Every finding on record at Kirtland Woods of Journey

Based on record review and interview the facility failed to ensure residents were not physically restrained to the memory care unit. This affected one resident, (Resident #4) of three residents reviewed for phyical restraints. The facility census was 61.Findings Include:Record Review of Resident #4 revealed an admission date of 04/30/26 with diagnoses of type II diabetes mellitus with diabetic neuropathy, fracture of the lower end of right femur, major depressive disorder, hypertensive chronic kidney disease with stage IV kidney disease. Resident #4 was cognitively intact.Review of Resident #4's care plan dated on 05/29/26 revealed Resident #4 exhibits behaviors such as verbal/physical.Review of progress note dated 07/04/26 revealed Resident #4 was transferred to the ACU (memory care unit) for behavioral management and resident safety due to increased behavioral concerns.Review of Resident #4's Brief Interview of Mental Status (BIMS) score completed on 07/28/26 revealed the resident scored 15 our of a possible 15 indicating the resident had intact cognition. Record review of neurology appointment note dated 08/07/26 revealed no signs of dementia based on assessment for Resident #4.Record review of elopement wandering risk evaluation dated 5/19/26 Resident #4 scored a zero, with a score of 1 or greater indicating a risk for elopement.Interview with Resident #4 on 08/12/26 at 9:00 A.M. revealed on July 4th he went out on the patio and none of the three gates were locked and there were no signs not to open. Resident #4 stated he was curious where it led to and that there was a path that led up to the front to where he stopped and was waving at cars to have fun. Resident #4 stated that if he wanted to leave, he would be a dummy because of his wheelchair and it being on route 306. Resident #4 stated he just wanted to have some fun, that was all, and that he didn't deserve to be put on the memory care unit because of that. Resident #4 stated he did not belong on the memory care unit and wanted to be back in his old room.Interview with Registered Nurse (RN) #500 on 08/12/26 at 9:15 A.M. revealed Resident #4 is upset of losing control and is sometimes forgetful with their short-term memory.Interview with Certified Nursing Assistant #501 on 08/12/26 at 9:21 AM revealed that SR #4 is forgetful and believes they belong on the unit.Interview with Registered Nurse (RN) #503 on 08/12/26 at 10:18 A.M. revealed Resident #4 never tried to elope when on the nursing home side and would go sit outside in the back, stated Resident #4 would be alert and oriented times II or III depending on the day. RN #503 stated he did have some behaviors but doesn't know if that qualified, revealed no other incidents of her knowledge. Stated Resident #4 goes to dialysis Monday, Wednesday, Friday. There is a sign out book if a resident wants to leave.Interview with Licensed Practical Nurse (LPN) #502 on 08/12/26 at 10:24 A.M. revealed they were never Resident#4's nurse but witnessed conversations because he can be argumentative. LPN #502 stated Resident #4 stated the code to staff for the door and it was immediately changed.Interview with Director of Nursing (DON) on 08/12/26 at 10:15 A.M. revealed Resident #4 was moved to memory care unit due to poor safety awareness, DON stated from care conferences Resident #4 had a change of behaviors over time. DON stated the resident scored high on the brief mini mental status, had threatened to leave, and is currently seeing psychiatric (Psych) services.Interview with Nurse Practitioner (NP) #601 on 08/12/26 at 11:45 A.M. revealed Resident #4 had left the facility multiple times to prove a point as he stated to the NP but never off campus just in the driveway. NP stated if Resident #4 doesn't get his way he acts out, and they were notified of the move after Resident #4 was placed on the memory care unit.Interview with Nurse Practitioner (NP) #601 on 08/12/26 at 12:05 PM revealed they had concerns with Resident #4 having dementia and did an assessment and the results indicated Resident #4 was borderline for being cognitively intact; NP #601 stated Resident #4 would act out if they didn't get their way.Interview with Director of Nursing (DON) on 08/12/26 at 12:53 P.M. confirmed there was no assessment for placing Resident #4 on the secured memory care unit. DON stated they met with Resident #4 and his wife several times and his plan was to go home. DON said the wife is unable to take care of him at home currently. The DON also explained when the resident is upset the Administrator is able to talk to him and calm him down, and Resident #4 had Administrator's telephone number to use if he needed it.Interview with Psych Nurse Practitioner (NP) #600 on 08/12/26 at 1:05 P.M. revealed they had only seen Resident #4 one time and that was on 07/30/26. Psych NP #600 stated their visit with Resident #4 revealed Resident #4 had poor judgement but was cognitively intact. Psych NP #600 stated Resident #4 had a lack of safety awareness, and that was due to psych issues not dementia issues.Record review of Dementia Care policy dated 02/01/24 revealed it is the policy of the facility to provide the appropriate treatment and service to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental, psychosocial well-being.This deficiency represents non-compliance investigated under Complaint Number 3120412.

Based on a review of personnel files, the Social Services Director job description, the Facility Assessment, and staff interviews, the facility failed to employ a qualified full time licensed social worker (LSW) as required. This deficiency had the potential to affect all 58 residents living in the facility.Findings include:Interviews conducted on 04/28/26 at 2:50 P.M. with the Director of Nursing (DON) #526 and Regional Nurse #568 confirmed that the facility, licensed for 180 beds, had not employed an LSW since 11/05/25. The DON stated that, following the departure of LSW #571, department heads had been performing social work duties. She also reported reaching out to a Social Worker at another facility for guidance; however, this off-site Social Worker did not complete or sign any work for the facility. Both the DON and the Regional Nurse confirmed that no LSW had provided services in any capacity since 11/05/25.A review of the personnel record for Former LSW #571 showed her last day worked was 11/05/25.The Facility Assessment updated on 01/05/26 indicated that the facility recognized the need for a full-time Social Worker as part of the interdisciplinary team to address resident care needs.A review of the job description for the Social Services Director (Licensed Social Worker), updated 08/25, revealed the position was responsible for overseeing the development, implementation, supervision, and ongoing evaluation of the Social Services Department, including ensuring medically related social services were provided in accordance with State and Federal regulations.

Based on record review and staff interview, the facility failed to notify residents or their responsible parties when resident personal fund accounts reached within $200 of the Medicaid resource limit, as required by regulation. This failure affected four of the six residents reviewed for personal funds (Residents #1, #22, #50, and #59). The facility census was 58.Findings include:1. Review of banking records for Resident #1 showed a balance of $20,702.70, exceeding the Medicaid resource limit of $2,000 as of 05/01/26.No documentation was found indicating the resident or responsible party was notified of the need to spend down funds.2. Review of the banking records for Resident #22 showed a balance of $6,007.89, exceeding the Medicaid resource limit as of 05/01/26.No documentation was found indicating the resident or responsible party was notified of the need to spend down funds.3. Review of the banking records for Resident #50 showed a balance of $24,237.64, exceeding the Medicaid resource limit as of 05/01/26.No documentation was found indicating the resident or responsible party was notified of the need to spend down funds.4. Review of the banking records for Resident #59 showed a balance of $4,280.00, exceeding the Medicaid resource limit as of 05/01/26.No documentation was found indicating the resident or responsible party was notified of the need to spend down funds.During an interview on 05/04/26 at 2:30 P.M., the Business Office Manager (BOM) #530 acknowledged awareness of residents' high personal fund balances. She stated the facility did not have a social worker to prepare and send spend down letters and no other staff were assigned to complete this responsibility. She also stated no spend down notifications were issued, and the facility lacked a process to assist residents in managing excess funds.

Based on observations, review of the Housekeeping Daily Checklists, staff and resident interviews, and review of facility policies, the facility failed to provide residents with a clean, safe, sanitary, and homelike environment as required. The facility did not ensure Resident #36's room was maintained in a clean condition, as evidenced by a stained window curtain that remained unaddressed despite multiple resident requests and observations by staff. Additionally, the memory care unit dining and common areas were kept clean, sanitary, and properly maintained. This affected one resident (#36) being directly affected out of seven residents reviewed for physical environment and had the potential to impact all 23 residents (#4, #6, #7, #10, #12, #13, #15, #16, #18, #22, #23, #25, #26, #28, #32, #33, #43, #46, #50, #52, #54, #55, and #58) in the memory care unit. The facility census was 58.Findings include:1. During an interview on 04/27/26 at 10:52 A.M., Resident #36 reported that his window curtain was dirty. He stated he had requested multiple times that staff clean the curtain, but no action was taken. Resident #36, who had lived in the room for approximately four months, noted that the curtain was already soiled when he moved in.An observation during that interview confirmed that the left window curtain panel had large reddish brown stains on its underside, visible upon entering the room.A follow-up observation on 04/29/26 at 9:03 A.M. showed the same stains remained and the curtain had not been cleaned.During an interview and observation on 04/29/26 at 10:35 A.M., Certified Nursing Assistant (CNA) #517 acknowledged the curtain was soiled with an unknown substance. The CNA stated that housekeeping was responsible for cleaning resident rooms.Interview and observation on 04/29/26 at 1:48 P.M. with Maintenance Director #557 confirmed the curtain was visibly soiled, stating it was pretty obvious and anyone cleaning the room should have seen it. He explained that staff should have submitted a work order through TELS, the facility's web based building management and work order system. Housekeeping staff did not have access to enter information directly into TELS; however, they were expected to report such issues to maintenance for entry.A review of the Daily Housekeeping Checklist indicated that windowsills were to be cleaned daily, a task during which the stained curtain should have been noticed.Review of the Environmental Quality policy, revised 02/16/24, showed that all staff were responsible for reporting any broken, defective, or malfunctioning equipment or furnishings immediately upon identifying an issue.A review of the facility's policy titled; Resident Rights revised 02/15/24 affirmed that residents are entitled to a safe, clean, comfortable, and homelike environment, including supports for daily living delivered safely.2. Observation of the memory care dining room on 04/28/26 at 11:48 A.M. revealed the environment was not maintained in a clean or sanitary condition. One dining table had not been wiped down and contained a clear sticky substance. A red juice stain and multiple brown spillage spots resembling pudding were noted on the floor beneath another table. A damp washcloth was observed on the floor; when CNA #510 moved it, additional brown spillage was identified. CNA #510 verified these findings and stated housekeeping is responsible for cleaning the dining room after meals, while unit staff perform limited cleaning during meals. An interview on 04/28/26 at 12:00 P.M., Unit Manager (UM)/Licensed Practical Nurse (LPN) #538 reported that housekeeping services were inconsistent and did not reliably clean the dining room after meals. UM/LPN #538 further stated that at times when housekeeping was unavailable, unit staff were required to clean the dining area.Observation of the memory care common area on 04/29/26 at 10:54 A.M. revealed a carpet with frayed edges, partially secured with blue tape. Several large dark stains were also present. Registered Nurse (RN) #563 verified these findings and stated he was unsure when the carpet was last cleaned.Observation of the dining room on 04/29/26 at 12:07 P.M. revealed four dirty, stained chairs along the back left wall. Four male residents were seated at the adjacent table. CNA #510 verified the condition of the chairs and the residents' proximity. Further observation revealed a wooden table in significant disrepair: loose and hanging trim on multiple sides, a missing 4-inch section of upper trim, and tennis balls attached to three of the four table legs. Resident #52 was seated at this table awaiting lunch. RN #563 verified the condition of the table and the resident's presenceA review of the facility's policy titled; Resident Rights, revised 02/15/24, stated that residents have the right to a safe, clean, comfortable, and homelike environment, including supports for daily living delivered safely.A review of the policy titled; Environmental Quality, revised 02/16/24, stated the facility is to be designed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further requires adequate space and furnishings in dining and activity areas, and mandates that staff report broken or malfunctioning equipment immediately upon identification.This deficiency represents non-compliance investigated under Master Complaint Number 2702909 and Complaint Numbers 2618473, 2689846 and 2567648.

