Every finding on record at Kingston Health Center of Perrysburg

Based on observation, staff interview, and facility policy review, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all residents who were identified to receive food from the kitchen. The facility census was 57. Findings Include:Observation on 07/13/26 at 7:40 A.M. of refrigerator in the first-floor kitchen revealed a container of [NAME] salad dressing with an expiration date of 04/26/26 and a container of Italian salad dressing with an expiration of 06/28/26. Interview on 07/13/26 at 7:40 A.M. with [NAME] #247 verified the container of [NAME] salad dressing had an expiration date of 04/26/26. [NAME] #247 also verified the container of Italian salad dressing had an expiration date of 06/28/26. Both containers were removed from the refrigerator by [NAME] #247 and discarded. Observation on 07/13/26 at 8:00 A.M. of patient refrigerator and freezer in the patient dining area on the third floor revealed an unmarked Styrofoam cup in the freezer with a frozen substance inside. The cup was not marked with a room number or expiration date. Continued observation of the patient refrigerator revealed a plastic bag marked with room [ROOM NUMBER] but no expiration date. The bag was removed and a sticky liquid substance was dripping from the bottom of the bag. Items were removed from the bag by [NAME] #247 and included, a closed bag of chips, an unwrapped muffin, a plastic container of green leafy vegetables, a container that appeared to have a salad dressing inside, and a container of grapes. Interview on 07/13/26 at 8:00 A.M. with [NAME] # 247 verified there was no date on the plastic bag of food removed from the refrigerator. [NAME] #247 also verified the bag was leaking a sticky substance. [NAME] #247 discarded all items. Observation on 07/13/26 at 8:18 A.M. of patient refrigerator and freezer in the dining area on the second floor revealed a container marked with a name, no room number or expiration date was noted. There was an unknown food substance inside the container. COncurrent interview with [NAME] #247 confimred the container had no room number or expiration date on the container. The container was discarded by [NAME] #247. Observation on 07/13/26 at 8:28 A.M. of patient refrigerator and freezer in the Bistro area located on the first floor revealed a plastic bag containing food items. The bag was not marked with a name or date. A second bag was removed from the refrigerator and was dated 05/05/26, the item inside the bag was removed and was marked as French onion dip. Continued observation revealed an opened jar of cherries without an opened-on date. Interview on 07/13/26 at 8:28 A.M. with [NAME] #247 verified there was an unmarked bag containing food items. [NAME] #247 stated the bag of food items was either expired or was the lunch of a nurse or therapist. [NAME] #247 verified staff should not be storing food items in the residents' refrigerators. [NAME] #247 also verified the opened jar of cherries did not have an opened-on date. [NAME] #247 stated the items opened in the refrigerator should have an opened-on date. Review of policy Food Brought into Facility last revised 07/09/25 revealed food and beverage items are to be properly labeled and date marked, stored and discarded in conjunction with the facilities Date [NAME] and Labeling Policy and Procedure. Review of the policy Food Labeling and Dating last revised 07/09/25 revealed any product removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following: item name, date and time the food was labeled, use by date, initials of the person labeling the item and securely cover the food item.

Based on observation, medical record review, staff and resident interview, the facility failed to ensure residents were informed of daily therapy schedules. This affected four (#85, #53, #98, and #108) of 54 resident identified by the facility to be receiving therapy services in a facility census of 57. Findings include: 1. Resident #85 admitted to the facility on [DATE] with the diagnosis including, left leg above knee amputation, Type II Diabetes Mellitus, hypertensive chronic kidney disease, malignant neoplasm of colon, alcoholic cirrhosis of liver, anemia, and atrial fibrillation. Review of the minimum data set assessment dated [DATE] Resident #85 was assessed with intact cognition, dependent on staff for activities of daily living, at risk for pressure ulcer development with a surgical wound. Observation on 07/14/26 at 9:08 A.M. noted Resident #85 up in the bathroom in room seated at the sink completing self activities of daily living. Resident #85 stated he was unaware when Occupational Therapy (OT) or Physical Therapy (PT) are scheduled for daily therapy sessions. Resident #85 stated he prefers to plan daily schedule to accommodate for showers, wound dressing changes, visits with guest, personal interests and wants to ensure this does not interfere with therapy treatments. Resident #85 stated he had guest arrive for visits and not be able to visit due to unannounced or lack of pre-scheduled therapy sessions. In addition to returning from therapy sessions to cold meals which needed reheated. On 07/14/26 at 10:52 A.M. Resident #85 was seated on his bed, dressed and groomed. Resident #85 stated he was continuing to wait for therapy and assistance with a shower followed by a wound dressing change. On 07/15/26 at 1:15 P.M. Resident #85 was observed up in room dressed and stated to be prepared for Occupational Therapy (OT) session. Resident #85 stated he attended Physical Therapy in the morning and was waiting for a family member to visit at 3:00 P.M. Resident #85 continued to state he was unaware of therapy sessions each day and wants to ensure attendance. The therapy staff do not provide a daily schedule for therapy services and arrive at various unscheduled times during the day. This caused interruptions in family visits, wound dressing changes, personal interest involvement and cold meals which need reheated. 2. Group interview during Resident Council meeting on 07/14/26 at 1:40 P.M. with five current residents identified by the facility with intact cognition revealed three of five residents (#53, #98, #108) were currently receiving therapy services. Residents #53, #98, #108 confirmed a new therapy scheduling process had been implemented for an undisclosed time. The process was described by the three residents as inconvenient and non-informative to residents who received therapy services. The residents stated they were unaware when therapy would take them to therapy and therapy staff arrive at rooms when residents are visiting or conducting personal unrelated business. At times residents return to rooms following therapy sessions to cold meals requiring them to get re-heated. On 07/14/26 at 2:15 P.M. interview with the Director of Therapy (DOT) confirmed the therapy department does not set a schedule for resident therapy sessions unless the resident makes a request. On 07/16/26 at 9:20 A.M. the Administrator provided a list of 54 current residents receiving therapy services.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure care-planned fall interventions were in place for Resident #108. This affected one resident (#108) of two residents (#56 and #108) reviewed for falls. The facility identified 10 residents (#2, #14, #50, #65, #69, #88, #106, #107, #108, and #111) as high-risk for falls. The facility census was 57. Findings Include:Review of the medical record for Resident #108 revealed an admission date of 07/09/26, with diagnoses including: unspecified fracture of first lumbar vertebra, unspecified nondisplaced fracture of fifth cervical fracture, unspecified nondisplaced fracture of sixth cervical vertebra, other specified fracture of left pubis, unspecified asthma, displaced fracture of body of scapula, hypertensive chronic kidney disease, hyperlipidemia, depression, stage 3B chronic kidney disease, atherosclerotic heart disease of native coronary artery, polyneuropathy, gastro-esophageal reflux disease, dysphagia, constipation, other symbolic dysfunctions, duodenal ulcer, diverticulitis of intestine, insomnia, presence of left artificial hip joint, history of falling, and generalized muscle weakness. Review of Resident #108's most recent admission Minimum Data Set (MDS) assessment, dated 06/05/26, revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating Resident #108's cognition was moderately impaired. Further review of this MDS assessment reveled Resident #108 required assistance with all functional abilities. Review of Resident #108's care plan revealed Resident #108 is at risk for falling related to weakness and history of falls with fractures with a goal of Resident #108 to remain free from falls with major injury. Care-planned interventions included staff to assist resident with transfers as needed, low bed and bilateral floor mats. Interview on 07/14/26 at 2:46 P.M. with Resident #108, daughter #400, and son-in-law #401, revealed the facility does not utilize both of the fall mats that are in Resident #108's room. Observation on 07/15/26 at 5:42 A.M. noted Resident #108 was in bed with lights off, eyes closed and bed in low position. Fall mat was noted in place next to the left bed. However, no fall mat was in place to the right side of the bed and was noted across the room leaning against the wall. Observation on 07/15/26 at 5:42 A.M. noted Resident #108 in bed with lights off, eyes closed and bed in low position. Fall mat was noted in place next to the left bed. However, no fall mat was in place to the right side of the bed and was noted across the room leaning against the wall. Interview on 07/15/26 at 5:45 A.M. with Certified Nursing Assistant (CNA) #280 verified the mat was not in place as indicated and Resident #108 was last observed at 4:00 A.M. Review of the facility policy titled, Fall Management Program Guidelines, dated 11/19/25, revealed the facility strives to mitigate fall risk factors and implement preventative measures. Care plan interventions should be implemented.

Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to timely address Resident #48's significant weight loss. This affected one resident (#48) of one resident reviewed for significant weight loss. This had the potential to affect five residents (#1, #42, #48, #56, and #68) identified by the facility has having significant weight loss. Additionally, the failed to ensure Resident #42's request for a protein snack after hemodialysis (HD) was honored. This affected one of one resident (#42) reviewed for post HD nutrition. The facility identified one resident (#42) who was on HD. The facility census was 57. Findings Include: 1. Review of the medical record for Resident #48 revealed an admission date of 05/22/26 with diagnoses including: displaced communal fracture of right femur, dysphagia, other symbolic dysfunctions, generalized muscle weakness, multiple fractures of ribs, cervical spinal stenosis, hypertensive chronic kidney disease, hyperlipidemia, stage four chronic kidney disease, asthma, driver injured in collision with unspecified motor vehicles in traffic accident, pure hypercholesterolemia, pleural effusion, polyneuropathy, malignant neoplasm of prostate, incisional hernia without obstruction or gangrene, fatty liver, anemia, iron deficiency anemia, calculus of kidney, presence of right artificial knee joint, presence of artificial hip joint, acquired absence of other genital organs, and acute pulmonary edema. Review of Resident #48's most recent admission Minimum Data Set (MDS) assessment, dated 05/29/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #48 was cognitively intact. Further review of this MDS assessment revealed Resident #48 required assistance with all functional abilities. Review Resident #48's medical record revealed a physician order, dated 05/27/26, to obtain monthly weight and vital signs on the first Tuesday of every month. Review of Resident #48's medical record revealed the following documented weights: an admission weight was obtained on 05/28/26 and was 169 pounds (lbs), his monthly weight was obtained on 06/02/26 and was 169 lbs, and his monthly weight was obtained on 07/08/26 and was 154 lbs. Review of Resident #48's documented weight measurements between 06/02/26 through 07/08/26 revealed a significant, unplanned, weight loss of 8.88%. Review of the medical record for Resident #48 revealed no documentation of communication for this significant, unplanned, weight loss of 8.88% until 07/14/26. Review of the progress notes for Resident #48 revealed a progress note dated 07/14/26 at 11:55 A.M. from Dietetic Technician #287 which documented Resident #48 had experienced a significant, unplanned, weight loss over the previous one month and suggested the addition of a nutritional supplement to provide added nutrition. Dietetic Technician #287's note documented she spoke with the facility Nurse Practitioner (NP) and the NP agreed with the addition of the nutritional supplement and was also planning on ordering Remeron (an oral medication used to increase appetite) to assist with Resident #48's appetite. Review of the medical record for Resident #48 revealed a physician order was placed on 07/15/26, beginning at 9:42 A.M., for Ensure Clear (clear liquid nutritional drink designed to provide essential vitamins, minerals, and hydration) every day. Review of the medical record for Resident #48 revealed no interventions were in place to address his significant, unplanned, weight loss of 8.88% between the date it was discovered on 07/08/26 and 07/15/26. Interview on 07/15/26 at approximately 12:30 P.M. with the Administrator revealed there were no interventions in place to address Resident #48's significant, unplanned, weight loss of 8.88% between the date it was discovered on 07/08/26 and 07/15/26. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery post fracture of left tibia, fracture of left fibula, end stage renal disease, kidney transplant and congestive heart failure. Review of the incomplete admission Minimum Data Set (MDS) for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors were documented. Review of the Inter Departmental (IDT) functional abilities assessment completed on 07/10/26 revealed Resident #42 needed substantial assistance with toileting hygiene, partial assistance with showering, and setup/cleanup assistance with personal hygiene. Review of the admission care plan for Resident #42 dated 07/08/26 revealed resident required increased caloric, protein and/or nutrient needs. Care plan also revealed Resident #42 was malnourished or at risk of malnutrition related to inadequate nutrient and energy intakes as well as metabolic demands. Review of physician orders for Resident #42 entered on 07/06/26 revealed diet order for consistent carbohydrate and 1800 milliliter fluid restriction. Additional diet order entered 07/06/26 for staff to offer high protein-caloric snack at bedtime as an intervention for risk of malnutrition. Interview on 07/15/26 at 8:30 A.M. with Resident #42 revealed she does not eat breakfast or lunch on her hemodialysis days due to not feeling well during dialysis if she eats. Resident #42 continued to state that she spoke with the Registered Dietitian and requested to have a protein snack after her return from hemodialysis. Resident #42 stated she has not received an after hemodialysis snack since her admission and she planned to bring this concern up in her care conference scheduled for 07/16/26. Review of Nutrition/RD Review for Resident #42 completed on 07/08/26 by Registered Dietitian (RD) #402 revealed Resident #42 disclosed she does not eat breakfast or lunch on the days she has hemodialysis completed. RD #402 also made note of Resident #42's complaint of being hungry upon her return from hemodialysis. RD #42 plan was to offer hard-boiled egg and sandwich in the afternoons and to offer yogurt at lunch. Interview on 07/16/25 with Unit Supervisor Registered Nurse (USRD) #317 revealed recommendations from the Dietitian are discussed in morning meetings and orders for diet changes are entered by nursing staff. USRD #317 verified there was not an order or diet change for Resident #42 to offer a hard-boiled egg and sandwich in the afternoons. USRD #317 also stated she could not