential for inadequate food intake due to anorexia and hospice with a goal to consume more than 25% of meals. Interventions included documenting meal intake amounts, providing snacks and preferences, assisting as needed, and monitoring weights and labs as ordered. Review of the physician orders for Resident #164 revealed an order for a Boost supplement twice per day (BID) beginning on [DATE] and weekly weights beginning [DATE]. Review of the resident's vital signs revealed Resident #164's weight was obtained on [DATE] and she weighed 171.4 pounds, [DATE] she weighed 137 pounds and [DATE] when she weighed 127 pounds. There was no documented evidence a reweight was obtained after the [DATE] weight of 137 pounds which was a 19.7% (significant) weight loss in two months. There was no documented evidence that the resident refused to be weighed. There was no documented evidence that the dietitian or physician were notified of the severe weight loss. Interview on [DATE] at 8:56 A.M. with Diet Tech #209 revealed weights were to be obtained monthly unless otherwise ordered by the physician, and refusals to be weighed would be documented in the resident's medical record. She added it was the facility's policy to discontinue weekly weights when a resident was placed on hospice. She could provide no documented evidence a weight had been obtained for Resident #164 in [DATE]. Interview on [DATE] at 12:26 P.M. with Medical Doctor (MD) #208 revealed Resident #164's health had been declining for several months after she contracted COVID in January of 2023. She had been in and out of the hospital for multiple issues including thyroid related issues which may have led to some issues with her weight. She revealed Resident #164 did not want any type of invasive procedure and only wanted to be comfortable therefore, MD #208 did not discuss the potential for a feeding tube with Resident #164. She also added a feeding tube was not indicated because the resident had already been significantly overweight and expressed multiple times that she was not interested in invasive procedures. MD #208 also felt the residents' health would not withstand a procedure of that nature. Review of the facility policy titled Weight policy, dated [DATE], revealed weights would be obtained once per month unless otherwise ordered, weekly weights would be obtained per physician orders, if a weight deviated plus or minus five pounds from the previously recorded weight, a reweigh would be completed, the dietitian or diet tech would be notified on the day of the variance and would complete a nutritional assessment, documenting their findings in the electronic medical record (EMR) with interventions as appropriate. Refusals would be documented in the EMR. This deficiency represents noncompliance investigated under Complaint Number OH00149924.

Based on record review, interview, and facility policy review the facility failed to ensure complete, thorough, and accurate medical record for Resident #164. This affected one resident (#164) of three residents reviewed for documentation. The facility census was 163. Findings include: Review of the closed medical record for Resident #164 revealed an admitted [DATE]. Diagnoses included arthritis, anemia, anorexia, stage four chronic kidney disease, and dysphagia. The resident expired in the facility on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #164 was moderately cognitively impaired. She had an impairment to both sides of her body on the upper and lower halves, required substantial or maximum assistance for eating, oral hygiene, personal hygiene, toileting, showering or bathing, and upper body dressing. She was totally dependent for lower body dressing. The resident had no swallowing disorders or dental issues. She had weight loss of 5% or more in the last month or 10% or more in the last six months and was on mechanically altered diet. She received hospice services. Review of the plan of care dated [DATE] for Resident #164 revealed the resident had the potential for inadequate food intake due to anorexia and hospice with a goal to consume more than 25% of meals. Interventions included documenting meal intake amounts, providing snacks and preferences, assisting as needed, and monitoring weights and labs as ordered. Review of physician orders for Resident #164 revealed an order for weekly weights beginning [DATE] and ending [DATE]. Review of the resident's vital signs in the electronic medical record (EMR) revealed Resident #164's weight was obtained on [DATE]. No weights were entered in the medical record for [DATE], [DATE], [DATE] or [DATE]. Review of the document provided by the facility titled QAPI Stand Up dated [DATE] revealed Resident #164 was weighed on [DATE] and [DATE]. There were no weights listed for [DATE] or [DATE]. The document was not signed, and the weights were not entered into the resident's medical record. Interview on [DATE] at 1:38 P.M. with Registered Nurse (RN) #211 confirmed the facility provided weights for Resident #164 on [DATE] and [DATE] were on the document titled QAPI Stand Up and were not included in the resident's medical record and as a result, the medical record was incomplete. Review of the facility policy titled Weight policy, dated [DATE], revealed weights would be obtained once per month unless otherwise ordered, weekly weights would be obtained per physician orders, if a weight deviated plus or minus five pounds from the previously recorded weight, a reweigh would be completed, the dietitian or diet tech would be notified on the day of the variance and would complete a nutritional assessment, documenting their findings in the electronic medical record (EMR) with interventions as appropriate. Refusals would be documented in the EMR. This deficiency represents noncompliance investigated under Complaint Number OH00149924.

