Every finding on record at Kingston Health Center of Vermilion

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure showers were provided to dependent residents as scheduled. This affected two (#72 and #37) of three residents reviewed for showers. Additionally, the facility failed to ensure residents received timely assistance with eating. This affected three (#37, #84, and #65) of three residents reviewed for assistance with eating. The facility identified 21 residents who required staff assistance with eating. The facility census was 99. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 06/29/23. Diagnoses included hypertensive heart disease with heart failure, unspecified dementia, and orthostatic hypotension.Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/14/25, revealed Resident #72 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup assistance with showering and bathing.Review of the care plan dated 06/29/23 revealed Resident #72 required assistance with activities of daily living (ADLs) related to lumbosacral spondylosis, impaired mobility, chronic pain, and arthritis. Interventions included assisting with showers twice weekly, or per resident preference.Review of the shower documentation for Resident #72 from 11/24/25 through 12/22/25 revealed a shower was given on 11/24/25, 12/11/25, 12/18/25, and 12/22/25 (four of nine opportunities).Interview on 12/18/25 at 9:43 A.M. with Resident #72 revealed showers were to be given on Mondays and Thursdays. Resident #72 further stated she rarely received a shower on Mondays, due to staff being too busy.Interview on 12/22/25 at 10:55 A.M. with Licensed Practical Nurse (LPN) #212 confirmed there was no evidence Resident #72 was provided showers on 12/01/25, 12/08/25, and 12/15/25 (all Mondays).2. Review of the medical record for Resident #37 revealed an admission date of 03/29/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, dysphagia, and dementia.Review of the quarterly MDS assessment, dated 10/02/25, revealed Resident #37 had impaired cognition as evidenced by a BIMS score of five. Resident #37 was dependent on staff to complete ADL care.Review of the care plan dated 03/29/23 revealed Resident #37 required ADL assistance related to cardiovascular accident (stroke) with right hemiparesis, dementia, anxiety, depression, and arthritis. Interventions included assisting with meals and assisting with showers twice weekly. Review of the shower documentation for Resident #37 from 11/26/25 through 12/20/25 revealed a sponge bath was given on 11/26/25 and a bed bath was given on 12/20/25 (two of seven opportunities), with no showers documented. Observation on 12/18/25 at 9:35 A.M. revealed Resident #37 was sitting in a wheelchair near the 600 hall. Resident #37 had dry skin on her scalp and face. Further observation revealed Resident #37 had a large amount of an unknown substance under all of her fingernails. Interview on 12/18/25 at 9:56 A.M. with Certified Nursing Assistant (CNA) #203 revealed shower documentation was only completed in the electronic medical record (EMR) and included the type of shower or washing, how much staff assistance the resident required, and if the resident refused care. CNA #203 confirmed Resident #37 was to receive a shower twice weekly and the resident did not receive showers as scheduled. CNA #203 verified Resident #37 had a large amount of an unknown substance under her fingernails. Observation on 12/22/25 at 11:47 A.M. of the lunch meal service revealed two CNAs were in the main dining room. Further observation revealed Resident #37 was sitting at a table with one other resident and her lunch meal was sitting in front of her. Resident #37 was asking for her husband. Continuous observation revealed Resident #37 was not assisted with her lunch meal until 12:15 P.M., when CNA #213 began assisting her and another resident. Interview on 12/22/25 at 12:08 P.M. with CNA #213 revealed there were two CNAs in the dining room on most days to assist residents with eating. CNA #213 stated Resident #37 needed encouragement to eat and often required staff assistance with eating. CNA #213 verified Resident #37 was not assisted with eating in a timely manner. 3. Review of the medical record for Resident #84 revealed an admission date of 08/20/25. Diagnoses included spastic quadriplegic cerebral palsy, Barrett's Esophagus with dysplasia, and dysphagia.Review of the quarterly MDS assessment, dated 11/26/25, revealed Resident #84 had intact cognition.Review of the care plan dated 08/20/25 revealed Resident #84 had potential for alteration in nutrition and hydration status related to a mechanically altered diet and spastic quadriplegic cerebral palsy. Interventions included assisting with meals as needed. Further review of the care plan revealed Resident #84 required ADL assistance due to impaired mobility. Interventions included staff assistance with eating.Observation on 12/18/25 at 11:50 A.M. of the main dining room revealed seven residents who needed assistance or encouragement with eating and two CNAs were present to provide needed assistance. CNA #220 assisted Resident #84 with his lunch meal and then proceeded to assist another resident. Continuous observation revealed at 12:20 P.M., Resident #84's dessert was placed in from of him. CNA #220 did not return to assist Resident #84 with his dessert until 12:30 P.M. Interview on 12/18/25 at 12:20 P.M. with CNA #220 revealed they often had two CNAs to assist residents with eating in the dining room. CNA #220 verified residents were not assisted timely and frequently had to wait for assistance, adding some residents required more assistance than others. Interview on 12/22/25 at 10:40 A.M. with Resident #84 revealed the wait times to receive staff assistance with meals was long. Resident #84 stated there were usually two staff in the dining room to assist with eating, but he often had to wait long periods of time in between bites of food.4. Review of the medical record for Resident #65 revealed an admission date of 03/13/24. Diagnoses included active primary progressive Multiple Sclerosis (MS), major depressive disorder, and dysphagia.Review of the quarterly MDS assessment, dated 10/15/25, revealed Resident #65 had impaired cognition and was dependent on staff for ADLs.Review of the care plan dated 03/14/25 revealed Resident #65 had potential for alteration in nutrition and hydration status related to MS, depression, and neuromuscular dysfunction. Interventions included assisting with meals as needed. Further review of the care plan revealed Resident #65 required ADL assistance related to MS and impaired cognition. Interventions included assisting with meals.Observation on 12/18/25 at 11:50 A.M. of the lunch meal service in the main dining room revealed seven residents who needed staff assistance or encouragement with eating. There were two CNAs present in the dining room. Further observation revealed at 11:59 A.M., Resident #65's lunch meal was placed in front of him. Continuous observation revealed CNA #220 did not assist Resident #65 with eating until 12:15 P.M. Interview on 12/18/25 at 12:20 P.M. with CNA #220 verified Resident #65 waited approximately 16 minutes before she provided assistance with eating his lunch meal. CNA #220 revealed they had two CNAs to assist residents with eating in the dining room. CNA #220 confirmed residents were not assisted timely and frequently had to wait for assistance, adding some residents required more assistance than others. This deficiency represents non-compliance investigated under Master Complaint Number 2695858 and Complaint Number 2672380.