verify Resident #42 was receiving or being offered a hard-boiled egg and sandwich after hemodialysis. Review of the facility policy titled, Clinical Services – Weight Monitoring, dated 07/01/26, revealed weight monitoring is to promote well-being of the residents and requires a multidisciplinary approach. Refer a 5% weight change to Registered Dietician (RD) or the Nutrition & Dietetics Technician, Registered (NDTR) for evaluation. Review of the facility policy titled, Guidelines for Weight Tracking, dated 07/01/26, revealed resident weight is monitored for weight gain and/or loss to prevent complications arising from complications arising from compromised nutrition/hydration. Residents will have their weight taken and recorded upon admission to establish a baseline. The facility dietician or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted. The physician, resident representative and dietician shall be notified of a weight variance of 5% in 30 days (unless on a planned weight loss or gain program.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions to promote range of motion were implemented as prescribed by the physician. This affected one resident (#56) of three residents reviewed for range of motion services. The facility census was 57. Findings include:Resident #56 admitted to the facility on [DATE] with the diagnosis including, cerebral infarction, aphasia, hemiplegia and hemiparesis affecting right dominant side, hypertensive chronic kidney disease, Type II Diabetes Mellitus, anxiety disorder, and polyneuropathy. According to the most current minimum data set assessment dated [DATE] Resident #56 was assessed with severe cognitive impairment, had no resistive behaviors, range of motion impairment to one side on both upper and lower extremities, was dependent on staff for the provision of activities of daily living, was incontinent of bowel and bladder, had no history of falls, was at risk for pressure ulcer development with no skin impairment, and received a diuretic, antiplatelet, hypoglycemic, and anticonvulsant medication. On 05/28/26 a physician order was implemented to apply right (R) resting whole hand finger orthotic for positioning to wear at night . Review of Treatment Administration Records between 06/16/26 and 07/15/26 routinely documented the resting hand splint as applied. Review of Resident #56 Profile Care Guide dated 05/28/26 noted the following interventions, [NAME] Hose/Splints: [NAME] Hose on A.M/off at bedtime (HS), Right finger orthotic applied at HS, Right hemi-lap tray on wheelchair (w/c) for positioning /comfort for right upper extremity (RUE) support as tolerated. compression stocking to RLE , on in A.M. and off at HS. Observation on 07/14/26 at 5:48 A.M. revealed Resident #56 was in bed with no resting hand splint applied and Resident #56's hand was in the closed fist position. On 07/14/26 at 8:50 A.M. Certified Nurse Aide (CNA) #259 and CNA #285 were observed to enter Resident #56's room and begin providing Resident #56 with morning activities of daily living. CNA #259 stated this was first opportunity to provide hands on contact with Resident #56 since assuming care at 6:00 A.M. CNA #259 stated Resident #56 did not have a resting hand splint in place when assuming care. CNA #285 went on to state she works night shift frequently and Resident #56 does not wear the resting hand splint. CNA #285 confirmed no alternative interventions had been attempted in place of the resting hand splint. On 07/15/26 at 5:49 A.M. Resident #56 was noted in low bed with no resting hand splint in place. Observation on 07/16/26 at 6:02 A.M. noted Resident #56 in bed. No resting hand splint was applied. Resident #56's hand was observed to be in the closed position. On 07/16/26 at 6:06 A.M. interview with Certified Nurse Aide (CNA) #286 verified Resident #56 did not have the resting hand splint applied. CNA #286 stated she assumed care of Resident #56 the previous night at 10:00 P.M. and the splint was not applied. CNA #56 indicated Resident #56 often refused to wear the splint. However, no attempts for alternative interventions had been implemented. On 07/16/26 at 6:16 A.M. interview with the Director of Nursing (DON) verified Resident #56 often refuses use of the resting hand splint. The DON went on confirm no additional interventions or refusals of the resting hand splint were documented in the medical record.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure a resident was placed in Enhanced Barrier Precautions (EBP) according to the facility policy. This affected one resident (#42) out of six reviewed for EBP. Total number of residents in the facility with EBP was 25. The facility census was 57. Findings Include:Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery post fracture of left tibia, fracture of left fibula, end stage renal disease, kidney transplant and congestive heart failure. Review of the incomplete admission Minimum Data Set (MDS) dated [DATE] for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors documented. Review of Inter Departmental (IDT) functional abilities assessment completed on 07/10/26 revealed Resident #42 needed substantial assistance with toileting hygiene, partial assistance with showering, and setup/cleanup assistance with personal hygiene. Review of the admission care plan for Resident #42 dated 07/03/26 revealed resident had renal failure resulting in the need for hemodialysis. Review of physician orders for Resident #42 entered on 07/07/26 revealed an order to monitor dialysis port, located to left chest, for signs and symptoms of infection once a day. Further review of the orders for Resident #42 revealed no order for EBP. Interview on 07/15/26 at 10:55 A.M. with Director of Nursing (DON) verified that Resident #42 should be in EBP due to the hemodialysis port to her left chest. DON also verified Resident #42 was currently not in EBP. Review of the policy titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure dated 04/01/24 revealed EBP will be in place during high-contact care activities for residents with the following conditions: all residents with indwelling medical devices including but not limited to catheters, central lines, feeding tubes, and tracheostomy.