Based on family and staff interviews, medical record review, review of the facility's Self-Reported Incidents, and review of camera footage, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) was safely repositioned in bed. This affected one (Resident #1) of three residents reviewed for ADL care. The facility census was 158. Findings include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required substantial/maximal assistance from staff to roll to the right and left side. Review of the facility's Self-Reported Incident (SRI) dated 11/06/23 revealed Resident #1's power of attorney (POA) (also Resident #1's grandson) reported an allegation of physical abuse towards Resident #1. The POA stated when watching the video of care provided to Resident #1 revealed on 11/04/23 (the facility had 11/04/23 but the video was marked 11/05/23), State tested Nursing Aide (STNA) #317 repositioned Resident #1 in bed and resulted in Resident #1 hitting her head on the railing. STNA #317 did not console or check to see if Resident #1 was okay after Resident #1 hit her head on the railing during repositioning. The POA also reported STNA #317 was rough with getting Resident #1 dressed over the weekend (11/04/23 or 11/05/23) as well. STNA #317 received safe repositioning education, abuse, customer service, and adverse events. The abuse was unsubstantiated based off the review of the video and STNA #317's statement where the head bump on the railing was not intentional on 11/14/23. Further review of the facility's SRIs dated 10/122/23 revealed STNA #317 was mentioned as an alleged perpetrator in a physical abuse allegation towards another resident (Resident #102). As a result of the investigation dated 10/30/23, staff received education on how to safely transfer Resident #102. Review of the video clip from Resident #1's room dated 11/05/23 at 1:03 P.M. with Resident #1's POA revealed a nurse and STNA #317 transferred Resident #1 to her bed. The nurse leaves the room and STNA #317 pulls Resident #1's hip and right arm towards her and then Resident #1 hits her head on the siderail. Resident #1 stated ouch my head. STNA #317 does not respond to Resident #1's comment and continues to remove the Hoyer pad and does not reposition Resident #1 off the siderail. Resident #1's head was resting on the siderail when Resident #1 was turned over and Resident #1 told STNA #317 she would hit her and bite her. STNA #317 continued to remove the pad and did not check Resident #1's head for any injury. Telephone interview on 11/08/23 at 12:33 P.M. with the POA revealed he has a video camera in Resident #1's room. On 11/05/23 at 1:03 P.M., Resident #1 was being cared for by STNA #317 and the STNA was being too rough. When the STNA #317 was rolling her over, Resident #1 hit her head on the siderail and yelled out Ouch that hurt my head. STNA #317 did not console Resident #1. STNA #317 just kept doing her care. The POA stated he went in the next day and spoke with Supervisor Registered Nurse (RN) #305 about the incident and showed her the video clip of the incident. RN #305 did not know anything about the incident of Resident #1 hitting her head on the siderail. RN #305 stated this was the first time she heard about the incident, STNA #317 had not reported the incident. Interview on 11/08/23 at 1:42 P.M. with RN #305 verified the POA showed her the video of Resident #1 being turned in bed and hitting her head on the siderail. STNA #317 did nothing and did not tell anyone of the incident immediately. RN #305 stated Resident #1's POA showed the video to her on Monday evening (11/06/23). When the POA told her of the incident, STNA #317 was suspended, she notified the Administrator, and started an investigation. RN #305 stated from her perception of the video, STNA #317 did not intentionally bump Resident #1's head. RN #305 stated the interview she had with STNA #317 revealed she did not think Resident #1 hit her head hard and may have turned her with more force than needed causing her to hit her head. RN #305 verified STNA #317 should have checked Resident #1 for an injury or should have asked her if she was ok. RN #305 verified STNA #317 should have reported the incident to the nurse immediately. Interview on 11/15/23 11:05 A.M. with STNA #317 revealed she was the aide taking care of Resident #1 on 11/05/23. STNA #317 stated she was removing the lift pad from under Resident #1 when she pulled Resident #1 towards her making Resident #1 hit her head on the bed. She did not think she hit her head very hard, and she did not see any red mark. STNA #317 stated she was busy and forgot to notify the nurse that Resident #1 hit her head on the siderail, and it slipped her mind to tell the nurses. This deficiency represents non-compliance investigated under Complaint Number OH00147500.