Based on closed medical record review, review of hospital records, and staff interview, the facility failed to ensure physician orders were in place to monitor medication levels. This affected one (#100) of three residents reviewed for medication monitoring. The facility census was 99.Findings include:Review of the closed medical record for Resident #100 revealed an admission date of 04/01/25. Diagnoses included encounter for orthopedic aftercare, streptococcal arthritis of the left elbow, and osteomyelitis of the left humerus. Resident #100 discharged from the facility on 04/07/25.Review of the hospital discharge documents, dated 04/01/25, revealed Resident #100 was ordered intravenous (IV) vancomycin (antibiotic), 1,250 milligrams (mg) IV every 24 hours for 28 days and a vancomycin trough level (blood test to measure the level of vancomycin in the bloodstream to ensure the medication remains within a safe and effective range) weekly. A Peripherally Inserted Central Catheter (PICC) line (a type of long catheter that is inserted through a peripheral vein and used when IV treatment is required over a long period) was placed in the right upper arm. Resident #100 was to be discharged to a skilled nursing facility (SNF) for IV antibiotic therapy and rehabilitation therapy. A vancomycin trough level was drawn at the hospital on [DATE], prior to discharge.Review of the admission Minimum Data Set (MDS) assessment, dated 04/06/25, revealed Resident #100 had impaired cognition as evidence of a Brief Interview for Mental Status (BIMS) score of five. Resident #100 received antibiotic therapy.Review of the care plan dated 04/01/25 revealed Resident #100 received IV therapy via a PICC line for an infection in the left elbow. Interventions included inspecting the IV site at least every day, document and notify the physician of any signs and symptoms of infiltration, extravasation, phlebitis, or other abnormality at the IV insertion site, obtain laboratory (lab) tests as ordered, and vital signs as indicated and as needed.Review of the physician orders dated 04/02/25 revealed Resident #100 was to have a complete blood count (CBC) and basic metabolic panel (BMP) laboratory (lab) test every Wednesday. Staff were to assess the PICC line site every shift for signs and symptoms of complications. Additionally, Resident #100 was ordered vancomycin IV solution, 1,250 mg per 250 milliliters (ml) IV every 24 hours for osteomyelitis of the left elbow for 28 days. Further review of the physician orders revealed no orders for a vancomycin trough level to be completed.Review of a physician progress note dated 04/07/25 revealed Resident #100 was seen by Medical Doctor (MD) #207. New orders were received for Ativan (antianxiety medication that is also used to treat seizure activity) and a neurological consult. No orders were given to complete a vancomycin trough.Interview on 12/17/25 at 1:44 P.M. with the Director of Nursing (DON) verified Resident #100 did not have a physician order to complete a vancomycin trough (due to have been drawn on 04/07/25) to monitor the medication. This deficiency represents noncompliance investigated under Complaint Number 2679714.

Based on observation, staff interview, record review, and facility policy review, the facility failed to post appropriate oxygen use signage for one (Resident #1) of three residents reviewed for respiratory care. The facility census was 94. Findings included:Review the admission record for Resident #1 on 06/06/25, with a diagnosis of pneumonia. Review of admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/13/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident received oxygen therapy while a resident at the facility. Review Resident #1's Care Plan, included a focus area initiated 06/08/25, that indicated the resident was at risk for impaired gas exchange due to sleep apnea, congestive heart failure, hypoxia, and exacerbation. Interventions directed staff to administer supplemental oxygen at the ordered flow rate by the practitioner. Review of the Physician Order, dated 06/23/25, specified Resident #1 was to receive oxygen at 2-4 liters per minute (lpm) via nasal cannula (NC) continuously for hypoxia related to pneumonia. Observation from the hallway of Resident #1's room on 07/28/25 at 11:01 A.M. revealed no Oxygen in Use sign on the resident's door. Observation of Resident #1's room on 07/30/25 at 9:24 A.M. revealed there was no Oxygen in Use sign on the resident's door. The resident was observed in bed sleeping and was receiving supplemental oxygen via nasal cannula. Interview on 07/30/2025 at 3:19 P.M., the Director of Nursing (DON) stated that an oxygen-in-use sign should have been on a resident's door whenever the resident was started on oxygen, and the resident's nurse or respiratory therapist should have put the sign on the door. Interview on 07/31/2025 at 10:28 A.M., with Administrator stated their expectation was that any resident on oxygen should have had a sign on their door. Review of policy titled, Oxygen Therapy, dated June 2024, indicated, 4.3.4 Fire hazard is increased in the presence of increased oxygen concentrations.

Based on record review, staf interview and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level 1 was updated and resubmitted following a new diagnosis of a serious mental illness for one (Resident #13) of three residents reviewed for PASRR. The facility census was 94.Findings included:Review of Resident #13's Preadmission Screen/Resident Review (PAS/RR) Identification Screen, dated 01/06/20, revealed that Resident #13 had a diagnosis of dementia/Alzheimer's disease, and had diagnoses that included mood disorder and major depressive disorder. A review of the clinical record for Resident #13 revealed no evidence of any additional PASRR forms. Interview on 07/30/25 at 12:28 P.M., with the Social Services Director (SSD) stated when a new psychiatric diagnosis was added to a resident record, a new Level I PASRR would be completed. The SSD stated a new PASRR Level I should have been completed for Resident #13 when their schizoaffective disorder diagnosis was added. Interview on 07/31/25 at 11:07 A.M., with the Administrator and the Director of Nursing (DON), the Administrator stated it was her expectation that the PASRR was accurate and resubmitted when there was a significant change in the resident's condition or a new psychiatric diagnosis was added. The Administrator stated it was her expectation that a PASRR Level I would have been resubmitted for Resident #13 at the time the new psychiatric diagnosis was added. The DON stated she would defer to the Administrator for PASRR-related questions.Review of the policy titled,PASRR and Level of Care Policies for Ohio, dated 06/11/18, revealed, it is the policy of [Facility Name] to follow the State and Federal regulations related to completing the appropriate PASRR and Level of Care as needed on admission, following a 30 day stay, appropriate change in level of condition and as needed for payor change to Medicaid. The results of the PASRR or Level of Care will be maintained in the electronic medical record.