Based on interviews, record review and facility policy, the facility failed to ensure routine care plan conferences were conducted. This affected six residents (#11, #13, #14, #22, #32, #49) out of 25 sampled residents. The facility census was 58. Findings include:1. Resident #13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis bilateral knees, squamous cell carcinoma of skin, basal cell carcinoma of face, anxiety disorder, major depressive disorder, dementia, protein-calorie malnutrition, dysphagia, need for assistance with personal care. Review of medical record revealed Resident #13's last care conference was completed on 07/02/25 by Former Licensed Social Worker (LSW) #571. No other care conferences were performed after July 2025. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #13 had intact cognition. The functional assessment revealed the resident required assistance and cueing with activities of daily living (ADL) including hygiene/toileting, showers, and transfer to wheelchair. Resident #13 was frequently incontinent of bowels and bladder and had no wounds. Interview with Resident #13 on 04/27/26 at 10:31 A.M. stated she has not had any care conferences at facility since July 2025. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, type two diabetes, major depressive disorder, anxiety, protein-calorie malnutrition, obesity, displaced comminuted fracture of left fibula, cerebral infarction, need for assistance with personal care. Review of medical record revealed Resident #14's last care conference was on 07/28/25 by Former LSW #571. No other care conferences were provided after July 2025. Review of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12/15, indicating Resident #14 had moderate cognitive impairment. The functional assessment revealed the resident required set up assistance for upper body ADL and was dependent on staff for hygiene, toileting, showers, and transfers to the wheelchair. Resident #14 was also frequently incontinent of bowels and bladder. 3. Resident #22 was admitted to facility on 01/13/23 with diagnoses of Alzheimer's disease, dementia, ulcerative colitis, protein-calorie malnutrition, and need for assistance with personal care. Review of medical record revealed Resident #22's last care conference was on 04/16/25 by Former LSW #571. No other care conferences were completed after April 2025. Review of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 indicating Resident #22 had severe cognitive impairment. The functional assessment revealed the resident was dependent on staff for all ADL, hygiene, and transfer/mobility needs. Resident #22 was always incontinent of bowels and bladder. 4. Resident #32 was admitted to facility on 08/28/23 with diagnoses of dementia, chronic obstructive pulmonary disease, major depressive disorder, protein-calorie malnutrition, bilateral hearing loss, post traumatic subdural hemorrhage, dysphagia, and frequent falls. Review of medical record revealed Resident #32's last care conference completed on 04/08/25 by Former LSW #571. No other care conferences were completed after April 2025. Review of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 indicating Resident #32 had severe cognitive impairment. The functional assessment revealed the resident was dependent on staff for all ADL, hygiene, toileting, and transfers/mobility. Resident #32 was always incontinent of bowels and bladder. 5. Resident #49 was admitted to facility on 02/09/21 with diagnoses of atherosclerotic heart disease, peripheral vascular disease, osteoarthritis, dementia, protein-calorie malnutrition, dysphagia, need for assistance with personal care. Review of medical record for revealed Resident #49's the last care conference was completed on 02/13/25 by Former LSW #571. No other care conferences were completed for Resident #49 after February 2025. Review of Annual MDS assessment dated [DATE] revealed a BIMS score of 2/15, indicating Resident #49 had severe cognitive impairment. The functional assessment revealed the resident was dependent on staff for all ADL, hygiene, toileting, transfer and mobility. Resident #49 was always incontinent of bowels and bladder. Interview with Resident #49's Power of Attorney (POA)/daughter on 04/27/26 at 10:12 A.M. revealed she has not had a care conference in over a year and there was not a social worker on site for a while. The POA stated she had requested care conferences in the past but had not received one in over a year. 6.Resident #11 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, generalized muscle weakness, congestive heart failure, atrial fibrillation, malignant neoplasm of thymus, and malignant neoplasm of endometrium. Review of medical record for Resident #11 revealed the last care conference was completed on 04/29/25 by Former LSW #571. No other care conferences were completed for Resident #11 after April 2025. Review of the Significant Change MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating Resident #11 was cognitively intact. The functional assessment revealed Resident #11 was dependent on staff for toileting, required maximal assistance for showers, dressing, transfers, and required set up assistance for eating and oral hygiene. Interview with Resident #11 on 04/29/26 at 8:42 A.M. revealed she and her son used to be involved in quarterly care conferences; however, she thought it had been about two years since the last care conference. Interview with Director of Nursing (DON) and Corporate Regional Clinical Nurse (RCN) #568 on 04/28/26 at 2:50 P.M. verified the facility did not currently have a LSW or designee with LSW oversight for social worker duties since November 2025. The DON and RCN #568 provided evidence that Former LSW #571's last day worked was 11/05/25. The facility has been actively recruiting, and the DON has taken on additional responsibilities of a LSW at the facility; however, no LSW had signed off on any evaluations or conferences. The DON also verified that care conferences have been missed on long stay residents. Review of the facility policy titled, Comprehensive Care Plans, revised 03/20/25, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. This deficient practice represents non-compliance investigated under Complaint Number 2567648.

Based on record review, review of the Social Services Director job description and interviews, the facility failed to provide medically related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well being. The facility had no Licensed Social Worker (LSW) providing or overseeing required social services for more than five months, resulting in missed care conferences, absence of required resident and representative involvement in care planning and failure to notify residents or representatives when personal fund accounts exceeded Medicaid limits. This affected nine residents (#13, #14, #22, #32, #49, #11, #1, #50, and #59) of 25 sampled residents and had the potential to affect all 58 residents in the facility. The facility's census was 58.Findings include:During an interview on 04/28/26 at 2:50 P.M., the Director of Nursing (DON) #526 and Regional Nurse #568 confirmed the facility is licensed for 180 beds and the facility had not employed a LSW since 11/05/25. The interview also confirmed no LSW had completed, overseen, or signed any social services documentation, assessments, or care conferences since that date. The department heads were informally attempting to perform social services tasks without training, qualifications, or LSW oversight and an off site Social Worker at another facility was contacted for advice only and did not perform or sign any work for this facility. The DON acknowledged that multiple long stay residents had missed required care conferences and that no system was in place to ensure completion of social services responsibilities.1. A review of Resident #13's medical record revealed an admission date of 01/13/23 with multiple medical and psychosocial needs. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15/15 which indicated intact cognition and dependence on staff for activities of daily living (ADL). The record review showed the last care conference was 07/02/25.An interview on 04/27/26 at 10:31 A.M. with Resident #13 confirmed she had not received any care conferences since July 2025.2. A review of Resident #14's medical record revealed an admission date of 06/30/22 with significant medical and psychosocial needs. A review of the Quarterly MDS assessment dated [DATE] showed a BIMS score of 12/15 which indicated moderate cognitive impairment. Further record review showed the last care conference was 07/28/25.3. A review of Resident #22's medical record revealed an admission date of 01/13/23 with dementia and total dependence for ADL. Her Quarterly MDS assessment dated [DATE] showed severe cognitive impairment (BIMS score of 00). The record review showed the last care conference was 04/16/25.4. A review of Resident #32's medical record revealed an admission date of 08/28/23 with dementia, chronic obstructive pulmonary disease, depression, dysphagia, and fall risk. Her Quarterly MDS assessment dated [DATE] showed severe cognitive impairment (BIMS score of 00). The record review showed the last care conference was 04/08/25.5. A review of Resident #49's medical record revealed an admission date of 02/09/21 with dementia and multiple chronic conditions. The Annual MDS assessment dated [DATE] showed severe cognitive impairment (BIMS score of 2). A record review showed the last care conference was 02/13/25.An interview with Resident #49's daughter on 04/27/26 at 10:12 A.M. revealed she had not participated in a care conference in over a year, despite requesting them.6. A review of Resident #11's medical record revealed and admission date of 01/16/23 with multiple chronic conditions. Review of the Significant Change MDS assessment dated [DATE] showed intact cognition (BIMS score of 15/15).An interview with Resident #11 on 04/29/26 at 8:42 A.M. stated she and her son had not participated in a care conference in approximately two years. An interview with the DON on 04/30/26 at 10:14 A.M. confirmed Resident #11 had not had a care conference in the past year, and a record review showed the last care conference was 04/29/25.7. The absence of a Social Worker also resulted in failure to notify residents or representatives when personal fund accounts exceeded Medicaid limits:- Resident #1: $20,702.70 as of 05/01/26- Resident #22: $6,007.89 as of 05/01/26- Resident #50: $24,237.64 as of 05/01/26- Resident #59: $4,280.00 as of 05/01/26During an interview on 05/04/26 at 2:30 P.M., the Business Office Manager (BOM) #530 confirmed she was aware of high personal fund balances and no spend down notifications were issued to residents. The interview also confirmed the facility had no Social Worker to send required notifications, no other staff were assigned to complete this responsibility, and the facility lacked a process to assist residents in managing excess funds.A review of the facility's Social Services Director job description (updated 08/25) confirmed that the position is responsible for ensuring the provision of medically related social services in accordance with State and Federal regulations. The facility had no individual fulfilling these duties.