Based on observation, staff interview, medical record review, and review of facility policy. The facility failed to ensure medications were appropriately and safely stored. This affected one resident (#108) of one resident reviewed for medication storage. The facility census was 57. Findings Include:Review of the medical record for Resident #65 revealed an admission date of 06/29/26 with diagnoses including right femur fracture, generalized muscle weakness, oropharyngeal dysphagia, other symbolic dysfunctions, presence of right artificial hip joint, solitary pulmonary nodule, cyst of pancreas, wedge compression fracture of first lumbar vertebra, vitamin D deficiency, dementia, diastolic heart function, cervical spondylosis, fracture of one rib on right side, other specified disorders of bone density and structure, depression, acute posthemorrhagic anemia, urinary tract infection, bradycardia, Parkinson's disease, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, Type Two Diabetes Mellitus, presence of aortocoronary bypass graft, hyperlipidemia, and hypothyroidism. Review of Resident #65's most recent Medicare 5-day Minimum Data Set (MDS) assessment, dated 07/02/26, revealed a Brief Interview of Mental Status (BIMS) score of three, indicating Resident #65 was cognitively impaired. Further review of this MDS assessments revealed Resident #65 required assistance for all functional abilities. Observation on 07/13/2026 at 11:03 A.M. revealed a white oblong pill was on Resident #65's bedside table. Upon picking this pill up, Resident #65 dropped it down her shirt. Observation on 07/13/2026 at 11:06 A.M. revealed a white oblong pill was retrieved from down Resident #65's shirt by Registered Nurse (RN) #271. Interview on 07/13/26 at 11:07 A.M. with RN #271 verified she retrieved a white oblong pill from down Resident #65's shirt and this medication was unsecured in Resident #65's room. Interview on 07/13/2026 at 11:09 A.M. with Licensed Practical Nurse (LPN) #293 revealed Resident #65 does not have an order to self-administer medication. Interview on 07/13/26 at 11:11 A.M. with LPN #293 and RN #317 revealed the white oblong pill observed in Resident #65's room was a 20 milliequivalent (mEq) tablet of Potassium Chloride (KCl) (mineral and electrolyte). Concurrent interview with LPN #293 revealed she administered the physician-ordered Potassium Chloride 20mEq to Resident #65 on 07/13/26 at 8:00 A.M. Review of the medical record for Resident #65 reveled she does not have an order self-administer medication. Further review of the medial record for Resident #65 revealed a physician order, dated 06/29/26, for 20 mEq of Potassium Chloride to be administered once per day for supplement. Review of the facility policy titled, Medication Administration General Guidelines, dated January 2018, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The person who prepares the dose for administration is the person who administers the dose. Residents are allowed to self-administer medications only when specifically authorized by the attending physician. The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, staff interview, medical record review, review of manufacturer's instructions for use, and review of facility policy, the facility failed to ensure a significant medication error did not occur for Resident #65. This affected one resident (#65) of four residents (#33, #65, #97, and #109) reviewed for medication administration. The facility identified two residents (#65 and #111) prescribed Carbidopa-Levodopa (the primary medication used to treat Parkinson's disease and related symptoms such as tremors, stiffness, and slow movement). The facility census was 57. Findings Include:Review of the medical record for Resident #65 revealed an admission date of 06/29/26 with diagnoses including right femur fracture, generalized muscle weakness, oropharyngeal dysphagia, other symbolic dysfunctions, presence of right artificial hip joint, solitary pulmonary nodule, cyst of pancreas, wedge compression fracture of first lumbar vertebra, vitamin D deficiency, dementia, diastolic heart function, cervical spondylosis, fracture of one rib on the right side, other specified disorders of bone density and structure, depression, acute posthemorrhagic anemia, urinary tract infection, bradycardia, Parkinson's disease, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, Type Two Diabetes Mellitus, presence of aortocoronary bypass graft, hyperlipidemia, and hypothyroidism. Review of Resident #65's most recent Medicare 5-day Minimum Data Set (MDS) assessment, dated 07/02/26, revealed a Brief Interview of Mental Status (BIMS) score of three, indicating Resident #65 was cognitively impaired. Further review of this MDS assessment revealed Resident #65 required assistance for all functional abilities. Review of the medical record for Resident #65 revealed a physician order dated 07/06/26 for 25-100 milligrams (mg) Carbidopa-Levodopa to be administered twice per day at 7:00 A.M. and 3:00 P.M. Observation on 07/15/26 at 10:33 A.M. revealed Resident #65's physician-ordered 7:00 A.M. dose of 25-100 mg Carbidopa-Levodopa was not administered until 10:33 A.M. Interview on 07/15/26 at 10:34 A.M. with Licensed Practical Nurse (LPN) #261 verified Resident #65's 25-100 mg Carbidopa-Levodopa was physician-ordered to be administered at 7:00 A.M. and was not administered until 10:33 A.M. Further interview with LPN #261 revealed the facility policy states that medications are to be administered within 60 minutes of their ordered administration time. Review of the manufacturer's instructions for use for Carbidopa-Levodopa revealed it is important that Carbidopa-Levodopa be taken at regular intervals according to intervals outlined by the prescribing physician. Review of the facility policy titled, Medication Administration General Guidelines, dated November 2018, revealed medications are to be prescribed and administered in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are to be administered within 60 minutes of scheduled time.

Based on observation, resident interview, medical record review, staff interview and facility policy review, the facility failed to change the dressing of a Vascular Access Device (VAD) according to physicians' orders and the facility policy. This affected one resident (#38) out of one reviewed for intravenous medications. The facility census was 57. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery and infection/inflammatory reaction due to right hip prosthesis. Review of the admission Minimum Data Set (MDS) assessment for Resident #38 dated 07/11/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors documented. Functional abilities included partial assistance with showering and substantial assistance with lower body dressing. Review of the admission care plan for Resident #38 dated 07/14/26 revealed resident requires intravenous (IV) medications related to a joint infection requiring antibiotics. Review of physician orders entered on 07/04/26 revealed an order for VAD dressing change every seven days. Interview on 07/14/26 at 9:05 A.M. with Resident #38 revealed a concern regarding her VAD dressing not being changed since admission. Observation on 07/14/26 at 9:05 A.M. of VAD dressing to Resident #38's upper right arm revealed a dressing date of 07/04/26. Review of the medication administration record for Resident #38 revealed VAD dressing was due to be changed 07/11/26. Interview on 07/14/26 at 9:30 A.M. with Staff Development Registered Nurse (SDRN) #265 verified the order for VAD dressing to be changed every seven days. VAD dressing was then assessed by SDRN #265 and verification received from SDRN #265 that VAD dressing was dated for 07/04/26. SDRN #265 also verified, according to the physicians' orders the VAD dressing is past due to be changed. Review of policy titled Vascular Access Device (VAD) Dressing Change last revised 12/10/25 revealed VAD dressing changes are to be completed at routine intervals every five to seven days and as needed if the integrity of the dressing is disrupted.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure Resident #112's call light was timely answered. This affected one resident (#112) reviewed for call light response time. The facility census was 57. Findings Include: Review of the medical record for Resident #112 revealed an admission date of 07/13/26, with diagnoses including: right achilles tendinitis, syncope and collapse, type two Diabetes Mellitus, hyperlipidemia, hypertension, morbid obesity, generalized anxiety disorder, orthostatic hypotension, hypothyroidism, neuralgia and neuritis, other cervical disc degeneration, history of falling, allergic rhinitis, body mass index 39.0 - 39.9, elevation of levels of liver transaminase, generalized muscle weakness, difficulty in walking, depression, and insomnia. Review of Resident #112's most recent Medicare 5-day Minimum Data Set (MDS) assessment, dated 07/15/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #112 was cognitively intact. Further review of this MDS assessment revealed Resident #112 required assistance for all functional abilities. Observation of the call light monitor on 07/14/26 at 7:31 A.M. revealed Resident #112's call light had been alarming for 35 minutes. Interview on 07/14/26 at 7:31 A.M. with Licensed Practical Nurse (LPN) #292 verified Resident #112's call light had been alarming for 35 minutes. During an interview on 07/14/26 at 7:33 A.M., Resident #112 tearfully stated that she has been pushing her call light for more than one-half hour in an attempt to request assistance with toileting. Further interview with Resident #112 revealed that staff is slow to answer her call light and she finds this upsetting. Interview on 07/14/26 at 7:37 A.M. with LPN #265 verified Resident #112's call light has been alarming for 39 minutes. Observation on 07/14/26 at 7:38 A.M. revealed LPN #265 and Certified Nursing Assistant (CNA) #306 entered Resident #112's room to assist her to the restroom. Interview on 07/14/26 at 8:41 A.M. with the Administrator revealed the facility does not have a specific policy for call light response time, but her expectation is for call lights to be answered timely. Further interview with the Administrator revealed call lights are ideally to be answered in five to 10 minute, but there should never be a time a call light is unanswered for greater than 30 minutes.