Based on record review, review of camera footage and picture, and family and staff interviews, the facility failed to ensure all residents received medication as ordered by the physician. This affected one (Resident #1) of five residents reviewed for medication administration. The facility census was 158. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included dementia, atrial fibrillation, hypertension, and pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Review of the physician orders for November 2023 revealed Xanax 0.25 milligram (mg) tablet as needed every four hours for anxiety was discontinued on 11/03/23. Xanax 0.25 mg half tablet as needed every four hour for anxiety was started on 11/03/23. Review of the camera footage from Resident #1's room revealed on 11/03/23 at 4:56 P.M., Resident #1's grandson was visiting Resident #1. Licensed Practical Nurse (LPN) #319 came into Resident #1's room to administer Resident #1's medication. LPN #319 came into the room with a medication cup with pudding and crushed medications in it. As she was giving Resident #1 her medications by spoon, the grandson was giving sips of nectar thickened water. LPN #319 was by the side of Resident #1's bed, and the grandson heard something drop. The nurse picked up the medicine cup off the floor and turned to leave. She threw the spoon and medication cup in the garbage. The grandson asked if LPN #319 if she was done administering Resident #1's medications and she replied yes and walked out of the room. The grandson walked over to the trash can and took the pill cup and spoon from Resident #1's garbage can. There was still pudding and medications on the spoon and in the cup. The grandson took a picture of the spoon and cup and left the room with the items. Review of the grandson's picture taken on 11/03/23 at 4:56 P.M. revealed there was crushed medications in the pill cup and medications and pudding on the spoon. Telephone interview on 11/08/23 at 12:56 P.M. with Resident #1's grandson revealed on 11/03/23 at 4:56 P.M., he was visiting Resident #1 and LPN #319 came into Resident #1's room to give Resident #1 her afternoon medication. LPN #319 came into the room with a medication cup with pudding and crushed medications in it. LPN #319 threw the spoon and medicine cup in the Resident #1's garbage can inside her room. The grandson asked if she was done giving Resident #1's medications and she stated yes and walked out of the room. The grandson walked over to the trash can, saw the pill cup and spoon in the garbage and noticed there was still pudding and medications on the spoon and in the cup. The grandson took it out of the trash, took a picture of it and took it to Registered Nurse (RN) #305 and told her what happened. She stated what can I say. Interview on 11/08/23 at 12:56 P.M. with Supervisor Registered Nurse (RN) #305 verified she observed the picture and contents of the medication cup the grandson showed her on 11/03/23. RN #305 verified Resident #1 did not receive all of her medications and the nurse should have given all the pudding that had medications in it as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00147500.

Based on record review, observation, interview and review of Centers for Disease Control (CDC) guidance, the facility failed to follow proper infection control procedures while doffing Personal Protective Equipment (PPE) after exiting Resident #245 and Resident #237's rooms who were diagnosed with COVID-19. This had the potential to affect all 164 residents in the facility. The facility census was 164. Findings include: 1. Review of the medical record for Resident #245 revealed an admitted [DATE]. Diagnoses included hemiplegia following cerebral infarction, heart failure, and vascular dementia. Review of the COVID-19 testing results dated 04/04/23 revealed Resident #245 tested positive for COVID-19. Review of the nurses notes from April 2023 revealed Resident #245 was on quarantine for COVID-19 from 04/04/23 to 04/13/23. Observation on 04/12/23 at 2:01 P.M. revealed State tested Nursing Assistant (STNA) #329 donned an N-95 mask, gown and gloves and entered Resident #245's room who was on isolation for COVID-19. Observation on 04/12/23 at 2:05 P.M. revealed STNA #329 exited Resident #245's room. STNA #329 did not change her N-95 mask after exiting the room and before walking up the hall. STNA #329 revealed she received one N-95 a day and confirmed she worked with residents with covid 19 and without COVID-19 during the same shift. STNA #329 revealed she placed a new N-95 mask on in the morning when she started her shift then threw it away at the end of her 7.5-hour shift. STNA #329 confirmed she did not wear goggles while caring for Resident #245. Observation on 04/12/23 at 3:56 P.M. revealed STNA #330 donned an N-95 mask, gown, hair cap and gloves and entered Resident #245's room who was on isolation for COVID-19. STNA #330 had prescription eyeglasses