Based on observation, record review, policy review, and interview, the facility failed to ensure residents were fed in a dignified manner. This affected one resident (#19) of four residents who were identified as needing assistance with meal intake. The facility census was 58.Findings include:A review of medical records for Resident #19 revealed the date of admission as 01/12/23. Significant diagnoses included unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance mood disturbance or anxiety, unspecified protein calorie malnutrition, Alzheimer's disease, dysphasia (difficulty swallowing), and need for assistance with personal care. Significant orders included regular diet, mechanical soft texture, nectar thick liquids. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a severe cognitive deficit and was rarely understood. The assessment also revealed Resident #19 was dependent on staff for eating.A care plan dated 02/25/26 revealed Resident #19 required assistance with activities of daily living (ADL). Interventions included Resident #19 was dependent on staff for eating.An observation on 04/27/26 at 12:43 P.M. revealed Resident #19 in the East dining room seated in his wheelchair being fed by Licensed Practical Nurse (LPN) #542. LPN #542 was standing over Resident #19 as she fed him. LPN #555 and Executive Director #505 verified the findings at the time of the observation. LPN #555 stated LPN #542 should be seated when assisting Resident #19.An observation on 04/30/26 at 12:40 P.M. revealed Resident #19 in the East dining room seated in his wheelchair being fed by Certified Nurse Aide (CNA) #517. CNA #517 was standing over Resident #19 as he was feeding him. Registered Nurse (RN) #567 verified the findings at the time of the observation.A review of the undated facility document titled; Validation Checklist-Assisting Resident with Meals revealed residents should be interacted with during mealtime. Examples include being courteous, seated next to the resident, not standing behind or over the resident, primarily conversed with the resident, and no other staff members or residents during the meal.A review of the facility policy titled; Resident Rights (revised 02/15/24) revealed the resident has a right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, review the Ohio Department of Health (ODH) Certification, Licensure and Survey System (CALS) website, and review of a facility self-reported incident (SRI) and policy review, the facility failed to prevent staff to resident verbal abuse. This affected one resident (Resident #6) of six residents who were reviewed for abuse. The facility census was 58.Findings include:Resident #6 was admitted on [DATE] with significant diagnoses including senile degeneration of the brain and vascular dementia with agitation, and was placed on the secured unit with behavior monitoring for anxiety, depression, agitation, physical and verbal behaviors, delusions, hallucinations, refusals, and attention seeking, with interventions such as redirection, environmental changes, diversion, food and fluids, toileting, and limit setting. Medication orders included multiple Depakote regimens for agitation and dementia. A care plan dated 02/03/26 showed the resident required assistance with all activities of daily living due to impaired cognition and was often resistive to care, with interventions encouraging resident choice, participation in care, praise for appropriate behavior, anticipating needs, ensuring safety during agitation, and reapproaching as needed. The resident was also at risk for adverse reactions to anti anxiety medications, requiring monitoring and reinforcement. An annual Minimum Data Set (MDS) dated [DATE] documented severe cognitive impairment, frequent physical behavioral symptoms such as hitting, kicking, pushing, scratching, grabbing, or sexually abusing others on four to six days during the seven-day look back period, and full dependence on staff for all activities of daily living.A review of the ODH CALS website revealed the facility created SRI tracking #269375 on 01/04/26 for staff-to-resident verbal abuse. The facility finalized the investigation on 01/10/26 and substantiated verbal abuse did occur to Resident #6.A review of SRI #269375 and subsequent facility investigation revealed the following:On 01/04/26 the facility administration became aware of an allegation involving inappropriate conduct toward a resident during hands-on care after staff reported that an audio recording existed depicting a care team member yelling at a resident. The allegation had surfaced after staff indicated that the content had been shared among employees. An immediate investigation was started, including skin assessments, resident and staff interviews.Upon notification, facility leadership immediately initiated protective measures to ensure resident safety. Nursing staff completed skin assessments on the resident involved and all residents in the memory care unit. There were no significant findings. Resident #6 was observed to be at baseline with no signs or symptoms of distress. A review of text message in the investigative file revealed Executive Director (ED) #541 made an attempt to reach an unidentified housekeeper for the audio recording on 01/04/26 at 2:41 P.M. The unidentified housekeeper denied the audio recording existed and resigned on 01/04/26 at 3:46 P.M.An investigation was conducted by the facility including staff interviews with involved staff and preservation of available information period two staff members independently reported that an audio recording had been shared with them depicting certified nurse aid (CNA) #570 using inappropriate language toward Resident #6 during care. On 01/06/26 at approximately 6:00 P.M. the reporting individual re-engaged with the administrator and provided additional information including identification of the involved CNAs and the existence of an audio recording. The audio recording was obtained and reviewed and secured by administration. CNA #570 was identified and immediately removed from resident care and placed on suspension pending investigation. Upon completion of the facility investigation and review of available evidence, the facility determined that a verbal altercation occurred during resident care involving inappropriate and unprofessional language towards Resident #6. CNA #570 was terminated. A review of the personnel file for CNA #570 revealed a date of hire as 08/13/25. The file further revealed a nurse aide registry (NAR), and all background checks were completed with no findings for abuse. The file revealed a final punch on 01/06/26 with an out time at 5:39 P.M.On 05/05/26 at 3:20 P.M. an interview with the Director of Nursing (DON) and ED #541 verified the findings in SRI #269375 as verbal abuse having occurred. The interview further revealed there was delay in identifying CNA #570 as the perpetrator as the unidentified housekeeper did not initially cooperate with the investigation.A review of the facility policy titled Abuse, Neglect, and Exploitation (revised 03/05/24) revealed it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property the policy further defines verbal abuse as a means of use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.The deficient practice was corrected on 01/16/26 when the facility implemented the following corrective actions: - On 01/04/26 skin assessments were completed on all residents in the memory care unit with no findings. Resident #6 was found to be at baseline cognition with no evidence of distress.- On 01/06/26 CNA #570 was identified as the perpetrator and removed from the schedule pending investigation.- On 01/09/26 facility wide education was initiated. This education included abuse prevention policy and mandatory reporting expectations.- On 01/10/26 the investigation findings were finalized, and determination was made that a verbal altercation occurred during resident care. CNA #570 was terminated from employment.- On 01/16/26 facility wide education was completed for all staff. Staff acknowledgement of the education was obtained.- Ongoing interventions include assessment of resident number six which reveals no change in condition or behavior. Other interventions include quality assurance (QA) monitoring weekly for any resident abuse for four weeks which was concluded and then monitored monthly for three months with no findings. Staff members will continue to be educated on abuse upon hire, yearly, and as needed.This deficiency represents non-compliance investigated under Complaint Numbers 2689846, 2594525,and 1363590 (OH00164779).

Based on record review, observation, interviews and facility policy review, the facility failed to ensure physician orders were followed and dressing changes were performed. This affected one (Resident #35) out of four residents reviewed for pressure and non-pressure skin conditions. The facility census was 58.Findings include:Resident #35 was admitted to facility on 01/30/26 with diagnoses of non-displaced fracture of lateral malleolus right fibula (ankle fracture), chronic osteomyelitis right ankle and foot, cellulitis right lower limb, epilepsy, anxiety disorder, depression, obesity, and need for assistance with personal care.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating Resident #35 was cognitively intact. The functional assessment revealed the resident needed set up for upper body activities of daily living (ADL) and required one staff assist for lower body ADL, hygiene, transferring and mobility.Interview with Resident #35 on 04/27/2026 10:12 A.M. revealed she had not received a dressing change to her right foot in over a week, and her last dressing change occurred at the podiatrist office. She stated her provider said they should occur daily. Resident #35 also stated she had never refused any dressing changes.Record review of Resident #35's physician's orders revealed an order dated 04/07/26 to the right ankle/foot surgical wound: cleanse with wound cleanser, apply betadine (antiseptic) moisten gauze to incisions then wrap with Ace wrap every day. Review of Treatment Administration Record (TAR) for Resident #35 revealed all dressing changes were signed off as the resident had refused dressing changes on 04/22/26, 04/25/26 and 04/26/26 which the resident denied.Observation of wound care on 04/28/26 at 12:20 P.M. performed by Licensed Practical Nurse (LPN) #542 revealed Resident #35 had an open wound to anterior of right foot which had crusted serosanguinous drainage adhered to gauze wrap. LPN #542 used saline to soften and remove gauze dressing and cleansed the wound per order with wound cleanser, applied betadine moisten gauze to open area and rewrapped with gauze and Ace wrap per order.Interview with LPN #542 on 04/28/26 at 12:30 P.M. verified Resident #35's statement regarding dressing changes and confirmed they were not performed daily. LPN #542 confirmed the previous order dated 03/31/26 for the dressing not to be changed until seen in podiatry office and believed the dressing change was only to be done at provider office. LPN #542 also confirmed she had signed off the dressing changes in the electronic medical record (EMR) as completed on 04/18/26, 04/19/26, 04/23/26, 04/24/26, 04/27/26, and 04/28/26 but thought the order meant that it was intact and did not review the updated order when she signed it off.Interview with the Director of Nursing (DON) on 04/28/26 at 1:45 P.M. verified staff were not following provider's orders and the order for the dressing change was to be completed daily on day shift. The DON confirmed nursing staff were signing off completion of dressing changes when they were not being performed as ordered.Review of facility policy titled, Wound Treatment Management, revised 02/14/24, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on record review and interview, the facility failed to identify and document individualized trauma triggers and coping mechanisms for a resident with a diagnosed trauma related disorder. This affected one resident (#3) of two residents reviewed for mood/behavior. The facility census was 58.Findings include:Record review revealed Resident #3 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, type II diabetes hypertension, congestive heart failure, non-rheumatic aorta insufficiency, and post-traumatic stress disorder (PTSD). Review of the plan revealed Resident #3 was a trauma survivor related to military service with a goal that coping mechanisms would be identified. The interventions included identifying triggers related to past trauma; however, none were identified in the care plan.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired and required maximal assistance for toileting and transfers and moderate assistance for dressing. Resident #11 also had PTSD listed as a psychiatric/mood disorder. Interview on 04/29/26 at 8:47 A.M. with Resident #3 revealed his triggers included certain television shows, sudden loud noises such as the fire alarm, when someone entered his room quietly and startled him because he felt like someone was sneaking up on him. Resident #3 also reported reciting The Lord's Prayer as a coping mechanism for his PTSD. Interview on 04/30/26 with the Director of Nursing (DON) confirmed triggers and coping mechanisms had not been identified for Resident #3.