Based on Observations, interviews and record review the facility failed to provide privacy during resident care. This affected six (Resident #13, #51, #65, #68, #71, and #106) of 20 residents residing on the memory care unit. Findings include: Review of medical record for Resident #106 revealed an admitted [DATE]. Resident #106 had impaired cognition. Review of medical record for Resident #13 revealed an admitted [DATE]. Resident #13 had impaired cognition. Review of medical record for Resident #15 revealed an admitted [DATE]. Resident #15 had impaired cognition. Review of medical record for Resident #51 revealed an admitted [DATE]. Resident #51 had impaired cognition. Review of medical record for Resident #68 revealed an admitted [DATE]. Resident #68 had impaired cognition. Review of medical record for Resident #74 revealed an admitted [DATE]. Resident #74 had impaired cognition. Observations on 07/18/24 at 9:52 A.M. revealed Podiatrist #152 set up in the dining room/ activity room trimming Resident #106's toenails. Residents #13, #15, #51, #68, and #71 were seated in the room because they also had their toenails trimmed. Interview on 07/18/24 at 9:56 A.M., the Activity Director #151 stated she did not know why the Podiatrist was in the dining room trimming nails. Interview on 07/18/24 at 10:00 A.M., the Activity Assistant #150 stated Podiatrist #152 trimmed the toenails for four other residents. Observations of the area where the trimming took place revealed toenail clippings approximately a two-by-two-foot area on the floor. The activity assistant verified the findings and stated he should have taken the residents to their room to provide care. Interview on 07/18/24 at 10:14 A.M., Podiatrist #152 stated he was not sure why the facility had him trimming nails in the dining room. The Podiatrist then went on to say it was difficult to bring 15 residents in wheelchairs to their rooms. The deficiency is an incidental findings discovered during the course of a complaint investigation.

Based on record review and interview the facility failed to use a mechanical lift for a transfer for one, (Resident #53) of three reviewed for falls. The facility census was 107. Findings include: Review of medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included unspecified dementia with psychotic disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/26/24, revealed the resident had impaired cognition. The resident was dependent for bed mobility, transfers, and ambulation. Resident #53 required a mechanical stand-up lift for all transfers. Review of the facility fall risk evaluation dated 06/17/24 revealed Resident #53 was at high risk for falls. The evaluation indicated an Agency State tested Nurse Assistant (STNA) #157 notified Licensed Practical Nurse #154 that Resident #53 was in the shower room and had to be lowered to the floor. Facility staff completed a thorough investigation which reported no injuries. Interview on 07/17/24 at 1:40 P.M., Medication Technician (MT) #155 stated STNA #157 did not use the stand-up lift to transfer Resident #53. MT #155 stated Resident #53 had to be lowered to the floor. Interview on 07/17/24 at 3:45 P.M., Physical Therapist (PT) #156 stated Resident #53 was in the shower room, the agency staff told Resident #53 she would not need the stand-up lift, that she could lift the resident by herself. PT #156 stated Resident #53 always required a stand-up lift for all transfers. Interview on 07/17/24 at 3:58 P.M., Resident #53 stated STNA #157 stated she would not use the stand-up lift because it would take to much time. Resident #53 stated she told STNA #157 that she was taller and bigger than her. Resident #53 stated STNA #157 lifted her by her arms and she slid onto the floor. Resident #53 said STNA #157 should have listened to her. Interview on 07/18/24 at 9:06 A.M., the Director of Nursing (DON) stated STNA #157 did not use the stand-up lift to transfer Resident #53. The DON stated all staff have resident information related to what devices are required to transfer each resident. The DON stated STNA #157 was placed on the do not return, list. This deficiency represents non-compliance investigated under Complaint Number OH00155197.

Based on observation, record review, staff interview, and review of policy, the facility failed to ensure proper portion sizes were served to residents. This had the potential to affect all residents, except for Resident #19 and #28 who were identified as consuming nothing by mouth. The facility census was 108. Findings include: Review of the dinner meal spreadsheet for 08/28/23, revealed that sloppy [NAME] should be served using a number 10 (three-ounce) scoop. Observation of tray line on 08/28/23 at 4:40 P.M., revealed Dietary Cook #867 served sloppy [NAME] with a number 16 (two-ounce) scoop instead of a number 10 scoop, as indicated on the spreadsheet. Interview on 08/28/23 at 4:43 P.M., with Dietary Manager #884 verified at time of observation, Dietary Cook #867 had been using the incorrect scoop size. Dietary Manager #884 then instructed Dietary Cook #867 to begin using two number 16 scoops (four ounces) in place of one number 10 scoop. Review of the facility-provided list revealed Resident #19 and #28 received nothing by mouth and did not receive food from the kitchen. Review of the facility policy titled Dietary/Nutritional Care Services/Meal Service, dated April 2014, revealed the dietary manager would perform meal rounds daily, as deemed appropriate and would observe meals for preferences, portion sizes, temperature, flavor, variety, and tray pass for accuracy. This deficiency represents non-compliance investigated under Complaint Number OH00144401.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were stored securely. This affected one (#61) and had the potential to affect four additional residents (#35, #54, #68, and #79) the facility identified as cognitively impaired and independently mobile on the 300 hall. The facility census was 108. Findings include: Review of Resident #61's medical record revealed an admitted ,d+[DATE] 22, with diagnoses including: dementia without behaviors, obstructive uropathy and urinary retention. Review of Resident #61's Admission Assessment/Observation, dated 02/01/22, revealed Resident #61 did not wish to administer his own medications. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 07, which indicated a severe cognitive impairment. Resident #61 required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Observation on 08/28/23 at 11:11 A.M., revealed Resident #61 in bed, with overbed table within reach. On the overbed table, a plastic medication cup contained twelve multi-colored pills. Resident #61 stated they were his medications but was unable to state when the nurse brought him the medications. Interview on 08/28/23 at 11:15 A.M., with Licensed Practical Nurse #891 verified the medications on Resident #61's overbed table had been left unattended. LPN #891 stated she did not bring the medications to Resident #61; it must have been the nurse before her. LPN #891 stated she began her shift at 8:00 A.M., so the medications were brought to Resident #61 prior to that time. LPN #891 verified Resident #61 requires all medications to be administered by the nurse and medications should not have been left at Resident #61's bedside. Review of the 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.