on. Observation on 04/12/23 at 4:01 P.M. revealed STNA #330 exited Resident #245's room, placed hair cap in her shirt pocket, did not change the N-95 mask then walked across the hall and entered Resident #186's room (who was not on isolation) and assisted Resident #186. Observation on 04/12/23 at 4:05 P.M. revealed STNA #330 left Resident #186's room and began to enter Resident #194's room (who was not on isolation) when she was stopped by the surveyor. STNA #330 confirmed she did not wear goggles while caring for Resident #245 who was positive for COVID-19, she did not change the N-95 mask after caring for Resident #245 and she placed the hair net she wore in Resident #245's room in her shirt pocket after exiting the room. STNA #330 revealed she only changed the N-95 mask once a day, at the beginning of her shift and confirmed she did not wear any goggles. STNA #330 revealed she kept the hair net in her shirt pocket to reuse. STNA #330 confirmed she worked with residents with COVID-19 and without COVID-19 during the same shift. Interview on 04/12/23 at 4:10 P.M. with Director of Nursing (DON) #313 revealed staff should be wearing a face shield or goggles, a gown, gloves, and an N-95 mask before entering a resident room diagnosed with COVID-19. The mask should be changed if soiled and at least once a day except when going into a COVID-19 room, the mask should be changed when exiting the room. Interview on 04/12/23 at 4:39 P.M. with the Administrator revealed each staff member changed their mask once a day, staff did not change their mask between caring for residents with COVID-19 and non-COVID-19 because she thought there was still a mask shortage. Administrator confirmed she had no difficulty in ordering masks and masks were available at multiple resources including online. 3. Review of the open medical record for Resident #237 revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, cognitive communication deficit, and hemiplegia. Review of the COVID-19 testing results dated 04/06/23 revealed Resident #237 tested positive for COVID-19. Review of the nurses notes for April 2023 revealed Resident #237 was on quarantine for COVID-19 from 04/06/23 to 04/16/23. Review of the physician's orders for Resident #237 for April 2023 identified no orders regarding isolation or quarantine for COVID-19. Observation on 04/13/23 at 11:47 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #327 donned PPE including a gown, goggles, N-95 mask and gloves to enter Resident #237's room. LPN #327 administered medications to Resident #237, doffed the PPE except for the goggles. LPN #327 did not doff or clean the goggles worn in Resident #237's room. LPN #327 verified he did not clean his goggles after exiting Resident #237's room revealing he cleaned his goggles at the end of each shift and obtained new goggles once a week. LPN #327 confirmed he worked with residents with covid 19 and without COVID-19 during the same shift and revealed he was never instructed to clean or remove his goggles after exiting a room with COVID-19. Review of the CDC guidance titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 dated, 06/03/20, included before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE. HCP must demonstrate competency in performing appropriate infection control practices and procedures. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care: remove gloves, remove gown, HCP may now exit patient room, perform hand hygiene, remove face shield or goggles, remove and discard respirator, perform hand hygiene after removing the respirator. Record review of the facility COVID-19 line list revealed the first positive resident case for COVID-19 at the facility was Resident #265 who tested positive on 03/23/23. Resident #159 tested positive for COVID-19 on 04/03/23. An additional 13 residents, Resident #245, #130, #270, #170, #178, #271, #272, #237, #214, #273, #274, #158, and #126 tested positive from 04/04/23 through 04/10/23. Review of facility policy titled Covid 19 Isolation, dated 05/26/22, did not include what the staff member was to donn or how to doff PPE. This deficiency represents non-compliance investigated under Complaint Number OH00141855.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and/or answered timely for all residents. This affected four residents ( #129, #142, #184 and #208) of five residents observed for call light response. The facility census was 164. Findings include: 1.Review of the open medical record for Resident #142 revealed an admitted [DATE]. Diagnoses included pulmonary fibrosis, vascular dementia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 Assessment, dated 03/06/23, revealed Resident #142 had a severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #142 had the potential for self-care deficit related to vascular dementia and a history of falls. Interventions included assist with care and tasks, Resident #184 was unable to complete herself, create a safe environment by keeping obstacles from path, and call bell within reach, monitor ability and limitations, and ensure call light was within reach at all times. Observation on 04/12/23 at 10:40 A.M. revealed Resident #142 was sitting in her lounge chair. The call light was placed over the night stand several feet away from Resident #142. Resident #142 verified she was unable to reach the call light. Observation and interview on 04/12/23 at 10:42 A.M. with Registered Nurse (RN) #332 confirmed Resident #142 could not stand without assistants and Resident #142 was unable to reach her call light. 