Based on medical record review, staff interview and policy review, the facility failed to develop a plan of care to address the administration and monitoring of an anticoagulant medication. This affected one resident (#20) out of 21 residents whose care plans were reviewed. The facility census was 57. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included fracture of left ischium, Type II Diabetes Mellitus, chronic pulmonary embolism, congestive heart failure and atrial fibrillation. Review of the Minimum Data Set (MDS) for Resident #20 dated 06/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #20 had no behaviors documented. Functional abilities included dependent on others for sit to stand, chair to bed transfer, toilet transfers and car transfers. Review of orders entered for Resident #20 revealed an order for Apixaban (anticoagulant) 5 milligrams (mg) to be taken orally twice a day. Special instructions noting medication is to be taken for atrial fibrillation. Review of the revised care plan for Resident #20 dated 06/08/26 revealed potential for cardiovascular distress related to diagnosis of peripheral vascular disease and atrial fibrillation. No care plan noted regarding risk for excessive bleeding related to anticoagulant medication.Interview on 07/15/26 at 9:29 A.M. with Director of Nursing verified Resident #20 did not have a care plan to monitor for the risk of excessive bleeding related to anticoagulants. Review of the policy titled Comprehensive Care Plan Guideline last revised on 05/22/18 revealed care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident.

Based on observation, staff interview, medical record review, review of maintenance documents, and review of the facility's policies, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing care for residents who were infected with COVID-19. This affected one (Resident #114) of one resident observed for droplet precautions. Additionally, the facility failed to complete weekly water flushes of equipment at risk for developing Legionella pneumophila (the cause of Legionnaire's Disease). This had the potential to affect all 55 residents in the facility. Findings include: 1. Review of the medical record for Resident #114 revealed an admitted [DATE] with a diagnosis of COVID-19 on 09/12/24. Review of modified 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 had intact cognition. Review of a physician order dated 08/27/24 revealed Resident #114 received occupational therapy (OT) five times weekly for 60 days. Review of a physician order dated 09/12/24 revealed Resident #114 was positive for COVID-19. Review of a physician order dated 09/17/24 revealed Resident #114 should remain in droplet precautions in single room isolation due to COVID-19 through 09/22/24. Review of the Matrix provided by the facility on 09/16/24 revealed Resident #114 tested positive for COVID-19 and was in droplet isolation. Observation on 09/16/24 at approximately 10:00 A.M. revealed Resident #114's door was closed. Upon the door was a yellow apron with several pockets containing PPE. Additionally, a sign indicated Resident #114 was in droplet precautions. Interview on 09/16/24 at approximately 3:15 P.M. with the Director of Nursing (DON) confirmed residents in droplet precautions require staff to wear PPE prior to entering the resident's room. Required PPE included an N95 mask, a gown, gloves, and eye protection. Observation on 09/18/24 at 2:59 P.M. revealed a housekeeper in the doorway of Resident #114's room removing PPE and placing it in the appropriate disposal bin. As the housekeeper exited the room and pulled the door closed, an observation was made of a person not wearing a yellow disposable gown and sitting in a chair inside Resident #144's room. Interview and concurrent observation on 09/18/24 at 3:00 P.M. with Occupational Therapist (OT) #437 revealed he was putting on a yellow disposable gown when he came to Resident #114's doorway to answer the surveyor's knock at the door. OT #437 confirmed he was sitting in Resident #114's for a moment, setting his things down, and was just putting on the gown. OT #437 was wearing an N-95 mask. Continued interview and observation confirmed OT #437 was not wearing eye protection or gloves. OT #437 continued to tie on the disposal gown during the interview. Review of OT #437's Daily Treatment Log for 09/18/24, printed 09/19/24, revealed Resident #114 was the last person OT #437 treated for the day. Review of the policy, Resident COVID-19 Quarantine Guidance, revised 01/05/24, revealed residents who tested positive for COVID-19 must be placed in transmission-based precautions and full PPE must be worn, including face mask, gloves, eye protection and a gown. Further review revealed an N95 mask was required to be worn by all staff providing direct patient care to residents in transmission based precautions. 2. Review of the maintenance document titled, Weekly Fixture Exercise Log, revealed each device must be exercised 30 seconds weekly minimum revealed the log identified several locations throughout the facility, including (but not limited to) trash chutes, the salon, the Bistro restroom, restrooms, housekeeping closets, and the education room. Review of the Weekly Fixture Exercise Logs dated January 2024 through May 2024 revealed the exercise occurred only the first week of the month. Further review revealed no logs were available for June 2024 through August 2024. Interview on 09/19/24 at 1:33 P.M. with Maintenance Manager (MM) #349 revealed he began working at the facility 12 days prior. MM #349 confirmed the facility identified the areas on the Weekly Fixture Exercise Log as areas at risk for growing Legionella pneumophilia and therefore, the areas needed to be flushed by letting water run for at least 30 seconds weekly. MM #349 could provide no evidence the areas were flushed weekly since January 2024. Review of the policy Water Management Protocol, dated 08/2019, revealed the policy was established to provide appropriate monitoring and proactive intervention relative to the skilled nursing facility potable water systems. Further review revealed fixtures will be exercised and allowed to flush with a moderate or better flow for 30 seconds weekly. The exercise would be documented on the Weekly Fixture Exercise Log.