Based on observation, interview, and facility policy review the facility failed to appropriately dispose of biohazardous materials and handle clean and soiled linen to prevent the spread of infection. This affected eight residents (#1, #8, #13, #24, #40, #58, #73 and #77) and had the potential to affect all 103 residents residing in the facility. Findings include: Observation on 07/22/24 at 8:53 A.M. the adjoining bathroom shared by Residents #8, #13, #58 and #77 revealed a feces soiled pillowcase crumpled on the bathroom floor next to the toilet. Interview at the time of the observation with State tested Nurse Aide (STNA) #488 confirmed the finding. Observation on 07/22/24 at 11:20 A.M. of the laundry room with Housekeeping District Manager (HDM) #611 revealed a pile of soiled linens placed on the floor in front of the middle washer which was not functioning and filled with washed linen. There were two wall mounted fans on in the clean laundry area, one blowing air toward the dryers and the other blowing air toward the folded and hanging linens/clothes. Both fans were visibly dirty and had lint, dirt, and debris buildup on the back and front fans. Interview at the time of the observation with HDM #611 verified the findings. Observation on 07/23/24 at 9:02 A.M. revealed Laundry Worker (LW) #606 walking through the 300-hallway toward the memory care unit pushing a rolling rack filled with residents' hanging personal clothes and a shelf on the rack bottom just above the wheels with a number of miscellaneous pieces of linen/clothing. Interview at the time of the observation with LW #606 verified the clothing was being delivered to residents. During the interview, LW #606 bent down and picked up a small thin blue sheet from the bottom shelf and swung it over the clothing then adjusted it to try and cover it. The sheet contacted the clothes and covered the width of the rack but only covered the upper half portion of the hanging clothes. The lower shelf also remained uncovered. LW #606 explained the sheet was used daily to cover the clothes, but she had forgotten to put it back over the clothes during delivery. LW #606 confirmed there was no covered linen/clothing cart available to use for delivering clean laundry. Observations on 07/23/24 at 10:43 during an environment tour with Maintenance Director (MD) #474 revealed Resident #24's bathroom had soiled linen on the floor. The adjoining bathroom shared by Residents #1, #40 and #73 had two large biohazardous red bags stored inside. One red bag was not closed and contained a large amount of soiled linen. On top of the other red bag there was a crumpled soiled disposable gown so it could not be determined if the bag was opened or closed or what was inside the red colored bag. Interview at the time of the observation with MD #474 verified the findings. Review of the facility policy, Laundry and Bedding, Soiled, revised September 2022, revealed soiled laundry and bedding was handled, transported and processed according to best practices for infection prevention and control. Clean linen was protected from dust and soiling during transport and storage to ensure cleanliness. This deficiency represents non-compliance investigated under master Complaint Number OH00155690 and Complaint Number OH00155647 and is a recite to the annual and complaint survey completed on 05/02/24.

Based on observation, interview, and facility policy review the facility failed to provide a safe, sanitary, and homelike environment. This affected 48 residents (#3, #6, #7, #8, #13, #15, #16, #17, #19, #21, #23, #24, #27, #31, #32, #34, #35, #37, #38, #39, #42, #44, #46, #47, #49, #51, #55, #58, #59, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #88, #89, #92, #93, #95, #97, #100 and #102) and had the potential to affect all 103 residents residing in the facility. Findings include: Observation on 07/17/24 at 10:49 A.M. of the adjoining bathroom shared by Residents #8, #13, #58, and #77 revealed a sticky floor and a toilet paper roll placed on the back of the toilet in lieu of a toilet paper holder, which was not secured tightly to the wall. The toilet water was low inside the commode with a large amount of soiled toilet paper, black/brown in color piled inside, and black/brown soilage dried around the inner commode walls. Residents #13 and #77's shared bedroom closet was missing a handle to functionally open/close the door with only a pointed screw protruding from it, and the floor was sticky in the area from the sink to the bathroom entrance. Resident #24's room had no closet door/cover, and the bathroom had a toilet paper roll placed on the back of the toilet in lieu of a toilet paper holder. Interview on 07/17/24 at 11:00 A.M. with State tested Nursing Assistant (STNA) #440 verified the findings in the rooms for Residents #8, #13, #24, #58, and #77. Observation on 07/17/24 at 11:26 A.M. of Resident #34 and #97's room revealed no curtain covering the window. Interview at the time of the observation with Licensed Practical Nurse (LPN) #434 confirmed there was no window covering and indicated Resident #97 complained of bright light at night while trying to sleep. Observation on 07/17/24 at 11:35 A.M. of Resident #74's bathroom revealed a toilet paper roll placed on the back of the toilet in lieu of a toilet paper holder. Observation on 07/17/24 at 11:37 A.M. of Resident #21's bathroom revealed a toilet paper roll placed over the attached toilet faucet/sprayer used for cleaning excrement in lieu of a toilet paper holder. Interview on 07/17/24 at 11:38 A.M. with Housekeeper #602 confirmed the observations of Residents #21 and #74's rooms, and indicated there were broken toilet paper holders so toilet paper was placed wherever possible. Observation on 07/17/24 at 11:42 A.M. of the memory care unit revealed a missing baseboard around the walls of the shower room and the area across the hall from the shower room. The hallways throughout the unit had numerous spackled or patched areas. Interview on 07/17/24 at 1:33 P.M. with Administrator verified the memory care unit painting and baseboard repair was planned although it had been that way since May 2024. Observation on 07/22/24 at 8:53 A.M. the adjoining bathroom shared by Residents #8, #13, #58, and #77 revealed dried feces smeared on the bathroom door frame toward Resident #13 and #77's bedroom, a feces soiled pillowcase crumpled on the bathroom floor next to the toilet, and visible dried feces on the toilet paper roll and holder which was not fully secured to the wall and hanging down. Dried feces were smeared over a significant portion of the toilet seat. Inside the toilet had a low water level and piles of feces soiled toilet paper piled inside it with dried feces covering most of the inner toilet walls. Interview at the time of the observation with STNA #488 verified the findings. On the floor blocking Resident #13 and #77's bedroom entrance was a large pile of debris including a medication cup with a dried pink substance inside, pieces of paper, food, dust, and dirt. A floor duster handle missing a duster head was left leaning against the wall outside the left entrance door. Interview on 07/22/24 at 8:59 A.M. with Housekeeper #609 verified the pile of swept debris was left in its place blocking Resident #13 and #77's bedroom entrance because a new floor duster head was being retrieved. Observation on 07/22/24 at 11:20 A.M. of the laundry room with Housekeeping District Manager (HDM) #611 revealed a gray colored blanket stuffed between the dryers closest to the door and the next dryer. The blanket was covered with lint, dirt, and debris. HDM #611 indicated it was placed there due to staff being concerned with critters coming through from behind the dryers but confirmed it did not belong there. After blanket removal, there was a large amount of dirt, debris, and lint visible between the dryers. Observations on 07/23/24 at 10:43 A.M. during an environment tour with Maintenance Director (MD) #474 revealed the following findings: Resident #19's bathroom had a protruding screw point from the wall into the toilet paper holder area where toilet paper was retrieved. The bedroom wall mounted light fixture had no light shade leaving a light bulb fully uncovered. Resident #95's bathroom had a burned-out light bulb. The bathroom paper towel dispenser was secured to the wall in such a way to block the light switch making it difficult to access for use. The 300-hall activity and puzzle room had one large and four small water stains on the ceiling tiles. MD #474 indicated a painted covering was used over the large stain, but the replacement tiles had not yet been obtained for replacement. Resident #78 and #80's bedroom had one shared closet with a folding door which did not function properly being off track, and the closet doorknob was loose and spinning. The lower bathroom wall opposite the toilet had a piece of tile broken off on the floor and a missing tile above the broken tile. Resident #17's bedroom closet floor contained numerous dead insects in scattered small and larger piles. The closet floor carpet had a large unsightly dark stain. The folding door of the closet did not function properly, being off track. MD #474 indicated the bedroom closet area was sprayed for insects and it was not cleaned up afterward. (Review of the pest control treatment and inspection records indicated Resident #17's bedroom was treated for swarmer ants on 06/14/24 and 06/24/24.) Resident #16 and #100's bedroom had one shared closet with a folding door. The closet doorknob was loose and spinning. Resident #13 and #77's bedroom had a large wall area to the right of the window with removed paint exposing wallpaper from underneath, a missing floor tile underneath the sink, and an unsecured toilet paper holder in the adjoining bathroom shared with Residents #8 and #58. Resident #44 and #84's bedroom had one shared closet with a folding door. The closet doorknob was not attached leaving a visible protruding pointed screw. Resident #8 and #58's bedroom had one shared closet with a folding door not functioning properly being off track. A broken unused wall mounted plastic bracket was protruding from the wall next to Resident #58's bed. Resident #31 and #47's bedroom had a missing piece of floor tile in the center of the room. Resident #35 and #93's bedroom had a window with vertical blinds. There were two missing slats from the vertical blinds. The one shared closet had a folding door not functioning properly being off its track. Resident #3's bathroom had a broken toilet paper holder. Resident #75's bathroom mirror had multiple areas of dark discoloration making the mirror unusable. Resident #59 and #82's bathroom had a combined light and fan which made a loud clanging noise when in use. Resident #23, #38, and #102's adjoining bathroom had a toilet paper roll placed over the attached toilet faucet/sprayer used for cleaning excrement in lieu of a toilet paper holder. Resident #32's bathroom had dried feces smeared on the toilet riser seat, and the left bathroom wall and floor had multiple areas with dried feces. Resident #39 and #55's inside bedroom door had exposed metal corner bead for drywall over approximately ten inches of the lower door frame. Resident #15, #39, and #55's adjoining bathroom had dried smeared feces on the toilet riser. The bathroom door handle used to exit from the bathroom into Resident #15's room had a child safety doorknob cover in place which prevented its use. Resident #27, #79, and #89's adjoining bathroom had a toilet riser with multiple rusted and peeled away coated areas. Resident #89's bedroom window had vertical blinds with three missing slats. Resident #37's bathroom had a toilet paper roll placed over the attached toilet faucet/sprayer used for cleaning excrement in lieu of a toilet paper holder. Resident #6, #7, #81, and #92's adjoining bathroom had a toilet riser with multiple rusted and peeled away coated areas. There was a toilet paper roll placed on the back of toilet in lieu of a toilet paper holder. Resident #6 and #81's bedroom had one shared closet with a folding door. The closet door had a missing handle leaving a protruding pointed screw. Resident #7 and #92's bedroom had a non-functioning paper towel dispenser. Resident #49's bedroom window had vertical blinds with one missing slat. The left folding closet door had a broken plastic handle with sharp edges remaining. Resident #21's bedroom had two folding closet doors with broken plastic handles leaving sharp edges remaining. Resident #46's bedroom had a folding closet door not properly functioning being off track, and the door was inappropriately sized, not covering the entire closet space. Residents #42, #76, and #88's adjoining bathroom had dried feces smeared on the toilet seat. There was a cracked and partially missing bathroom tile piece next to the bathroom door leading toward Resident #76's bedroom. The damaged tile had rough edges exposed. Resident #34, #51, #83, and #97's adjoining bathroom a clump of hair hanging from the toilet riser. The toilet paper roll was placed over the attached toilet faucet/sprayer used for cleaning excrement in lieu of a toilet paper holder. Interview at the time of the observations with MD #474 verified the above findings. This deficiency represents non-compliance investigated under Master Complaint Number OH00155690 and Complaint Number OH00155684 and is a recite to the surveys completed on 05/02/24 and 06/18/24.