2. Review of the open medical record for Resident #184 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 03/06/23, revealed Resident #184 had a severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #184 had the potential for self-care deficit related to malaise, muscle weakness, osteoarthritis, and dementia. Interventions included assist with care and tasks Resident #184 was unable to complete herself, create a safe environment by keeping obstacles from path and call bell within reach, monitor ability and limitations, and ensure call light was within reach at all times. Observation on 04/12/23 at 11:00 A.M. revealed Resident #184 was sitting up in her chair in her room next to her bed. Observation revealed the call light was bundled up and located behind the nightstand out of reach of Resident #184. Resident #184 verified she was unable to reach the call light. Observation and interview on 04/12/23 at 11:02 A.M. with Speech Therapist #333 verified Resident #184's call light was behind the night stand and Resident #184 would not be able to reach the call light. 3. Record review for Resident #208 revealed an admitted [DATE]. Diagnosis included Parkinson's disease, unspecified convulsions, and dysphagia. Record review of the MDS dated [DATE] revealed Resident #208 had severe cognitive impairment and required extensive assistants of one to two for ADLS. Record review of the care plan for Resident #208 dated 03/12/23 revealed Resident #208 had a potential for self-care deficit related to lack of coordination, muscle weakness and Parkinson's disease. Interventions included call light within reach at all times. Observation on 04/13/23 at 3:32 P.M. revealed Resident #208 was up in his chair. As the surveyor was passing Resident #208's room, Resident #208 called out to the surveyor for assistants. Observation revealed Resident #208 was unable to reach his call light located on his bed and no other staff was in the area. Resident #208 was requesting assistants. Observation and interview on 04/13/23 at 3:35 P.M. with Licensed Practical Nurse (LPN) #325 confirmed Resident #208 was not able to reach or get to his call light located on the bed. 4. Review of the open medical record for Resident #129 revealed an admitted [DATE]. Diagnoses included vascular dementia with agitation, anxiety disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 03/30/23, revealed Resident #129 had a moderate cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #129 had the potential for self-care deficit related to dementia, general muscle weakness, somnolence, and bilateral upper extremity muscle wasting. Interventions included assist with care and tasks Resident #129 was unable to complete herself, create a safe environment by keeping obstacles from path and call bell within reach, monitor ability and limitations, and ensure call light was within reach. On 04/13/23 at 2:03 P.M., observation of the memory care unit revealed Resident #129's call light was on and there was no audible indicator for the call light. Resident #129's room was around the corner from the unit entrance and was not visible from the entrance. At that time, the three staff members for the unit were congregated by the unit entrance talking amongst themselves. At 2:10 P.M., the Administrator entered the unit, spoke to the staff by the entrance, and then left the unit. At 2:14 P.M., staff began making popcorn in the kitchenette by the unit entrance. At 2:23 P.M., Licensed Practical Nurse (LPN) #310 entered the memory care unit and began walking down the hallway. At 2:24 P.M., LPN #310 answered Resident #129's call light, 21 minutes after it was observed to be on. No other staff on the unit walked down the hallway between 2:03 P.M. and 2:24 P.M. On 04/13/23 at 2:26 P.M., interview with LPN #310 verified she answered Resident #129's call light as soon as she entered the unit. She confirmed Resident #129's call light indicator was not visible from the unit entrance and there was no audible indicator for the call light. LPN #310 stated staff were supposed to have pagers for the call lights and staff should have been walking the halls to ensure call lights were answered. The deficiency resulted from incidental findings during the investigation of Complaint Numbers OH00141855, OH00139480, OH00138154 and OH00135223.