Based on observation and staff interview, the facility failed to ensure the gap between mattresses and bed rails were safe and appropriate. This affected one (#32) of two residents reviewed for bed rails. The facility census was 55. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure and quadriplegia. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was rarely/never understood and was dependent on staff for all Activities of Daily Living (ADLs). Review of the Bed Rail Safety assessment dated [DATE] revealed Resident #32 was appropriate for bed rails to assist in alerting staff when unsafe transfers were attempted. Review of the current care plan for Resident #32 revealed bed rails were in place to provide a feeling of comfort/security, increase mobility, and act as a bed perimeter reminder. Interview on 09/16/24 at 9:25 A.M. with Licensed Practical Nurse (LPN) #362 revealed Resident #32 was quadriplegic and had no function of his arms and legs. Observation on 09/17/24 at 5:25 P.M. revealed Resident #32 lying in bed on an air mattress. A large gap was identified between Resident #32's mattress and the bed rails. Interview and observation on 09/18/24 at 10:15 A.M. with the Director of Nursing (DON) confirmed the gap between Resident #32's mattress and bed rail was 5.25 inches on his left side, measured at the narrowest point, and 3.25 inches on his right side, measured at the narrowest point. Interview on 09/18/24 at 4:47 P.M. with the DON revealed she was unable to obtain manufacturers guidelines for Resident #32's bed regarding the acceptable distance between the mattress and bedrails; however, the DON confirmed the gaps Resident #32's were too large and were potentially unsafe.

Based on observation, resident interview, staff interview, and policy review, the facility failed to assist dependent male residents with shaving. This affected two (Residents #22 and #157) of two reviewed for activities of daily living. The facility census was 55. Findings include: 1. Review of Resident #22's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia, hemiparesis, and diabetes mellitus. Review of Resident #22's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required substantial assistance for showering and bathing. Review of Resident #22's most recent care plan revealed the resident required assistance with activities of daily living related to weakness. He required assistance with dressing and grooming. Observation of Resident #22 on 09/16/22 revealed he had a full beard which was uneven and approximately 1.5 inches long. Interview with Resident #22 on 09/16/24 at 1:23 P.M. revealed he wanted his beard shaved off, but staff were unable to do so due to not having the proper equipment. The resident required assistance with shaving due to the inability to lift his left arm. Review of Resident #22's progress note dated 09/18/24 revealed the resident voiced he would like to have his beard shaved off. The nurse informed the resident that the beautician does provide beard trims, but the resident stated he wanted it shaved all of the way. The nurses informed the resident that staff could assist with shaving and Resident #22 agreed and asked the nurse to assist and she stated she didn't have time, but staff would assist him in the morning. Interview with Occupational Therapy Assistant #356 on 09/18/24 revealed she did assist Resident #22 with trimming his neck area with a razor, but the facility did not have a trimmer to shave off the beard. She stated he would have to wait to get home to shave where he owned the proper equipment. 2. Review of Resident #157's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia, hemiparesis, dysphasia, aphasia, and congestive heart failure. Review of Resident #157's admission MDS dated [DATE] revealed he had was cognitively intact. The resident required set up for personal hygiene including shaving. Review of Resident #157's most recent care plan revealed he required assistance with ADL care related to left hemiplegia and dysphasia. The resident should receive appropriate assistance for ADLs through next review. Observation on 09/16/24 at 9:50 A.M. revealed Resident #157 had approximately 1/2 inch of beard growth and stated he was unable to get assistance from staff for shaving. Interview with Resident #157 on 09/16/24 at 9:50 A.M. revealed he wanted to have his beard trimmed, but could not receive assistance from staff. Interview with State tested Nursing Aides (STNA) #316 and #359 on 09/17/24 between 8:10 A.M. and 8:32 A.M. revealed the residents usually brought their electric razors on admission, but the facility did supply disposable razors. Once the resident's beards were longer the disposable razors were ineffective. Review of the facility policy titled, Shaving the Resident, dated 01/2024 revealed the purpose of this procedure is to promote cleanliness and to provide skin care. Notify the supervisor if the resident refuses the procedure document the reasons why and interventions taken.

Based on medical record review, observation, resident interview, staff interview, and review of policy, the facility failed to ensure pressure ulcer reducing interventions were implemented as ordered. This affected one (#41) of one residents reviewed for pressure ulcers. The facility census was 55. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included other incomplete lesion at C1, C2, C3, and C4 level of cervical spinal cord, acute and chronic respiratory failure with hypoxia, type two diabetes mellitus with hyperglycemia, pressure ulcer of sacral region stage four, and pressure ulcer of other site stage four. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had range of motion impairment on the upper and lower extremities. Resident #41 required substantial/maximal assistance with toileting, bathing and was dependent for transfers. Review of physician orders dated 03/25/24 revealed Resident #41 to off-load heels when in bed if the resident tolerates or will allow. Review of physician orders dated 04/02/24 revealed Resident #41 had an order for a pressure relieving aircushion to the wheelchair to promote skin integrity. With an additional note to plug in at nighttime. Review of the most recent care plan revealed Resident #41 was care planned for impaired skin integrity due to coccyx pressure wound, right posterior leg (calf), and pressure injury right heal. Interventions included offloading boots on while in bed, elevate heels when in bed, and pressure relieving aircushion to the wheelchair. Review of pressure injury review dated 09/13/24 revealed Resident #41 had coccyx wound currently at a stage three measuring 1.4 centimeter (cm) x 0.5 cm x 0.1 cm., a right posterior leg stage 4 measuring 4.6 cm x 1.7 cm x 0.9 cm, and a deep tissue pressure injury of the right heel measuring 0.6 cm x 1.5 cm x 0.0. Review of wound documentation revealed no worsening of the pressure wounds from the previous week. Observation on 09/16/24 at 2:19 P.M. of Resident #41 revealed the resident laying in bed with no heel boots applied and heels not elevated. Resident was observed to be wearing thin slippers on her feet. Interview on 09/16/24 at 2:21 P.M. with Resident #41 revealed the heel boots and elevating the heels was typically only done at nighttime. Resident #41 stated she had not refused to have her heels elevated. Interview on 09/16/24 at 2:59 P.M. with the Administrator verified Resident #41 did not have the heel boots applied and the heels were not elevated while Resident #41 was in bed. Observation on 09/17/24 at 8:58 A.M. revealed Resident #41 sitting up in her wheelchair in the resident room. Observation of the alternating pressure wheelchair seat cushion was turned off. Interview on 09/17/24 at 9:01 A.M. with Licensed Practical Nurse (LPN) #407 verified the alternating pressure wheelchair seat cushion was off stating it needed to be plugged in and turned on. Review of policy Pressure Injury: Assessment and Prevention, approved 06/09/22, verified the facility will identify residents at risk for developing pressure injuries and implement interventions to prevent the development of pressure injuries. Interventions include to encourage and assist residents to assist to float/offload heels to keep the heels off the bed and use pillows, wedges, and/or other devices for repositioning.