Based on record review, observation, staff interview, and review of policy, the facility failed to safely store resident food items in the refrigerator/freezer located in the staff break room. This had the potential to affect all residents, except for Resident #19 and #28 who were identified as consuming nothing by mouth. The facility census was 108. Findings include: Interview on 08/29/23 at 8:48 A.M., with Registered Nurse (RN) #703, revealed resident food items were stored in a refrigerator/freezer located in the staff breakroom. Interview on 08/29/23 at 8:56 A.M., with Dietary Manager #884, revealed the environmental service department was responsible for maintaining the specified refrigerator/freezer. Interview on 08/29/23 at 9:00 A.M., with Housekeeper #971 revealed housekeeping staff were responsible for maintaining the refrigerator located in the staff breakroom. Housekeeper #971 reported she knew the refrigerator needed a good cleaning. Observation of the refrigerator on 08/29/23 at 9:00 A.M., with Housekeeper #971, revealed the refrigerator had an internal temperature of 41 degrees Fahrenheit. There was no temperature log present in the area. The top three shelves of the refrigerator were stuffed full of miscellaneous items. Observation of food items contained inside of the refrigerator revealed: a container of chili fries was labeled with Resident #70's name and room number and was undated; a container of unidentified meat with onions which were covered in a mold like substance, labeled with a resident room number where no resident currently resided, and was undated; a container of ravioli was labeled with a resident room number and was undated; a bag containing chicken with a mold like substance in a paper box was unlabeled and undated; a burrito wrapped in saran wrap was unlabeled and undated; a bag containing strawberry yogurt with an expiration date of 07/12/23; a clear plastic container containing sliced sausage and potatoes which was undated and unlabeled; a frosted cake was unlabeled, undated, and uncovered aside from a paper towel which was stuck to the frosting; dried up chicken wrapped in a paper towel was unlabeled and undated; a nutritional bar with an expiration date of 11/15/22; a Tupperware container with pot roast and a mold like substance was unlabeled and undated; a pizza fold over was unlabeled and undated; a white Styrofoam container containing meat and vegetables which were covered in mold like substance was unlabeled and undated; a plastic grocery bag containing a storage container with an unidentified food substance was unlabeled and undated; a container of salsa with a mold like substance and was undated and unlabeled; a clear plastic container of salad which was covered in a mold like substance and was unlabeled and undated; a clear plastic container with cabbage rolls which were covered in a mold like substance was unlabeled and undated; a container with two pizza slices which were covered in a mold like substance and was unlabeled and undated; and a dried up donut wrapped in a paper towel was unlabeled and undated. Continued observation of the attached freezer revealed: a pink container with a frozen white substance was uncovered, unlabeled, and undated; a clear plastic cup which was filled with a pinkish-brown substance was unlabeled and undated; a clear plastic container with a frozen white substance was labeled with Resident #33's name and was undated; an ice cream sundae was labeled with an unidentified resident name and room number and was undated. Interview at the time of observation, with Housekeeper #971, verified the aforementioned findings. Housekeeper #971 also verified staff and resident food items were stored in the refrigerator/freezer and that temperature checks had not been completed/documented. Review of the facility-provided list revealed Resident #19 and #28 received nothing by mouth and did not receive food from the kitchen. Review of the policy titled Food Storage, dated May 2018, revealed leftover food would be stored in covered containers or wrapped carefully and securely, each item would be clearly labeled and dated before being refrigerated, and leftover food would be used within two to three days or discarded. The policy also stated each nursing unit with a refrigerator/freezer unit would be monitored for appropriate temperatures and all refrigerated foods would be covered, labeled, and dated. The policy further stated all food items in the freezer would be covered, labeled, and dated, and temperatures would be checked daily and recorded. This deficiency represents non-compliance investigated under Complaint Number OH00144401.

Based on observation, staff interview, policy review, and medical record review, the facility failed to ensure dignity was respected regarding urinary catheter use. This affected three (#61, #89 and #357) of three residents reviewed for dignity. The facility census was 108. Findings include: 1. Review of Resident #89's medical record revealed an admitted [DATE], with diagnoses including: displaced intertrochanteric fracture of right femur, hydronephrosis, obstructive and reflux uropathy, chronic kidney disease, hypertensive heart, acute congestive heart failure and paroxysmal atrial fibrillation. Resident #81 required use of a urinary catheter (a tube inserted into the resident's bladder to drain urine) due to obstructive and reflux uropathy of the bladder and urinary retention. Observation on 08/29/23 at 9:35 A.M., revealed Resident #89 was in bed in her room. The resident's urinary catheter drainage bag did not have a privacy bag covering it. Interview on 08/29/23 at 9:42 A.M., with Staff Development Registered Nurse (RN) #880 verified there was no privacy bag covering the urinary catheter drainage bag. 2. Review of Resident #357's medical record revealed an admitted [DATE], with diagnoses including: status post diagnostic laparoscopy with ovarian mass removal and appendectomy. Resident #357 required the temporary use of a urinary catheter due immobility and pain. Observation on 08/28/23 at 9:45 A.M., revealed Resident #89 was in bed in her room and urinary catheter drainage bag did not have a privacy bag covering it. Interview on 08/28/23 at 9:48 A.M., RN #880 verified there was no privacy bag covering the urinary catheter drainage bag. 47990 3. Review of Resident #61's medical record revealed an admitted [DATE], with diagnoses including dementia without behaviors, obstructive uropathy and urinary retention. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment, dated 06/29/23 revealed the resident had a severe cognitive impairment. Resident #61 was coded to have a indwelling urinary catheter. Review of Resident #61's physician order, dated 02/01/23, revealed an order for a Foley (indwelling urinary) catheter due to a diagnosis of obstructive uropathy. Review of Resident #61's care plan, revised on 06/21/23, revealed Resident #61 required an indwelling urinary catheter. Interventions listed in the care plan included to cover the drainage bag to promote dignity. Observation on 08/28/23 at 11:11 A.M., revealed Resident #61 lying in bed and the urinary drainage bag was hanging on the bed uncovered, with yellow urine visible in the drainage bag. Interview on 08/28/23 at 11:15 A.M., with Licensed Practical Nurse (LPN) #891 verified the urinary drainage bag was uncovered. LPN #891 stated the drainage bag should be covered, and normally the facility used drainage bags with attached vinyl coverings. Observation on 08/28/23 at 2:13 P.M., of Resident #61 in the therapy gym on the 600 hall revealed Resident #61 seated on an exercise bike, with an unknown therapist at his side. The urinary drainage bag was hanging on the side of the bike and remained uncovered. Observation on 08/28/23 at 2:56 P.M., revealed Resident #61 lying in bed. Resident #61's drainage bag was hanging on the side of the bed frame uncovered, with yellow urine visible in the bag from the doorway. Interview on 08/28/23 at 2:56 P.M., with Environmental Services Aide (ESA) #844 verified Resident #61's urinary drainage bag was uncovered and visible from the hallway. Review of the policy titled Dignity dated 10/10/22, indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered.