Based on observation and interview, the facility failed to provide a private closet space separate from roommates' clothing. This affected 46 residents (#1, #2, #4, #6, #7, #8, #11, #13, #16, #20, #22, #23, #27, #31, #34, #35, #41, #42, #44, #47, #50, #51, #58, #59, #61, #64, #69, #73, #77, #78, #79, #80, #81, #82, #83, #84, #86, #88, #92, #93, #94, #97, #98, #100, #102 and #103) out of 103 resident rooms reviewed for closet space. The facility census was 103. Findings include: Observations on 07/23/24 at 10:43 A.M. during a facility tour with Maintenance Director (MD) #474 revealed the following residents were roommates and had one closet shared by both residents that did not separate the roommates' clothing: Residents #78 and #80 Residents #100 and #16 Residents #77 and #13 Residents #84 and #44 Residents #58 and #8 Residents #31 and #47 Residents #93 and #35 Residents #98 and #61 Residents #20 and #64 Residents #50 and #11 Residents #4 and #94 Residents #82 and #59 Residents #23 and #102 Residents #73 and #1 Residents #27 and #79 Residents #7 and #92 Residents #81 and #6 Residents #42 and #88 Residents #41 and #86 Residents #22 and #69 Residents #2 and #103 Residents #97 and #34 Residents #83 and #51 Interview at the time of the observations with MD #474 confirmed the above findings. This deficiency represents non-compliance investigated under Master Complaint Number OH00155690 and Complaint Number OH00155684.

Based on record review, facility self-reported incident (SRI) review, and interview the facility failed to prevent resident-to-resident abuse for residents #41 and #104. This affected two residents (#41 and #104) of three residents reviewed for abuse. The facility census was 103. Findings include: Review of the closed medical record for the Former Resident #104 revealed an admitted [DATE]. The resident was discharged to the hospital on 06/27/24. Diagnoses included Alzheimer's disease, diabetes, and dementia with agitation. The resident was at the facility for a respite stay. Review of the Admission Minimum Data Set (MDS) assessment, dated 06/20/24, revealed Resident #104 had severely impaired cognition. The resident's hearing and vision were adequate without devices. Behaviors included physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, and rejection of care. Review of physician orders for June 2024 revealed orders for: Haloperidol Oral Tablet 1 milligram (mg) (antipsychotic) by mouth every three hours as needed for behaviors. The order was dated 06/27/24 at 10:15 A.M. Alprazolam Oral Tablet (Xanax) 0.5 mg (antianxiety) every four hours as needed for agitation/anxiety. The order was dated 06/25/24. Alprazolam Oral Tablet (Xanax) 0.5 mg every eight hours as needed for anxiety. The order was dated 06/13/24 to 06/25/2024. Sertraline HCl Oral Tablet 100 mg (antidepressant) by mouth in the morning for depression. The order was dated 06/14/24. Risperidone Oral Tablet 0.25 mg (antipsychotic) by mouth at bedtime for behaviors. The order was dated 06/13/24. Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg 9anticonvulsant) by mouth two times a day. The order was dated 06/13/24. Review of the plan of care dated 06/17/24 revealed Resident #104 exhibited verbal and physical behaviors related to diagnosis of dementia. He can become combative with hands on care. Interventions included: administering medications as ordered. Monitoring for effectiveness. Intervening as necessary to protect the rights and safety of others. Approaching/speaking in a calm manner. Diverting attention. Removing from the situation and take to an alternate location as needed. Review of the plan of care dated 06/17/24 revealed Resident #104 was an elopement risk/wanderer. Wanders in and out of other's rooms. Interventions included: Gently redirect away from exit doors. Review of the plan of care dated 06/21/24 revealed Resident #104 had potential for delirium or an acute confusional episode related to Alzheimer diagnosis, change in environment, use/side effects of psychotropic medication. Interventions included: engaging the resident in simple, structured activities that avoid overly demanding tasks. Monitor for/address environmental factors recent change in environment, environmental noise and commotion. Provide medications to alleviate agitation as ordered by the physician. Monitor/document side effects and effectiveness. Redirect and provide gentle reality orientation as required. Reorient to person, place, time, situation as required. Review of the nurse's progress note dated 06/22/24 at 6:43 A.M. revealed resident #104 exhibited behaviors of combativeness with care and redirection. The as needed Xanax 0.5 mg was effective. Review of the nurse's progress note dated 06/23/24 at 7:15 P.M. revealed Resident #104 was restless, walking around touching other residents. The as needed Xanax 0.5 MG was effective. Review of the nurse's progress note dated 06/25/24 at 12:15 A.M. revealed Resident #104 was highly agitated, constantly getting out of bed. Review of the nurse's progress note dated 06/25/24 revealed nurse contacted hospice to notify them that resident #104 was highly agitated after dinnertime. The resident was very difficult to redirect even after evening meds and as needed Xanax. Resident #104 was constantly getting up, touching other residents, and going into their rooms. Review of the nurse's progress note dated 06/25/24 revealed the hospice nurse contacted the doctor and increased Resident #104's Xanax 0.5 mg to every four hours as needed for agitation/anxiety. Review of the behavior note dated 06/25/24 at 9:00 P.M. revealed the state tested nurse aide (STNA) stated Resident #104 was constantly getting up out of the wheelchair touching other residents and touching anything in site. Review of the behavior note dated 6/26/24 at 9:30 P.M. revealed Resident #104 had high anxiety and was very agitated with care. Review of the nurse's progress note dated 06/26/24 at 10:00 P.M. revealed Resident #104 was constantly moving out of chair, was very agitated, had high anxiety, was touching other residents, and going in their rooms. On 06/27/24 at 1:02 A.M., Xanax was noted as ineffective. Review of the nurse's progress note dated 06/27/24 at 10:06 P.M. revealed Xanax was given to Resident #104 for increased anxiety Review of the nurse's progress note dated 06/27/24 at 10:16 A.M. revealed a new order for Haldol 1 mg was sent to the pharmacy. Review of the nurse's progress note dated 06/27/24 at 11:55 A.M. revealed Xanax 0.5 mg was effective. Review of the incident note on 06/27/24 at 8:30 P.M. revealed an STNA observed Resident #104 being physically aggressive with Resident #41. Resident #104 was observed hitting Resident #41 in her room. When the STNA attempted to remove Resident #104 from the room, he became combative. The STNA notified the nurse. The residents were assessed, and no injuries were noted. The nurse was instructed by the unit manager to send Resident #104 to the hospital for evaluation. Resident #104 was placed on one-to-one observation until he left for the hospital. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included dementia, anxiety disorder, chronic obstructive pulmonary disease (COPD), and bilateral hearing loss. Review of the quarterly MDS assessment, dated 06/06/24, revealed Resident #41 had impaired cognition and wandering behaviors. Review of the e-INTERACT SBAR Summary for Providers dated 06/27/24 at 8:30 P.M. revealed a change in condition was reported for Resident #41. There was a change in skin color or condition. Review of the comprehensive encounter note 06/28/24 at 1:00 A.M. revealed Resident #41 was seen for a resident associated incident. Resident #41 was alert and oriented to self. Per report, the resident was recently assaulted and hit in the face [by Resident #104]. At the time of assessment, Resident #41 was sitting in the dining room finishing lunch. She ate the entire meal without difficulty. She appeared to be in no distress, smiling during our interaction. Assessment and palpation of the face revealed no signs or symptoms of discomfort. Review of the Incident note 06/28/24 at 1:17 A.M., Late Entry, revealed the nurse was called to Resident #41's room due to an incident with Resident #104. The STNA stated Resident #104 was seen in Resident #41's room hitting her. The STNA separated the residents. Resident #104 was escorted from the room. Resident #41 was assessed for injuries and noted to have a small, reddened area below her left eye. The resident seemed startled and kept stating that a man had hit her on her head. No injuries were noted to her head. Emotional support and comfort were provided. Later, the police officer arrived to interview Resident #41, and she stated that nobody had hit her, no man had hit her in her head. Resident #41 was calm with no behaviors. Resident #41 was resting quietly in bed at this time. Nursing continued to monitor the resident throughout the night for any changes. Review of the Incident Note dated 06/28/24 at 12:20 P.M. revealed Resident #41 had a small pink area noted under her left eye. The area was not raised. The resident denied pain or discomfort. The resident did not remember anything from last evening and was up ambulating with her walker. Review of the social service progress note dated 06/28/24 at 1:15 P.M. Resident #41 was sitting in the dining room eating lunch and in no distress. The resident spoke and was in good spirits. Resident #41 did not seem to recall any events from the night before. Review of the behavior note dated 06/29/24 at 5:14 A.M. revealed Resident #41 was in bed at onset of this nurse's shift and roused easily without being startled. Resident #41 was pleasant and cooperative with no behaviors observed/reported. Resident #41 slept throughout the night. Review of the nurse's note dated 06/29/24 at 11:25 A.M. revealed an aide reported to the nurse that Resident #41 had bruising to both hands. The nurse reviewed the areas and noticed the scant bruising. The resident did not report any pain at the time. Review of the social service note dated 06/29/24 at 12:32 P.M. revealed Resident #41 was sitting in the dining room with a few of her friends talking and waiting for lunch. The resident was behaving fine and did not realize that there had been an incident. Review of the SRI tracking number 249132 and facility investigation dated 06/27/24 revealed on 06/27/24 at approximately 8:30 P.M. staff responded to a commotion in a resident room. Staff entered the room to find Resident #104 standing over Resident #41, who was in bed. Resident #104 was striking Resident #41 in the head. Staff intervened and attempted to remove Resident #104 from the room. Resident #104 then removed a dry erase board from the wall and repeatedly hit staff with it. Resident #104 maneuvered back to Resident #41 and took the pillow and covered Resident #41's head. Staff were able to remove Resident #104 from the room and remained with him. Resident #41 was evaluated for injuries. A red mark was noted on resident #41's left eye, no other injuries were noted. The physician was notified and gave order for Resident #104 to be sent to the hospital for further evaluation. Resident #104 departed from facility at approximately 8:50 P.M. Resident #104 was placed on one-to-one supervision until departure to the hospital. Resident #104's wife was made aware of the altercations and transfer to the hospital for further evaluation. The police were notified and arrived at the facility to take report of altercation. Follow-up evaluation for injuries revealed bruising to Resident #41's bilateral wrist/forearm, the resident denied pain. Continued emotional support and psychosocial follow-up was provided to Resident #41. Body audits were completed on like residents with no negative findings. Abuse audits were completed on like residents with no negative findings. Psychosocial follow up was completed with no negative findings. On 06/27/24 four STNAs and two Licensed practical Nurse (LPNs) were interviewed and completed witness statements. The statements confirmed the investigation's findings. Reviewed of the closed medical record for aggressive Resident #104 revealed he did not return to the facility. During observations made on 07/17/24, 07/18/24, and 07/22/24 revealed Resident #41 was in good spirits and responded positively to staff and residents. There were no concerns. Interview on 07/24/24 at 3:15 P.M. Unit Manager #428, unit manager for the memory care unit, stated Resident #104 was a fidgeter. He was terminally restless. He would touch everything and everyone around him. It was not in an aggressive way. Unit Manager #428 was shocked when she was called regarding the incident. Resident #104 walked into other resident's rooms but had not done anything physical. The resident had not been violent with staff, just resistant to care. There was only one regular aide and three agency aides the night of the incident. The nurse was also an agency nurse the night of the incident. Unit Manager #428 verified the incident had occurred. Interview on 07/24/24 at 5:23 P.M. LPN #455, the usual day shift nurse on the memory care unit, revealed day shift on 06/27/24 received the order for Haldol from hospice. The hospice nurse came in on 06/27/24 at around 9:30 A.M. The night shift nurse had called hospice the previous evening and left a message that Resident #104 had increased behaviors in the evenings, and nursing wanted something in place. However, Resident #104 did not have behaviors that morning or during the day. When LPN #455 left at 7:00 P.M. on 06/27/24, Resident #104 had not exhibited any behaviors of concern and had not needed the new order for Haldol or the previously ordered Xanax. This deficiency represents non-compliance investigated under Master Complaint Number OH00155690 and Complaint Number OH00155684.