Based on medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure care conferences were offered quarterly. This affected two (#13 and #41) of three residents reviewed for care plan conferences. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart disease without heart failure, major depressive disorder recurrent, and mixed hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not assessed for cognition. The previous MDS assessment, dated 04/04/24, revealed Resident #13 was cognitively impaired. Review of the social service progress note dated 11/02/23 revealed a care conference was held. Further review of the medical record revealed no additional care conferences were completed. Interview on 09/19/24 at 10:54 A.M. with Licensed Social Worker (LSW) #460 verified a care conference had not been held for Resident #13 since the documented care conference on 11/02/23. LSW #460 reported Resident #13's resident representative did not want to meet over the summer due to personal reasons. LSW #460 reported the interdisciplinary team met but did not attempt to include the resident and did not document meeting as a care conference. 2. Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included other incomplete lesion at C1, C2, C3, and C4 level of cervical spinal cord, acute and chronic respiratory failure with hypoxia, type two diabetes mellitus with hyperglycemia, pressure ulcer of sacral region stage four, and pressure ulcer of other site stage four. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the social service progress notes dated 04/10/24 revealed a care conference was held. Further review of the medical record revealed no other documented care conferences taking place. Interview on 09/16/24 at 2:37 P.M. with Resident #41 revealed she could not recall having a care conference. Interview on 09/18/24 at 11:10 A.M. with LSW #460 verified Resident #41 has not had a documented care conference since April 2024. Review of policy, Care Update Meeting, approved 03/06/19, verified care update meeting will be held every 90 days on all residents. If the resident or representative cancels or does not come to the scheduled meeting the medical record should reflect this.

Based on observation, record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents were provided a bed long enough to accommodate their height. This affected one (#107) of one resident reviewed for bed length. The facility census was 55. Findings include: Review of the medical record for Resident #107 revealed an admitted [DATE] with diagnoses of osteoarthritis, anxiety, and gout. Review of the Admission Evaluation/Observation dated 09/03/24 revealed Resident #107 was alert and oriented to person, place, time, and event. Review of the Resident #107's height, documented 09/03/24, revealed he was 78 inches tall (six feet, six inches tall). Review of a nurses progress note dated 09/03/24 revealed a tall bed was ordered for Resident #107. Observation and interview on 09/16/24 at 9:33 A.M. revealed Resident #107 in bed with the head of the bed elevated to allow him to sit up in bed. Resident #107's head was at the same height as the top of the mattress and he had pillows under each knee keeping his knees bent. A flat footboard was flush against the end of the mattress and extended approximately one-and-one-half feet above the mattress. Resident #107 stated he was not comfortable in the bed and stated he was given the extended bed but it was still too short. Resident #107 stated he was six feet, six inches tall. Observation on 09/17/24 at 1:58 P.M. revealed Resident #107 in bed with the head of bed elevated and both legs propped up at the knees with pillows in such a way to keep both legs bent. Observation and interview on 09/17/24 at 5:16 P.M. with Resident #107 and his daughter revealed Resident #107 again with the head of bed elevated and both legs bent at the knee with pillows under them. Resident #107 stated he had not slept well the previous evening and again confirmed the bed was too short. Interview on 09/18/24 at 10:22 A.M. with the Assistant Director of Nursing (ADON) #319 stated she was aware Resident #107 had a long bed. ADON #319 stated she did not know whether Resident #107's height was considered when the facility requested a long bed from the contracted supplier. ADON #319 stated she was not aware Resident #107's bed was too short for him; however, she was aware his bed had a very high footboard. Interview on 09/18/24 at 10:34 A.M. with State tested Nurse Aide (STNA) #359 revealed he was familiar with Resident #107 and was aware the bed seemed a little short for Resident #107. STNA #359 stated there were a few techniques, such as bending his legs and sliding Resident #107 to the very top of the bed, to keep Resident #107 from being so tight in the bed. STNA #359 stated he reported his concern regarding the length of Resident #107's bed to the nurse but could not recall which nurse he reported it to. Follow up interview on 09/18/24 at 11:10 A.M. with ADON #319 revealed she spoke with the bed supplier and learned Resident #107's bed was 80 inches (six feet, eight inches) long and further stated she ordered a longer bed for Resident #107 and was told by the contracted supplier the bed would be delivered later in the day. Interview on 09/18/24 at 12:16 P.M. with ADON #319 revealed she did not visualize Resident #107 in his bed before calling to order a longer bed. ADON #319 stated she spoke with Licensed Practical Nurse (LPN) #362, who was the floor nurse for Resident #107, and LPN #362 told ADON #319 Resident #107 looked uncomfortable in his bed. Observation on 09/18/24 at 12:18 P.M. revealed Resident #107 lying in the newly delivered bed. Resident #107 was able to fully extend his legs without his feet pressing against the footboard. Interview on 09/19/24 at 8:18 A.M. with Resident #107 stated the longer bed was much better. Resident #107 stated he slept for seven hours the previous night due to the comfort of his bed. Review of the policy, Accomodation of Needs, dated October 2023, revealed the resident's individual needs and preferences, including the need for modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. Additionally, the resident's individual needs and preferences shall be accommodated to the extent possible.