Based on staff interview and medical record review, the facility failed to ensure a resident had an accurate and consistent advance directive in place throughout the medical record. This affected one (#39) of eight residents reviewed for advance directives. The facility census was 108. Findings include: Review of Resident #39's medical record revealed an admitted [DATE], with diagnoses including: cerebrovascular accident (stroke), adenocarcinoma (cancer) of lung, and dementia. Review of the Significant Change in Status Minimum Data Set (MDS) assessment, dated 08/09/23, revealed Resident #39 had severe impaired cognition, required extensive assistance of 1-2 staff for transfers, bed mobility, toileting, dressing and hygiene. The assessment further revealed Resident #39 received hospice services. Review of Resident #39's care plan, initiated on 08/11/18 and revised on 08/29/23, revealed a code status of Do Not Resuscitate Comfort Care (DNRCC). Review of the Do Not Resuscitate (DNR) Order form in Resident #39's chart revealed a selection of DNRCC, dated 06/14/23, signed by Resident #39's physician. Review of physician orders revealed Resident #39 was admitted to hospice care on 08/01/23 with a diagnosis adenocarcinoma of the lung. Resident #39 had a physician order, dated 06/14/23, of DNRCC-Arrest listed in the electronic medical record. Interview on 08/29/23 at 2:29 P.M., with Assistant Director of Nursing (ADON) #879 revealed Resident #39 received comfort care with hospice at the facility. ADON #879 verified Resident #39's medical record contained mismatched advance directives between the hard chart and the electronic medical record. ADON #879 stated Resident #39 recently signed on to hospice, and staff must not have changed the advance directive after hospice enrollment. Interview on 08/29/23 at 4:30 P.M., with Director of Nursing (DON) revealed the facility did not have an advance directives policy.

Based on record review, observation, staff interview, and review of policy, the facility failed to ensure a resident was safely transfered utilizing a mechanical lift. This affected two (#54 and #71) of three residents reviewed for transfers. The facility census was 108. Findings include: 1. Review of Resident #71's medical record revealed an admitted d of 11/09/20, with diagnoses including: hemiplegia, aphasia, dysphagia, unspecified convulsions, osteoarthritis, schizoaffective disorder, insomnia, obesity, and scoliosis. Review of Resident #71's quarterly Minimum Data Set (MDS) assessment, dated 06/28/23, revealed the resident was cognitively impaired and was totally dependent on the assistance of two staff for transfers. Review of Resident #71's physician orders, revealed an order dated 01/04/21 and revised 04/29/23 for assistance of two staff with mechanical lift, with full body sling for transfers into tilt in space wheelchair for proper positioning and pressure relief. Review of Resident #71's current plan of care, dated 11/20/20, revealed the resident required assistance with activities of daily living. An intervention was implemented on 04/29/23 for assistance of two, mechanical lift with full body sling for transfers into tilt in space wheelchair for proper positioning and pressure relief. Observation on 08/29/23 at 1:29 P.M., revealed Resident #71 was in her wheelchair which was located in the hallway across from her room. Resident #71 had a mechanical lift transfer sling underneath of her. State tested Nurse Aide (STNA) #913 attached the loops of the mechanical lift sling to the mechanical lift and used the mechanical lift to lift the resident up into the air. STNA #913 then pushed the mechanical lift across the hall and into the resident's room. Once in the room, STNA #913 lowered Resident #71 into Resident #71's bed. No other staff were present to assist with the mechanical lift transfer. Interview on 08/29/23 at 1:40 P.M., with STNA #913 verified the staff member transferred Resident #71 via mechanical lift with no other staff present and pushed the resident fromt he hallway to the room while the resdient was in the lift. STNA #913 reported she always transferred Resident #71 by herself, and stated most residents only required one staff member to be present for mechanical lift transfers. STNA #913 reported STNAs found resident transfer statuses, including how many staff members were required, on a Resident Information Sheet (RIS) located at the nursing station. Review of the RIS located at the nursing station, dated 08/27/23, revealed Resident #71's transfer status was two-assist mechanical lift, full body sling. 47990 2. Review of Resident #54's medical record revealed an admitted [DATE], with diagnoses included intracranial injury, hemiparesis affecting right dominant side, dementia, and obesity. Review of Resident #54's Minimum Data Set (MDS) assessment, dated 08/12/23, revealed the resident was not assessed for cognition. The resident was totally dependent on the assistance of two staff for transfers. Review of nursing summary progress note, dated 08/13/23, revealed Resident #54 was alert and oriented to self. Review of Resident #54's physician orders, identified an order dated 08/10/23 for the use of a full body mechanical lift for transfers using a criss-cross sling with the assist of two staff. Review of Resident #54's care plan, initiated 03/22/23, revealed Resident #54 required assistance with activities of daily living. An intervention was implemented on 08/01/23 for assistance of two staff with use of mechanical lift for transfers into a tilt in space wheelchair. Observation on 08/28/23 at 2:00 P.M., revealed Resident #54 in his wheelchair in the 300 hallway across from his room. Resident #54 had a mechanical lift transfer sling underneath him. STNA #913 attached the loops of the mechanical lift sling and lifted the resident up into the air. STNA #913 then pushed the mechanical lift into Resident #54's room, to his bed which was positioned by the window, approximately 15 feet. STNA #913 then lowered Resident #54 into his bed. No other staff were present to assist STNA #913 with the mechanical lift transfer. Observation on 08/28/23 at 2:04 P.M., revealed Resident #54 lying in his bed with the mechanical lift sling still underneath him. STNA #913 remained in Resident #54's room and returned the mechanical lift device to the hallway directly outside of Resident #54's room. STNA #954 then entered Resident #54's room and closed the door. Interview on 08/28/23 at 2:11 P.M., with STNA #913 verified she transferred Resident #54 alone and in the mechanical lift for approximately 15 feet. STNA #913 further stated she always transferred Resident #54 alone and did not need another STNA's assistance while using the mechanical lift. STNA #913 verified STNA #954 entered the room after the transfer was complete and was only needed to assist with Resident #54's personal care. Review of the RIS located at the nursing station, dated 08/27/23, revealed Resident #54's transfer status was two-assist mechanical lift, full body sling. Review of the policy titled Patient/Resident Transfer Policy, dated 2020, revealed transfers would be conducted following the principles of proper body mechanics and resident safety.