Based on observation, interview and record review, the facility failed to accurately document fall interventions for Resident #62 and make vaccination documentation readily accessible in the medical record for Residents #97 and #102. This affected three residents (#62, #97 and #102) of 23 medical records reviewed. The facility census was 103. Findings include: 1. Review of the medical record for Resident #62 revealed an admitted [DATE]. Diagnoses included muscle weakness and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment completed 06/19/24 indicated Resident #62 had moderately impaired cognition and received hospice services. Review of the physician's orders revealed an order initiated 12/01/23 and effective July 2024 indicated Resident #62 was to have a floor mat to the left bedside while in bed. Observation on 07/17/24 at 11:50 A.M. revealed Resident #62 was in bed with no fall mat to the left bedside as ordered. Interview at the time of the observation with State tested Nursing Assistant (STNA) #470 confirmed there was no mat in place next to the bed, but indicated it was not on the Kardex (a quick reference for resident information). Review of Resident #62's Kardex effective 07/17/24 did not indicate a floor mat was required at the bedside. Review of Resident #62's care plan effective 07/17/24 indicated the fall intervention for a floor mat to the left bedside was discontinued on 06/24/24. Interview on 07/17/24 at 12:21 P.M. with Unit Manager (UM) #447 verified Resident #62 no longer required a left bedside floor mat as a fall intervention, and it was to be discontinued on 06/24/24. UM #447 indicated the active physician's order for the floor mat was an error, and not discontinued on 06/24/24 when required. 37097 2. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, dementia, and anxiety disorder. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #97 was cognitively impaired. Review of the immunization status for Resident #97 revealed only the first step of tuberculosis testing was recorded and Pneumococcal 20 had been refused. Interview on 07/23/24 at 11:32 A.M. with UM #447 revealed not all the immunizations had been put into the immunization tab, but they were done. Tuberculosis testing first step was done on 07/03/24. The second step was done on 07/11/24 and read on 07/14/24 but recorded in different places. 3. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE] with diagnoses including fracture of the fifth lumbar vertebra, adult failure to thrive, Parkinson's disease, and chronic pain syndrome. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #102 was cognitively intact. Review of the immunization status for Resident #102 revealed the resident had tuberculosis testing upon admission and had received Pneumovax 23 historically, but there was no information on the status of influenza immunization status. Interview on 07/23/24 at 11:32 A.M. with UM #447 revealed the facility looked for information on influenza immunization and were able to find it, but it was not entered in the correct location. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation and interview, the facility failed to provide an adequate bathroom door for privacy for Resident #25. This affected one resident (#25) of 103 residents whose rooms were observed for privacy. The facility census was 103. Findings include: Observations on 07/23/24 at 10:43 A.M. during a facility tour with Maintenance Director (MD) #474 revealed Resident #25's room had a bathroom entrance with a full-length curtain installed to cover the doorway in lieu of a door. The curtain was placed on a rod which extended approximately two to three inches away from the wall/door opening so when the curtain was drawn completely closed, it left a wide gap on both sides leaving ample opening to see inside the bathroom. With Resident #25's bedroom door opened and the bathroom curtain closed, the inside bathroom remained visible through the left bathroom curtain gap from the facility hallway outside of the bedroom. Interview at the time of the observation with MD #474 verified the findings. This deficiency represents non-compliance investigated under Master Complaint Number OH00155690 and Complaint Number OH00155684.