Based on record review, family interview and staff interview, the facility failed to ensure resident representatives were notified of significant changes, including medication changes, for Resident #268. This affected one resident (#268) of three residents reviewed for notification of change. The census was 164. Findings include: Review of the medical record for Resident #268 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included fracture of the right rib, mild cognitive impairment, and dementia with anxiety. Review of the physician's orders for October 2022 identified orders for Lexapro (an antidepressant) five milligrams (mg) once daily for behaviors, ordered on 10/12/22. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/17/22, revealed Resident #268 had a severe cognitive impairment, required extensive assistance for activities of daily living (ADLs), and received an antidepressant medication for five out of seven days for the seven day lookback. Review of the Medication Administration Record (MAR) for October 2022 through November 2022 revealed Resident #268 received Lexapro daily from 10/13/22 to 11/15/22. Review of the nurses notes from October 2022 identified no documentation of notification to Resident #268's representative regarding the addition of Lexapro. A note dated 10/14/22 at 2:42 P.M. revealed a care conference was held with Resident #268's family and there was nothing indicating medications were reviewed at the care conference. Review of Physician #322's note dated 10/12/22 revealed Resident #268 was anxious. The note indicated Lexapro five mg daily was being added for underlying anxiety. Resident #268 had a fair to poor prognosis. On 04/12/23 at 5:00 P.M., interview with Resident #268's representative stated she was not notified about the addition of Lexapro. On 04/17/23 at 1:24 P.M., interview with Director of Nursing (DON) #313 stated the floor nurse or the physician would notify resident representatives of any changes and the notification would be documented in the chart. She said if there was no documentation of the notification, there was no way to guarantee the notification occurred. On 04/17/23 at 2:40 P.M., interview with DON #312 verified there was no evidence that Resident #268's family was notified of the new order for Lexapro. She stated the floor nurse or the physician were responsible for making the notification. She also stated the floor nurse who signed the telephone order for the Lexapro was an agency nurse who no longer worked in the facility. On 04/18/23 at 1:50 P.M., interview with Physician #322 verified he ordered Lexapro for Resident #268 for anxiety and stated he did not call the family. He stated the facility nurse was responsible for notifying the family of medication changes if the family was not present at the time of the physician visit. Physician #322 stated Resident #268 was alert at the time of his visit, so it was likely that he discussed the new order for Lexapro with Resident #268 during the visit instead of discussing it with her representative. This deficiency represents non-compliance investigated under Complaint Number OH00139480.

Based on interview and record review, the facility failed to ensure Resident #256's CPAP (continuous positive airway pressure) machine was maintained in a clean and sanitary manner. The affected one resident (Resident #256) of three residents reviewed for use of CPAP machines. The facility census was 164. Findings include: Record review for Resident #256 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease (COPD). Record review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #256 was cognitively intact. Resident #256 required extensive assistance of two for bed mobility and transfers. Record review of the care plan for Resident #256 revealed the potential for altered respiratory status related to chronic obstructive pulmonary disease (COPD) as evidence by use of CPAP machine. Interventions included to provide oxygen as ordered. Record review of the physician orders revealed Resident #256 had an order to use the CPAP machine at night and off at 6:00 A.M. Further review of the physician orders revealed no orders were present for cleaning the CPAP. Interview on 04/13 23 at 1:51 P.M. with Resident #256 confirmed staff placed her CPAP on at night and removed it in the morning. Resident #256 revealed she had been at the facility for nearly one month and no one had ever cleaned her CPAP machine including the water reservoir, tubing, masks nor anything else on the machine. Resident #256 revealed the CPAP she had at home had to be cleaned two times a week by her daughter. Interview on 04/13/23 at 12:25 P.M. with DON #312 confirmed Resident #256 did not have orders for cleaning her CPAP machine but should have. The CPAP machine should have been cleaned weekly on Sundays. DON #312 confirmed the CPAP machine had not been cleaned while at the facility. This deficiency represents non-compliance investigated under Complaint Number OH00135223.