Based on medical record review, observation, staff interview, and review of the policy, the facility failed to ensure infection control was maintain for oxygen tubing, by storing nasal cannula's to prevent contamination and changing oxygen tubing as ordered. This affected two (#22 and #62) of two residents reviewed for oxygen. The facility census was 108. Findings include: 1. Review of Resident #22's medical record revealed an admitted [DATE], with diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure, heart disease with heart failure, obstructive sleep apnea, and asthma. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. The resident received oxygen. Review of Resident #22's physician orders for August 2023, identified current orders for oxygen saturation level while on three liters nasal cannula during the day, four liters nasal cannula at bedtime, and respiratory therapy to change oxygen tubing, nebulizer, set-up, and/or non-invasive ventilation supplies every Tuesday. Observation on 08/28/23 at 9:42 A.M., revealed Resident #22's oxygen tubing with nasal cannula and oxygen extension tubing were dated 08/18/23. Observations on 08/28/23 at 11:03 A.M., on 08/29/23 at 1:24 P.M., on 08/29/23 at 4:37 P.M., and on 08/30/23 at 7:46 A.M. revealed the oxygen/extension tubing were dated 08/18/23. Review of the respiratory administration record for August 2023, revealed the order for oxygen tubing to be changed was documented as completed on 08/01/23, 08/08/23, 08/15/23, 08/22/23, and 08/29/23, which were all Tuesdays. The administration record did not indicate the oxygen tubing was changed on Friday, 08/18/23 or on Monday 08/28/23. Interview on 08/30/23 at 12:52 P.M., with Respiratory Therapist (RT) #984, verified Resident #22's oxygen tubing was supposed to be changed on a weekly basis. RT #984 also verified the Treatment Administration Record (TAR) was not signed off on the dates the tubing was changed, and was subsequently signed off on dates the tubing was not changed. 37096 2. Review of the medical record for Resident #62 revealed an admitted [DATE], with diagnoses including: chronic respiratory failure, osteoarthritis, chronic obstructive pulmonary disease (COPD) type II diabetes, osteoporosis, and history of falling. Review of the plan of care dated 06/12/23 revealed the resident had impaired gas exchange related to chronic respiratory failure. Interventions included to administer respiratory treatments and to elevate the head of the bed to facilitate breathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance from staff for bed mobility and transfers. Review of the physician orders for August 2023 revealed an order to administer continuous oxygen at a rate of two liters to four liters to maintain an oxygen saturation greater than 92 percent (%). There was an order for Respiratory Therapy to change oxygen tubing every Tuesday. Review of the respiratory therapy administration record for August 2023 revealed the oxygen tubing was changed on 08/15/22, 08/22/23 and 08/29/23. Observation on 08/28/23 at 9:16 A.M., of Resident #62 revealed she was laying in her bed receiving oxygen by nasal cannula from an oxygen concentrator. The oxygen tubing was dated 08/18/23. Resident #62 had a portable oxygen canister located on the back of her wheelchair. The nasal cannula tubing to the portable oxygen canister was rolled up and shoved into the holder with the oxygen tank. The nasal cannula tubing was not stored in a way to prevent contamination and infections. Interview at the time of the observation with Clinical Manager #984, verified the tubing was dated 08/18/23. Observation on 08/28/23 at 9:30 A.M., of Resident #62 revealed Respiratory Therapist (RT) #984 changing out the tubing to the oxygen concentrator and the tubing for the portable oxygen container. The nasal cannula for the portable oxygen container was stored in a plastic bag. Interview on 08/28/23 at 10:51 A.M., with RT #984 stated she is responsible for changing out oxygen tubing every Tuesday on Resident #62's hall. However, she delegates the task to the RT's that work as needed (PRN). RT #984 stated she was not sure when the last time the tubing was changed. Further observation on 08/29/23 at 5:23 P.M., of Resident #62's wheelchair revealed the nasal cannula to the portable oxygen container was rolled up and shoved into the holder for the oxygen tank. The nasal cannula was not stored in a way to prevent contamination and infection. Interview at the time of the observation, with Licensed Practical Nurse (LPN) #993, verified the nasal cannula was not stored properly. Interview on 08/30/23 at 12:52 P.M., with RT #984 verified she changed Resident #62's oxygen tubing on 08/28/23 and documented as completed on 08/29/23. RT #984 stated the computer only lets her document oxygen changes on Tuesdays even though it was changed on Monday 8/28/23. Review of the policy titled Disposable Equipment Replacement, dated July 2022 revealed equipment storage bags and oxygen delivery systems such as masks, nasal cannula, oxygen supply tubing is to be changed weekly or as needed.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure bedrail consents were obtained and assessments were accurate. This affected three (#40, #13, and #62) of three residents reviewed for bedrails. The facility idenitfied 103 residents with orders for assist rails. The facility census was 108. Findings include: 1. Reviw of Resident #40's medical record revealed an admitted [DATE], with diagnoses including: Parkinson's Disease, dementia, osteoporosis, and polyneuropathy. Review of Resident #40's Significant Change in Status Minimum Data Set (MDS) assessment, dated 07/25/23, revealed Resident #40 was severely cognitively impaired. Resident #40 required extensive assist of 1-2 staff with bed mobility, toileting, and hygiene. Resident #40 was dependent on two staff for transfers. Review of Resident #40's physician orders, identified an order dated 05/26/22 for assist rails. The order further specified one or two rails could be used for turning and repositioning. Review of Resident #40's current plan of care identified the need for assistance with activities of daily living (ADLs). Resident #40's ADL care plan listed an intervention of assist rails as needed for bed mobility and positioning. Review of Resident #40's Bed Assist/Side Rail (SR) Assessment, dated 07/28/23, revealed Resident #13 did not express a desire to have rails raised while in bed for her own safety and/or comfort. The assessment further identified recommendations for the resident to use no side rails. Observation on 08/30/23 at 10:20 A.M., revealed Registered Nurse Clinical Manager (RNCM) #945 and Registered Nurse (RN) #841 performed ordered wound care to Resident #40's sacral wound. Resident #40 was lying in bed and was repositioned by RNCM #945 and RN #841. Resident #40's bed had metal bedrails on both sides of the bed and both rails were in the raised position. Throughout wound care observation, Resident #40 was not observed to grasp the side rail nor assist in her own positioning. RN #841 held Resident #40 on her left side throughout the duration of wound care. RNCM #945 stated two staff members are needed when performing Resident #40's wound care as Resident #40 is not able to turn on her side on her own or aid in her own positioning. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Interview on 08/31/23 at 10:01 A.M., with the Director of Nursing (DON) verified the facility does not complete consents for the use of side/assist/bedrails. 2. Review of Resident #13's medical record revealed an admitted [DATE], with diagnoses including ataxia (loss of coordination of voluntary movements) following cerebrovascular accident (stroke), osteoporosis, and chronic kidney disease. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment, dated 08/16/23, revealed Resident #13 was cognitively intact. Resident #13 required extensive assist of 1-2 staff for bed mobility, toileting, and hygiene. Resident #13 was dependent on two staff for transfers. Review of Resident #13's physician orders, identified an order dated 05/26/22 for assist rails. The order further specified one or two rails could be used for turning and repositioning. Review of Resident #13's current plan of care identified the need for assistance with activities of daily living (ADLs). Resident's ADL care plan listed an intervention of assist rails as needed for bed mobility and positioning. Review of Resident #13's Bed Assist/SR Assessment, dated 08/16/23, revealed Resident #13 did not express a desire to have rails raised while in bed for her own safety and/or comfort. The assessment further identified recommendations for the resident to only utilize a left bed rail. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Observation and interview on 08/31/23 at 10:25 A.M., with Resident #13 revealed the resident in bed, with both metal side rails in the raised position on the bed. Resident #13 stated she uses both bedrails to aid in her own positioning, and the bedrails have been on the bed since her admission to the facility. Interview on 08/31/23 at 10:27 A.M., with State tested Nurse Aide (STNA) #954 revealed she is familiar with Resident #13's care. STNA #954 verified Resident #13 uses bilateral bedrails to help her turn and reposition in the bed during care. STNA #954 stated Resident #13 always has both bedrails in the raised position while she is in bed. Interview on 08/31/23 at 10:01 A.M., with the Director of Nursing (DON) verified the facility does not complete consents for the use of side/assist/bedrails. 37096 3. Review of Resident #62's medical record revealed an admitted [DATE], with diagnoses including chronic respiratory failure, osteoarthritis, chronic obstructive pulmonary disease (COPD) type II diabetes, osteoporosis, and history of falling. There was no evidence of consent for side rails. Review of the plan of care dated 06/12/23 revealed the resident requires assistance with activities of daily living related to inflammatory lumbar spondylopathy, and osteoporosis. Intervention included the use of assist rails as needed for bed mobility and positioning. Review of the quarterly MDS assessment, dated 06/26/23 revealed the resident had intact cognition and required extensive assistance from staff for bed mobility and transfers. The assessment indicated bed rails were not used. Review of the quarterly assessment dated [DATE], revealed the assessment indicated bilateral assist rails. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Interview on 08/31/23 at 11:54 A.M., with the DON stated the facility does not have a consent for side/assist rails. Review of the titled, Bed Safety/Maintenance, dated June 2023, revealed if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. The staff shall obtain consent for the use of side rails from the resident or the resident's representative prior to their use, including the benefits and potential hazards associated with side rails.