Based on observation, interview, and facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 110 residents residing in the facility. Findings include: Observations on 06/17/24 between 11:03 A.M. and 11:14 A.M. of the East wing revealed the window at the east end of the East wing was open, hot air was blowing in, grayish-black spots were noted on the seals of the window and along the top and bottom edges of the top and bottom windowpanes, there were multiple tears in the screen, and at least 25 dead insects on the windowsill. The light fixtures in the East halls contained multiple dark spots, some shaped like insects, under the fixture covers. Further observation of the common sitting area on the East wing revealed windows were on the north and south side of the room, each side had a window open, blowing hot air into the facility. Closer observation of the sitting area on the East wing revealed one window with no screen, one with the screen partially detached, and one with several tears. The windowsills had dead insects, dust and debris, and black and gray spots around the seals of the windows and on the windows. The wall next to the table in the sitting area contained thick yellow-like hardened substance splashed and dried to the wall and there were thick yellow dried drip-shaped spots on the wall near the trash can. Interview on 06/17/24 at 11:08 A.M. with Housekeeper #398 confirmed hot air was blowing into the facility from the open window on the east end of East wing and that there were several holes large enough for insects to enter. He further confirmed there was a broken vinyl blind panel, a greasy black substance along the edges of the window, dead insects, stating the majority were stink bugs, and confirmed there were insects under the light covers in the halls. A follow-up interview with Housekeeper #398 on 06/17/24 at 11:25 A.M. confirmed that there were thick dried splashes on the walls in the sitting area on the East wing that should have been cleaned, there were screens coming loose and with tears, there was hot air coming into the facility from the open windows, and there were blackish spots scattered along the inside and outside edges of the windows, as well as the seals along the windows that he was unable to remove with cleaning attempts at the time of the interviews. Housekeeper #398 indicated he did not know who was responsible for window cleaning at the facility. Observation on 06/17/24 11:50 A.M. of the window on the East wing near room [ROOM NUMBER] revealed the window consisted of glass louvers with gaps between each louver exposing the outside. At the time of the observation, hot air was noted flowing from the window into the hallway. Interview on 06/17/24 at 11:50 A.M. with Housekeeper #398 confirmed there was a gap between each louver large enough for insects to enter and for outside temperatures and weather to affect the area adjacent to the window. Housekeeper #398 further confirmed the knob to open and close the louvers was broken and there was no screen or additional windowpane covering the window from the outside elements. Interview on 06/17/24 at 12:42 P.M. with State tested Nurse Aide (STNA) #397 verified the hallway near room [ROOM NUMBER] by the glass louvered window was hot and she could feel the heat coming in from the window. She further confirmed two insects were flying around the light fixture closest to that window and there were several dark spots under the light cover. Observation on 06/17/24 at 12:52 P.M. of Shower Room C revealed a foul odor that got stronger near a floor drain on the side of the room where the sink and the toilet were located. Closer observation revealed hair and lint-like substances on top of the drain and standing water, with several black flecks floating in the water, in front of and to the right of the toilet. Interview on 06/27/24 at 1:02 P.M. with Maintenance Director #357 confirmed the following: a. An odor emitting from floor drain on side of the room with sink, some hair-like substance observed on top of the drain, standing water by toilet, one light inside the entrance of shower room was not working. b. Maintenance Director #357 was uncertain who was responsible for cleaning the outside of the facility windows but was trying to find out whether it was a service they contracted out or not. c. Several windows on the East wing were open and should not be left open on such hot days. d. Several screen with tears, one in the common area coming loose and another bowed. e. The window by room [ROOM NUMBER] was glass louvers, had a broken control knob and gaps between louvers which allowed for temperature concerns and did not prevent insects from entering the building. f. Light covers in the East wing were dirty, some visibly containing dead bugs. During this interview, Maintenance Director #357 revealed it only took a few days for insects to build-up under the light fixtures once cleaned. Observation on 06/17/24 at 3:10 P.M. revealed two sit to stand mechanical devices located in the hallway of the East-2 wing were soiled. Lift number 34410F+4L23G140 was missing a handle grip piece and had a soiled footboard. Lift number 3110022 had caked-on substance noted on both handle grips and a soiled footboard. Interview on 06/17/24 at 3:15 P.M. with Registered Nurse (RN) #326 confirmed the [NAME] 3000 sit to stand devices in the East-2 hallway needed to be cleaned. RN #326 said equipment should be cleaned on night shift or when visibly soiled or after use with any resident in isolation. Interviews conducted on 06/18/24 between 1:16 P.M. and 1:25 P.M. with STNA #359 and STNA #353 confirmed night staff were responsible for cleaning wheelchairs and mechanical lift equipment. Review of the facility example housekeeping checklist and procedure for room and bathroom cleaning from the Environmental Operations Manual revealed Housekeepers were to tour their assigned sections to identify any immediate issues and communicate Deep Cleans within the first thirty minutes of their shift. The procedure further revealed all vertical surfaces were to be spot cleaned with a cloth and disinfectant. The procedure did not address window cleaning. This deficiency represents non-compliance investigated under Complaint Number OH00153775. This deficiency is an example of continued noncompliance from the survey dated 05/02/24.

Based on observation and interview the facility failed to ensure call lights were within reach at all times. This affected one (Resident #86) of five sampled residents. The facility census was 110. Findings include: Review of the medical record for Resident #86 revealed an admitted [DATE] with diagnoses including visual hallucinations, hemiplegia and hemiparesis affecting right dominant side, type two diabetes mellitus with diabetic retinopathy and macular edema, asthma, neuromuscular dysfunction of the bladder, unspecified psychosis, anxiety disorder, essential (primary) hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment completed on 03/20/24 revealed Resident #86 had intact cognition. Further review of the MDS revealed Resident #86 had an impairment on one side, was dependent for toileting and bathing, was always incontinent of bowel and bladder, and required maximal assistance for transfers. Review of the care plan dated 06/13/24 revealed Resident #86 required assistance with incontinence care. Interventions included assisting with toileting and incontinence care as needed and ensuring her call light was within reach when she was in bed. Observation and interview on 06/17/24 at 11:58 A.M. with Resident #68 revealed she was in bed wearing a stained tee-shirt and an incontinence brief. Resident #68's call light was wrapped on the bottom of her left side rail and dangling on the ground. At the time of this observation, Resident #86 expressed relief, stating she was hot and needed someone to adjust her air conditioner, change her incontinence brief, dress her, and assist her into her chair before lunch. Resident #86 stated she had not been changed since 4:00 A.M. that morning, was able to tell when she needed checked and changed but had been unable to call for any assistance since she could not find or reach her call light. Interview on 06/17/24 at 12:10 P.M. with Registered Nurse (RN) #326 confirmed Resident #86 did not have a call light within reach. RN #326 was observed adjusting the air conditioner setting and providing Resident #86 her call light at that time. Interview on 06/17/24 at 12:42 A.M. with State tested Nurse Aide (STNA) #397 revealed she was unaware Resident #86 needed changed, adding there was a lot going on that morning. She further confirmed Resident #86 had her call light wrapped around the bottom of her side rail and not clipped to her bedding where Resident #86 could not reach.

Based on observation, interview and review of facility policy, the facility failed to ensure choices were honored for one (Resident #86) of five residents reviewed for choices. The facility census was 110. Findings include: Review of the medical record for Resident #86 revealed an admitted [DATE]with diagnoses including visual hallucinations, hemiplegia and hemiparesis affecting right dominant side, type two diabetes mellitus with diabetic retinopathy and macular edema, asthma, neuromuscular dysfunction of the bladder, unspecified psychosis, anxiety disorder, essential (primary) hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment completed on 03/20/24 revealed Resident #86 had intact cognition. Further review of the MDS revealed Resident #86 had an impairment on one side, was dependent for toileting and bathing, was always incontinent of bowel and bladder, and required maximal assistance for transfers. Review of the care plan dated 06/13/24 revealed Resident #86 had an alteration in physical functioning related to impaired mobility and self-care ability. Interventions included encouraging resident choices with care and assisting Resident #86 with completion of activities of daily living (ADLs) to ensure her needs were met. Observation and interview on 06/17/24 at 11:58 A.M. with Resident #68 revealed she was in bed wearing a stained tee-shirt and an incontinence brief. Resident #86 stated during this interview she preferred to be up in her chair before lunch and assisted back into bed by 3:00 P.M. but staff often did not get her up at her preferred time and when they did, they often left her in the chair through the evening because staff were too busy, handed her off to the next shift, who left her until after dinner and then transferred her last due to her room being at the end of the hall. Observation on 06/17/24 at 12:14 P.M. revealed Resident #86 remained in bed and her lunch tray was brought into her room at that time. Continued observation on 06/17/24 revealed State tested Nurse Aide (STNA) #397 provided Resident #86's incontinence care, assisted with dressing, and then obtained the assistance of another staff member to transfer Resident #86 to her chair. Lunch was set-up for Resident #86 at 12:40 P.M. Interview on 06/17/24 at 12:42 A.M. with STNA #397 revealed she was unaware Resident #86 wanted out of bed prior to lunch, she had not worked that hall in several weeks, and was not informed of Resident #86's preferences. Review of facility policy titled Resident Rights, revised February 2021 revealed residents had the right to self-determination and to a dignified existence.

Based on observation, interview, and review of the National Weather Service website (forcast.weather.gov) the facility failed to ensure a comfortable and safe ambient temperature for all residents. This affected one of five sampled residents, Resident #73. Findings include: Observations on 06/17/24 between 11:03 A.M. and 11:14 A.M. of the East wing revealed the window at the east end of the East wing was open, hot air was blowing into the building. Further observation of the common sitting area on the East wing revealed windows were on the north and south side of the room, each side had a window open, blowing hot air into the facility. Interview on 06/17/24 at 11:08 A.M. with Housekeeper #398 confirmed hot air was blowing into the facility from the open window on the east end of East wing. A follow-up interview with Housekeeper #398 on 06/17/24 at 11:25 A.M. confirmed there were screens coming loose and with tears and there was hot air coming into the facility from the open windows., Observation on 06/17/24 11:50 A.M. of the window on the East wing near room [ROOM NUMBER] revealed the window consisted of glass louvers with gaps between each louver exposing the outside. At the time of the observation, hot air was noted flowing from the window into the hallway. Interview on 06/17/24 at 11:50 A.M. with Housekeeper #398 confirmed there was a gap between each louver large enough for outside temperatures and weather to affect the area adjacent to the window. Housekeeper #398 further confirmed the knob to open and close the louvers was broken. Interview on 06/17/24 at 12:42 P.M. with State tested Nurse Aide (STNA) #397 verified the hallway near room [ROOM NUMBER] by the glass louvered window was hot and she could feel the heat coming in from the window. Interview on 06/27/24 at 1:02 P.M. with Maintenance Director #357 revealed several windows on the East wing were open and should not be left open on such hot days. He also confirmed the window by room [ROOM NUMBER] was glass louvers, had a broken control knob and gaps between louvers which allowed for temperature concerns. Observation on 06/18/24 at 11:10 A.M. of Resident #73 revealed she was in her bed, appeared restless, and was trying to remove her clothing. Further observation revealed the window above her bed was open, hot air was blowing into the window, and the room felt uncomfortably hot. Observation and interview on 06/18/24 at 11:20 A.M. with Maintenance Director #357 confirmed with his thermometer that the ambient temperature of Resident #73's room registered 82.9 degrees Fahrenheit (F) at the center of the room. During the interview, Maintenance Director #357 confirmed the window was open and there was no window air conditioner in the room. He further confirmed the room temperature was not appropriate and Resident #73 would have a window air conditioner installed. Review of the National Weather Service website (forcast.weather.gov) revealed the average temperatures for Cleveland, Ohio and surrounding areas where the facility was located had a daily air temperature ranging between 82 degrees F and 93.9 degrees F with heat index as high as 100 degrees F on 06/17/24 and a daily air temperature ranging between 77 degrees F and 91.9 degrees F with a heat index reaching 99 degrees F on 06/18/24. This deficiency represents non-compliance investigated under Complaint Number OH00153775.