Based on observation and staff interview, the facility failed to ensure residents had access to a call light. This affected one (#32) of one resident reviewed for call light accessibility. The facility census was 55. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure and quadriplegia. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was rarely/never understood and was dependent on staff for all Activities of Daily Living (ADLs). Review of the current care plan for Resident #32 revealed he had a communication problem, Resident #32 was unable to communicate and had been working with speech language pathology (SLP) therapy, outpatient, to use eye gaze device. Interventions included keeping Resident #32's call light in reach. Interview on 09/16/24 at 9:25 A.M. with Licensed Practical Nurse (LPN) #362 revealed Resident #32 was quadriplegic and had no function of his arms and legs. Observation on 09/16/24 at 2:29 P.M. revealed Resident #32 lying in bed with a standard push-call light button clipped to his bed near his left upper arm. Resident #32 had an electronic communication board in front of his face propped up by a metal stand. Observation of Resident #32's communication board revealed he requested help and wanted the head of his bed lowered. The ODH surveyor pressed the call light and LPN #362 entered the room. LPN #362 confirmed Resident #32 could not use the call light and staff would frequently check on him. LPN #362 did not believe Resident #32's communication board was connected to the call light system. Interview on 09/17/24 at 2:31 P.M. with SLP #410 revealed she was familiar with Resident #32 who used the electronic communication board and stated Resident #32 was able to use the device well to communicate and answer questions. SLP #410 explained Resident #32 used his eyes to focus on a word or letter and the device would detect what his eyes focused on and would type the letter or word on the monitor. SLP #410 stated Resident #32's computer also had an audible button that would speak and say I need the nurse or I need help. SLP #410 stated his device was not connected the call light system. Further interview revealed SLP #410 was not aware if the facility had access to a breath-activated call light device but thought Resident #32 could be able to use one. Observation on 09/17/24 at 1:52 P.M. revealed Resident #32 lying in bed. Resident #32's electronic communication board was backed against the wall on Resident #32's right side and was not within visual range for him. Observation on 09/17/24 at 3:08 P.M. revealed Resident #32 lying in bed. Resident #32's electronic communication board remained backed against the wall on Resident #32's right side and was not within visual range for him. Continuous observation on 09/17/24 from 3:08 P.M. until 4:35 P.M. revealed State tested Nurse Aide (STNA) #417 providing care to Resident #37, Resident #104, and Resident #105. STNA #417 was not seen providing care to Resident #32 during the observation. Interview on 09/17/24 at 4:35 P.M. with STNA #417 stated she began her shift at 1:50 P.M. and the STNA from first shift left the floor when STNA #417 arrived. STNA #417 confirmed she had not yet provided care for Resident #32 since beginning her shift. STNA #417 confirmed Resident #32's electronic communication board was placed out of range for him to use it. STNA #417 confirmed she observed Resident #32 effectively use the electronic communication board. Interview and observation on 09/17/24 at 5:25 P.M. with STNA #417 confirmed Resident #32 was repositioned; however, his electronic communication board remained out of range. STNA #417 stated it took time to reposition the electronic communication board and had not returned to his room to place it in range. Review of the policy, Answering the Call Light, dated 02/2023, revealed the use of call lights should be explained and demonstrated to residents and staff should ensure the resident can use the call system.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (Resident #34 and #152) out of 28 resident bedrooms observed on the second floor of the facility. The census was 52. Findings include: 1. Review of Resident #34's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders dated between 05/03/22 and 06/07/22 revealed Resident #34 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of medication administration records (MARs) from May 2022 and June 2022 revealed no documentation of Resident #34 ever having received artificial tears while in the facility. Review of progress notes between 05/03/22 and 06/07/22 revealed no documentation of Resident #34 having received artificial tears while in the facility. Observation on 06/06/22 at 11:17 A.M. revealed Resident #34 had a bottle of artificial tears eye drops, a medication for dry eyes, inside of its box located on a shelf in Resident #34's bedroom among other personal items. Observation inside the box revealed the plastic seal on the eye drops bottle was removed. Observation on 06/07/22 at 1:17 P.M. revealed the box with the bottle of artificial tears medication remained in Resident #34's bedroom. Interview on 06/07/22 at 1:17 P.M. with Resident #34 revealed an unidentified nurse gave him the bottle of artificial tears because he complained about having an itchy left eye. Resident #34 stated he could not remember the nurses name, what she looked like, or the day the bottle was given to him, and stated he only used the eye drops once. Resident #34 stated he did not know the eye drops were still in his bedroom and stated the nurse must have left them in the room in case he needed to use them again. Observation on 06/08/22 at 2:12 P.M. revealed the box with the bottle of artificial tears medication still remained in Resident #34's bedroom. Interview on 06/08/22 at 2:46 P.M. with Licensed Practical Nurse (LPN) #464 verified there was a bottle of artificial tears medication in Resident #34's bedroom and LPN #464 removed it. LPN #464 stated she was not aware of anytime Resident #34 received the medication and verified it should not be stored in his bedroom. 2. Review of Resident #152's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE] revealed Resident #152 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders dated between 05/19/22 and 06/08/22 revealed Resident #152 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MARs from May 2022 and June 2022 revealed no documentation of Resident #152 having received [MEDICATION(S)] in the facility. Review of progress notes between 05/19/22 and 06/08/22 revealed no documentation of Resident #152 having received [MEDICATION(S)] while in the facility. Observation on 06/06/22 at 11:10 A.M. revealed a partial bottle of [MEDICATION(S)], a antacid medication, tablets on a shelf under the television in Resident #152's bedroom. Observation on 06/07/22 at 1:15 P.M. and on 06/08/22 at 8:32 A.M. revealed the partial bottle of [MEDICATION(S)] tablets remained in Resident #152's bedroom. Observation on 06/08/22 at 2:14 P.M. revealed the partial bottle of [MEDICATION(S)] remained in Resident #152's bedroom. Interview with Resident #152 at that time revealed she brought the medication with her from home because she sometimes had acid reflux but had not taken any of the [MEDICATION(S)] since she was in the facility. Interview on 06/08/22 at 2:40 P.M. with LPN #464 verified the partial bottle of [MEDICATION(S)] in Resident #152's bedroom and LPN #464 told Resident #152 she was going to secure the medication. At that time, Resident #152 told LPN #464 she had not taken any of the medication since she was admitted to the facility. LPN #464 stated she was not aware of anytime Resident #152 received the medication and verified it should not be stored in her bedroom. Review of a facility policy titled Storage of Medications, dated 01/07/21, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems and each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure medications were not left at bedside and were administered appropriately. This affected one (Resident #30) out of 24 residents on the third floor. The facility census was 52. Findings include: Review of Resident #30's medical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)], multiple fractures due to a preadmission fall, diabetes mellitus, and depression. Review of Resident #30's 5-day Admission Minimum Data Set assessment dated [DATE] revealed Resident #30 had a high cognitive function. Review of Resident #30's most recent care plan revealed the resident had impaired swallowing related to dysphagia and wearing a cervical collar. Interventions included to observe the resident for signs and symptoms of swallowing issues. Observation on 06/06/22 at 9:51 A.M. revealed Resident #30 was laying in bed with a plastic cup on her bedside table. The cup contained four medication tablets. Interview with Resident #30 on 06/06/22 at 9:52 A.M. revealed she had taken a couple of pills like but liked to take the rest at her leisure so the nurse would leave the medication at the bedside. Interview with Licensed Practical Nurse (LPN) #462 on 06/06/22 at 9:54 A.M. verified she placed Resident #30's medications in a cup on her bedside table for her to take on her own because Resident #30 took the medication slowly. Interview with the Administrator, Director of Nursing, and Corporate Nurse #463 on 06/09/22 at 10:48 A.M. verified Resident #30 was not to have medications left at the bedside table. Review of the facility policy titled Administering Medications, dated June 2019, revealed residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.