Based on medical record review, policy review and staff interview, the facility failed to ensure medications were administered to residents as prescribed by physician's orders. This affected one (#48) of five resident reviewed for medication administration. The facility census was 108 residents. Findings include: Review of Resident #165's medical record revealed an admitted [DATE], with diagnoses including ulcerative colitis with rectal bleeding, essential hypertension, atherosclerotic heart disease, left and right shoulder osteoarthritis, atrial fibrillation, diverticulitis of intestine, anxiety disorder, unilateral inguinal hernia, adult failure to thrive, acute kidney failure, anxiety, and depression. Review of Resident #48's physician orders revealed an order for Tofacitinib Citrate 10 milligrams (mg), twice a day for gastrointestinal issues. Review of Resident #48's August 2023 Medication Administration Record (MAR) revealed the morning dose of Tofacitinib Citrate 10 mg was not administered on 08/21/23, 08/22/23, 08/23/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23 and 08/28/23. The evening dose of Tofacitinib Citrate 10 mg was not administered on 08/20/23, 08/21/23, 08/22/23, 08/23/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23 and 08/28/23. Interview on 08/01/23 at 1:00 P.M., with the Director of Nursing (DON) indicated Resident #48 did not receive the prescribed doses of Tofacitinib Citrate from 08/20/23 through 08/28/23 due to the medication being misplaced after delivery. The DON indicated the night shift nurse signed for the medication that was included with other medication. When the medication was scheduled to be administered, the medication could not be found. The DON stated the facility ultimately had to pay for a new shipment of the prescribed medication which did not arrive until 08/28/23. The DON indicated that Resident #48 experienced no adverse effects from the missed medication administration and additional gastrointestinal medications were prescribed during that period of time. Review of the policy titled, Administering Medications, dated February 2023, indicated medications must be administered in accordance with the orders, including any required time frame.

Based on record review, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure the pneumococcal vaccine was offered according to guidelines. This affected one (#62) of five residents reviewed for immunizations. The facility census was 108. Findings include: Review of the medical record for Resident #46 revealed an admitted [DATE], with diagnoses including: multiple sclerosis, anxiety, osteoarthritis, type II diabetes, neuromuscular bladder, kyphosis, and depression. Review of the immunization tab revealed the Pneumococcal conjugate vaccine (PCV13) was administered on 10/14/23. The Pneumococcal polysaccharide vaccine (PPSC23) was documented as not eligible on 10/14/23. Interview on 08/30/23 at 4:15 P.M., with the Infection Control Preventionist (ICP) #880 stated Resident #46 received the PCV13 on 10/14/23 and at that time the PPCV23 was sign off as not eligible due to the immunization needed to be administered a year apart. ICP # verified the facility did not follow up to offer the PPCV23 at a later date. Review of the website for Centers for Disease Control and Prevention (CDC) titled Pneumococcal Vaccine Recommendations, dated 02/13/23 recommended for adults 65 and older, routine administration of pneumococcal conjugate vaccine (PCV15 or PVC20) for all adults [AGE] years or older who have ever received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. Review of the policy titled Pneumococcal Vaccine dated 08/22/22 revealed administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on record review, review of the facility's policy, observations and staff interviews, the facility failed to ensure food was labeled, sealed, and dated appropriately and equipment was cleaned. This had the potential to affect 97 of 100 residents who received meals from the kitchen. The facility identified three residents (#16, #20, and #86) who received no food by mouth. The facility census was 100. Findings include: Tour of the kitchen on 08/19/22 from 7:15 A.M. through 7:35 A.M. revealed in the walk-in refrigerator, there were hamburgers not covered properly, pre-made pancakes not wrapped properly or dated when opened, and sliced turkey, and sliced cheese not labeled or dated. In the walk-in freezer, a bag of frozen pitas was not wrapped properly or dated when the bag was opened. In the kitchen area, the mixer had dried splatter on the backsplash of the mixer. Breakfast tray line was being done and four food delivery carts were dirty with food splatter and residue inside them. Dietary Manager #256 verified the findings on 08/19/22 at 7:35 A.M. Tour of the memory care unit on 08/19/22 from 7:48 A.M. through 7:53 A.M. revealed the pantry's microwave was dirty with food residue in it and the reach-in freezer had one breakfast sandwich and one unidentifiable item not labeled or dated. This was verified at time of observation with Medication Technician #334. Interview on 08/19/22 at 7:35 A.M. with Dietary Manager #256 revealed all food items should be covered correctly, labeled, and dated and the mixer should be clean. The state tested nursing aides (STNAs) on the memory care unit should keep the pantry clean. Interview on 08/19/22 at 10:39 A.M. with Registered Dietitian #380 revealed he does a sanitation audit monthly. Review of the resident's diet list provided by the Director of Nursing revealed Resident #16, #20 and #86 received no food by mouth. Review of the facility's policy titled Sanitation of the Dietary Department, dated 04/2014, revealed the dietary staff shall maintain the sanitation of the dietary department. This deficiency substantiates Complaint Number OH 859.