Based on observation and interview the facility failed to ensure residents were provided privacy during COVID-19 testing. This affected four residents (Resident #42, Resident #73, Resident #78, and Resident #145) of 17 residents who resided in the [NAME] Garden unit. Findings include: Observation on 05/09/22 at 10:45 A.M. of the [NAME] Garden dementia unit revealed a table of six residents doing activities in the common area dining room. Resident #42 was sitting at a dining room table by himself, Resident #45 was sitting at another table by herself, and Resident #73 was sitting at a third table by herself. Laboratory Technician #302 approached Resident #42 and swabbed his nose for COVID-19 testing. Interview on 05/09/22 at 10:53 A.M. with Laboratory Technician (LT) #302 revealed she worked for a contracted company and was responsible for completing the COVID-19 testing for residents. LT #302 stated the process was quicker if the residents were in a common area and residents were easily identified by staff as she completed the testing. Observation on 05/09/22 at 10:56 A.M. revealed Resident #145 sitting at the table in the common area. LT #302 approached Resident #135 and swabbed her nose for COVID-19. Observation on 05/09/22 at 11:10 A.M. revealed Resident #78 walking out of his room into the main area with two state tested nursing assistants (STNAs). LT #302 walked up to Resident #78 and swabbed his nose. Observation on 05/09/22 at 11:15 A.M. revealed Resident #73 sitting at a table in the common area. LT #302 approached Resident #73 and swabbed her nose for COVID-19. Interview on 05/10/22 at 2:00 P.M. with STNA #303 verified the above observations and stated on COVID-19 testing days residents were tested between 10:00 A.M. and 12:00 P.M. The STNAs gathered the residents in a common area for testing. STNA #303 stated staff was able to identify the residents to the laboratory technician for testing. Review of the facility's policy titled Resident Rights dated 06/12/18 revealed it was the responsibility of every staff member to promote and to protect the rights of the residents.

Based on observation, interview, record review and policy review the facility failed to ensure oxygen tubing was dated to ensure timely replacement. This affected six residents (Residents #1, #2, #65, #164, #266 and #270) of seven residents reviewed for respiratory care. The facility census was 162 residents. Findings include: 1. Review of Resident #1's medical record revealed an order dated 04/14/22 for keeping nasal cannula oxygen at three liters with goal of 88% [oxygen saturation] and an order dated 05/07/22 for two to four liters of oxygen via nasal cannula continuously. Observation on 05/12/22 starting at 4:43 P.M. with the Interim Director of Nursing (IDON) verified Resident #1's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 2. Review of Resident #2's medical record revealed an order dated 05/11/22 indicating do not go above two liters of oxygen due to increased cannula, call physician if pulse oxygenation is less than 88; continuous for oxygen. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #2's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 3. Review of Resident #65's medical record revealed an order dated 05/05/22 for oxygen via nasal cannula three liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #65's oxygen tubing and humidifier bottle were not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 4. Review of Resident #164's medical record revealed an order dated 05/10/22 for oxygen via nasal cannula two liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #164's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 5. Review of Resident #266's medical record revealed an order dated 04/30/22 for oxygen via nasal cannula three liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #266's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 6. Review of Resident #270's medical record revealed an order dated 04/30/22 for oxygen two liters via nasal cannula continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #270's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. Review of the facility policy, Oxygen, dated 09/26/05 revealed the concentrator filter, prefilled humidifier bottle, tubing and plastic bags were changed weekly by the service tech from the oxygen service company and the humidifier bottles and tubing would be labeled with the date, resident's name and room number. This deficiency substantiates Complaint Number OH 637.

Based on record review and interview the facility failed to ensure accurate and complete transmission of Minimum Data Set (MDS) assessments. This affected two residents (Resident #2 and Resident #3) out of three residents reviewed for resident assessment. The facility census was 162 residents. Findings include: 1. Review of Resident #2's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment lookup tab indicated Resident #2 discharged on [DATE] but no date of submission or acceptance was listed. Interview on 05/12/22 at 8:12 A.M. with MDS Licensed Practical Nurse (LPN) #605 verified Resident #2's discharge MDS assessment had not been submitted. Further review of the discharge MDS assessment during the interview indicated sections A, J and O were also incomplete. MDS LPN #605 verified questions A0310, A1200, J0200, J1100, J1550 and O0400 on the MDS assessment were not completed and should have been. MDS LPN #605 indicated the facility did not have a scrubber or other system to check for MDS errors. 2. Review of Resident #3's record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment lookup tab indicated Resident #3 had a quarterly assessment dated [DATE] but no date of submission or acceptance was listed. Interview on 05/12/22 at 8:12 A.M. with MDS LPN #605 verified Resident #3's quarterly MDS assessment was not completed, submitted or accepted even though it was signed. MDS LPN #605 verified question M1040 on the MDS assessment was not completed and should have been. MDS LPN #605 indicated the facility did not have a scrubber or other system to check for MDS errors.

Based on observations, interview and record review, the facility failed to complete nail care for residents who could not provide self-care. This affected two (Resident #101 and Resident #155) of 10 residents reviewed for nail care. The facility census was 162 residents. Findings include: 1. Review of medical record for Resident #101 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/05/22, revealed Resident #101 had impaired cognition and required extensive assistance for bed mobility, toilet use and personal hygiene. Observation on 05/09/22 at 9:40 A.M. revealed Resident #101's fingernails were long and jagged with brown material located under the nails. Interview with Resident #101 at the time of the observation revealed he would like to have his nails trimmed because they were long. Interview on 05/09/22 at 2:40 P.M. with State tested Nurse Assistant (STNA) #602 revealed Resident #101 was not resistant to nail care and the activity staff trimmed resident nails. Interview on 05/09/22 at 2:45 P.M. with Licensed Practical Nurse (LPN) #603 revealed nursing staff were responsible for trimming resident fingernails. LPN #603 stated she observed Resident #101's nails and they were horrific and LPN #603 trimmed the nails. LPN #603 stated Resident #101 played with his feces at times. 2. Review of Resident #155's record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #155's admission Minimum Data Set (MDS) assessment revealed Resident #155 was moderately cognitively impaired and required the extensive assistance of one staff for hygiene care. Nurses' notes did not indicate that Resident #155 refused nail care. Observation on 05/09/22 at 12:03 P.M. of Resident #155 revealed his nails were long, jagged and dirty. Interview with Resident #155 at the time of observation revealed his nails were last cut about a month ago and it was annoying because his nails would chip and then be jagged. Observation on 05/10/22 at 3:53 P.M. of Resident #155 revealed his nails were still long and dirty and he was seated in his wheelchair watching television. Observations on 05/11/22 at 8:52 A.M., 11:51 A.M. and 2:40 P.M. revealed Resident #155's nails remained long, dirty and jagged as he was seated in his wheelchair in his room. Interview on 05/11/22 at 4:06 P.M. with Licensed Practical Nurse (LPN) #607 indicated Resident #155 did not refuse care. LPN #607 accompanied the surveyor to observe Resident #155's nails during the interview and verified his nails should not be long, dirty and jagged. Interview on 05/11/22 at 4:10 P.M. with State tested Nursing Assistant (STNA) #608 indicated Resident #155 did not refuse care. STNA #608 stated nail care was to be provided on shower days or upon request. Interview on 05/11/22 at 5:07 P.M. with Registered Nurse (RN) #609 verified nail care was to be provided on shower days and was unaware of any residents with nail care not being provided in a timely manner.

Based on observations, interview, and review of manufacturer instructions, the facility failed to date insulin vials when opened and remove expired insulin vials from the medication cart. This affected three (Resident #27, Resident #36, and an unidentified resident) of 15 residents who received insulin. The facility census was 162 residents. Findings include: Observations of medication cart on the main level on [DATE] at 10:36 A.M. revealed an opened vial of [MEDICATION(S)] insulin which was not dated for Resident #27, an opened [MEDICATION(S)] insulin vial dated [DATE] for Resident #36 and a used [MEDICATION(S)] [MEDICATION(S)] ([MEDICATION(S)]) insulin pen with no name or date. Interview with Licensed Practical Nurse (LPN) #500, at the time of the observation, verified the [MEDICATION(S)] insulin was not dated as to when it was opened, the opened vial of [MEDICATION(S)] insulin was expired, and the insulin pen did not have a name or date. Review of the manufacturer instructions dated [DATE] revealed open (in use) [MEDICATION(S)] insulin vials should be thrown away 28 days after the first use even if it still had insulin in it. Review of the manufacturer instructions dated [DATE] revealed in use (opened) Taujeo [MEDICATION(S)] single-patient use prefilled pens stored at room should be discarded after 56 days. Review of the manufacturer instructions dated [DATE] revealed for open (in use) [MEDICATION(S)] insulin the vial should be thrown away 28 days after the first use even if it still had insulin in it.