Based on medical record review, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to immediately isolate Resident #49 who tested positive for Coronavirus Disease 2019 (COVID-19), when the facility allowed Resident #49 who tested positive for COVID-19 to cohort with Resident #95 who was negative for COVID-19. This affected one (#95) out of three residents sampled for infection control practices. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's minimum data set (MDS) assessment, dated 02/15/22, revealed the resident was moderately cognitively impaired. Review of the COVID-19 immunization record revealed Resident #49 received the Pfizer vaccine on 03/04/21 and 03/26/21. Review of the progress note, dated 02/07/22 at 1:58 P.M., revealed Resident #49 tested positive for COVID-19 via a rapid COVID-19 test on 02/07/22 and a polymerase chain reaction (PCR) test was conducted. Review of resident census revealed Resident #49's roommate and Resident #95 shared a resident room from 01/26/22 to 02/08/22. 2. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #95's MDS assessment, dated 02/17/22, revealed the resident was cognitively intact. Review of the COVID-19 immunization record revealed Resident #95 received the Pfizer vaccine on 12/23/20 and 01/13/21. The Pfizer booster was provided on 10/07/21. Interview on 02/24/22 at approximately 11:30 A.M. with the Director of Nursing (DON) verified Resident #49 tested positive on 02/07/22 with a rapid test and on 02/08/22 a PCR test also returned positive. The DON verified Resident #49 remained in the same resident room with Resident #95 who was not yet COVID-19 positive. On 02/08/22 when Resident #49's PCR test returned positive Resident #49 was moved to the designated COVID-19 unit. DON verified Resident #95 is fully up to date on his COVID-19 vaccine but did also test positive for COVID-19 on 02/12/22. Interview on 02/24/22 at 3:46 P.M. with the DON verified Resident #49 was confirmed positive on 02/07/22 between 9:00 A.M. and 11:00 A.M. and was not moved out of the shared resident room until 02/28/22 sometime after 8:00 A.M. to 12:21 P.M. The DON confirmed Resident #49 should of been isolated immediately upon receiving a positive COVID-19 test on 02/07/22. The DON confirmed the facility policy doesn't specifically address isolating COVID-19 positive residents immediately but the facility should follow CDC guidelines for isolation of COVID-19 positive residents. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22, revealed a resident with suspected [CONDITION(S)]-CoV-2 or COVID-19 infection should isolated and ideally moved to a single-person room with a private bathroom. This deficiency substantiates Complaint Number OH 203.

Based on medical record review, and staff interview, the facility failed to obtained informed consent of a responsible party prior to administering a Coronavirus Disease 2019 (COVID-19) vaccination. This affected one (#4) out of four residents reviewed for the provision of informed consent. Facility census was 77. Findings include: Resident #1 admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record noted Resident #1's son identified as the primary contact and responsible party. According to the most current minimum data set (MDS) assessment dated [DATE] Resident #1 was identified as alert, able to make needs known, had moderately impaired cognition, dependent on staff for the completion of activities of daily living including eating, frequently incontinent of bowel and bladder, on a prescribed weight loss regimen, received a therapeutic diet, at risk for skin breakdown with no concerns, received an antibiotic and opiod medication. On 10/04/21 the residents brief interview for mental status score was obtained at 12 and recorded with moderate cognitive impairment. According to the facility COVID-19 vaccine consent form dated 10/06/21 noted Resident #1 was unable to sign but gave consent to receive the COVID-19 vaccine Pfizer booster. The medical record lacked documentation indicating the residents responsible party was contacted to obtain informed consent prior to the administration of the vaccine. Review of the residents COVID-19 vaccine administration card noted the vaccine booster administered to Resident #1 on 10/07/21 by the Director of Nursing (DON). On 12/15/21 at 1:30 P.M. interview with the DON during record review verified Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed there was no documentation contained in the medical record indicating Resident #1's responsible party was contacted to obtain an informed consent prior to the administration of the COVID-19 vaccine booster. This deficiency substantiates Complaint Number OH 103.

Based on review of physician orders, review of nursing progress notes, staff interview and review of facility policy, the facility failed to ensure a resident was notified of a newly ordered medication. This affected one (#14) of four residents reviewed for notification of new medication orders. The total facility census was 93. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].>[MEDICAL CONDITION], dysphagia, [MEDICAL CONDITION] with behavioral disturbance, anxiety and [MEDICAL CONDITION]. Review of a physician order dated 04/07/20, revealed Resident #14 was ordered [MEDICATION NAME] Sprinkles Capsule delayed release 125 milligrams, one capsule by mouth every morning and at bedtime for agitation. Review of the nursing progress notes from 04/07/20 through 05/14/20, revealed the resident was not notified of the new medication order. Further review of the progress notes revealed the resident was not made aware of the medication order until the medication was increased to three times per day on 05/14/20. Interview on 10/26/20 at 4:09 P.M., with the Director of Nursing (DON), verified there was no documentation Resident #14 was made aware of the medication order for [MEDICATION NAME] until 05/14/20. Review of the facility policy titled, Change in a Resident's Condition or Status, dated 11/25/19, revealed regardless of the resident's current mental or physical condition, the nursing supervisor/charge nurse would inform the resident of any changes in his/her medical care or nursing treatments. This deficiency substantiated Complaint Number OH 465.