Based on observation, record review, and interview, the facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104. This affected one resident (#104) of three residents reviewed for activities of daily living. The facility census was 120. Actual Harm occurred on 04/22/24 when Resident #104, who was admitted on [DATE] with severe cognitive impairment and was known to use contact lenses, developed right eye redness and pain and was diagnosed with conjunctivitis (pink eye) which required antibiotic treatment due to a lack of routine eye care for the resident. Findings include: Review of the medical record for Resident #104 revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, aphasia (inability to understand and express language), restlessness and agitation, psychotic disorder with delusions, anxiety, and bipolar disorder. Review of Resident #104's plan of care initiated 11/06/23 revealed no focus on eye care or the care of contact lenses. There was a focus on behavior which indicated Resident #104 refused taking her contacts out for regular washing. Interventions included to educate on non-compliance with treatment or care and reapproach with resistance to activities of daily. Review of the nursing progress note dated 11/07/23 revealed Resident #104's family reported Resident #104 wore contacts but had not utilized them since the hospital admission about one month prior and had a history of refusing contacts. Resident #104's family was advised the facility offered house eye exams and eye glass services if needed in the future. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had severe cognitive impairment with no use of corrective lenses. Review of the nurse practitioner progress note dated 11/27/23 indicated Resident #104 was examined with no concerns related to the eyes. The note indicated a contact lens remained within the right eye. Review of Resident #104's physician orders for November 2023 revealed no orders related to eye care or the care of contact lenses. Review of the eye physician's progress note date 12/04/23 revealed Resident #104 was examined and had an air optic color contact lens in the right eye which was removed on this date. Staff were instructed to not let Resident #104 wear contact lenses. Resident #104 was scheduled to return for a follow-up in 12 to 15 months or in six to nine months for a retina evaluation. Review of the nursing progress note dated 01/15/24 indicated Resident #104 placed a contact lens into the right eye. Staff made several attempts to remove the contact lens but Resident #104 continued to refuse. The family was made aware. There was no evidence the resident's physician or nurse practitioner were notified at this time. Review of a social service progress note dated 01/25/24 revealed Resident #104's family decided to allow Resident #104 to wear contact lenses despite education on the risks of leaving contact lenses in place for lengthy time periods and not removing for routine washing. Nursing staff were made aware. There was no documented evidence that the physician or nurse practitioner were notified. There was no documented evidence nursing staff followed through with the information provided by social services or that the resident's care plan was updated related to the use of contact lenses. Review of Resident #104's physician orders and progress notes from 01/25/24 through 04/21/24 revealed no care or assessments related to Resident #104's use of contact lenses was completed during this time period. In addition, there were no changes to the resident's care plan during this time period or evidence of ongoing resident or family education related to the use of the contact lens. Review of the nursing progress note dated 04/22/24 revealed Resident #104's eye was red, and the resident complained of eye pain. The previous shift reported attempts to remove the right eye contact lens without success. Nursing would request the nurse practitioner to assess Resident #104 on this date. Interview on 04/22/24 at 6:37 P.M. with Resident #104's family revealed a concern Resident #104 had a blue contact lens in the right eye which had been left in place for almost one year. The family member stated it was noticeable because the resident's left eye was green, her natural color, and the right eye was blue, the color of the contact lens. The family indicated staff explained they could not get it out, but stated the eye looked swollen now and it was concerning because the contact lens had been in for too long. Resident #104's family stated the contact lenses were brought in a while back but could not state a time frame. During the interview, the family revealed staff had spoken to the resident's son in January 2024 but not to the resident's first emergency contact. The family member interviewed denied any education or information being provided to him related to the risk of the contact lens use for the resident. Interview on 04/24/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #584 verified Resident #104 had used a contact lens since admission and currently only had one contact lens in the right eye which had been there for a while. LPN #584 confirmed the right eye was now reddened, and the nurse practitioner was supposed to look at the eye, but nothing was provided in report, so LPN #584 was uncertain if anything was done about Resident #104's right eye. LPN #584 further stated staff do try to get the contact lens out of the right eye but Resident #104 would not allow it. LPN #584 indicated personally attempting it over the previous weekend but was unsuccessful. Record review revealed no documentation had been completed to reflect this. Interview on 04/24/24 at 9:02 A.M. with Unit Manager LPN #607 verified Resident #104 had a right eye contact lens in place. LPN #607 revealed Resident #104 was admitted with a contact lens in the right eye. Resident #104 was encouraged to remove the contact lens but refused. The eye doctor had come to the facility and removed it. Social services told the family that due to Resident #104's dementia, it was not best to wear contacts and it was agreed but additional contact lenses were brought in which resulted in Resident #104 placing another contact lens in the right eye. There was never a contact lens in the left eye. Resident #104 would not allow staff to remove it or touch the eye. The family was asked to assist in getting the contact lens out but they had not. The LPN revealed the lens needed to be removed. The LPN also indicated the nurse practitioner was aware of it but not sure what was done about it. Observation on 04/24/24 at 9:15 A.M. with Unit Manager LPN #607 of Resident #104's eyes revealed the left eye was green in color with no abnormal findings. The right eye was blue in color and had some swelling and redness. There was a red raised area on the mid lower lid, and Resident #104 complained of right eye pain. Interview on 04/24/24 at 9:18 A.M. with Nurse Practitioner (NP) #610 revealed the NP had knowledge of Resident #104 wearing contact lenses and wearing one in the eye at one time but was not aware of Resident #104 wearing the same contact lens for months. NP #610 indicated it was not a good idea for contact lenses to be worn for long periods because it could lead to complications like infection. NP #610 further indicated she had not been previously made aware of Resident #104's right eye being swollen, red, and painful but stated she would look at it on this date. Interview on 04/24/24 at 11:19 A.M. with Unit Manager LPN #607 revealed the eye physician last examined Resident #104 on 12/04/23, and the resident was scheduled to see the eye doctor on each visit thereafter to remove the right contact lens. Review of the nurse practitioner progress note dated 04/24/24 revealed Resident #104 was examined for complaint of right eye pain. Resident #104 was unable to state when it started. The right eye contained a contact lens and now the eye was reddened. The right upper eye lid was swollen and the lower eyelid had a small bump. It was uncertain how long ago the contact lens was placed. Staff reported the family was to come in and assist in removal of the lens and attempts to remove the lens were unsuccessful. Resident #104 previously had a right contact lens removed by the eye doctor but placed a new lens in after removal. The resident had a diagnosis of acute right eye conjunctivitis with a plan to start Besifloxacin antibiotic eye drops (used for the treatment of bacterial conjunctivitis) for seven days and warm compresses to the right eye. Review of the nursing progress note dated 04/24/24 revealed Resident #104's family planned to visit in approximately one week to change the contact lens in the right eye. An additional review of Resident #104's plan of care (initiated 11/06/23), revealed a new focus area was added on 04/25/24 (following surveyor intervention) for the resident's risk of injury related to infection due to use of contact lenses and refusing to allow staff to assist with inserting and removing. Interventions included administer antibiotic as ordered; apply warm compress as ordered; arrange eye care practitioner consult as required; document all refusals to allow staff to assist with contact lens; family would assist with placement and cleaning of contact lenses; keep spouse informed of refusal of assistance with contacts; monitor for, document and report as needed any signs and symptoms of acute eye problems; and per ophthalmology appointment on 12/04/23 Resident #104 not to wear contacts. Review of the eye doctor visits to the facility from 12/04/23 to current revealed the eye doctor was present in the facility on 01/29/24 and 03/25/24. The resident was not seen on either of these dates. Interview on 04/25/24 at 10:15 A.M. with Assistant Social Services Director #605 indicated the eye doctor sets up the visit list and staff add on any resident who needed seen and if residents refused, staff kept re-adding the resident to the next visit list. Resident #104 was known to put contact lenses back into the eyes and staff like it taken out and cleaned, so Resident #104 was on the list routinely for every eye visit. Review of email communication between the facility and eye physician dated 04/25/24 revealed Resident #104's last eye physician examination was on 12/04/23 with a follow-up scheduled for June 2024. Resident #104 could be seen on the next visit scheduled 05/20/24 if desired and all following visits thereafter. Interview on 04/25/24 at 2:06 P.M. with the Director of Nursing verified the above findings and confirmed the facts were accurate.

Based on observation, record review, policy review and interview the facility failed to provide adequate assistance, supervision and/or assistive devices to prevent falls and consistently implement fall interventions for Resident #57 and Resident #101. Actual harm occurred on 04/14/24 when Resident #57, who was moderately cognitively impaired and required two staff assist with bed mobility, sustained a fall out of bed when being provided hands on care by only one staff member. The resident sustained a right shoulder fracture as a result of the fall. This affected two residents (#57 and #101) of three residents reviewed for falls. The facility census was 120. Findings Include: 1. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), depression, diabetes, high blood pressure, osteoporosis, and anxiety. A new diagnosis of right shoulder fracture was added on 04/14/24. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was moderately cognitively impaired and was dependent on staff for personal care. Review of Resident #57's falls care plan, initiated on 07/24/19, revealed the resident was at risk for falls due to impaired mobility, impaired decision making, impaired cognition, and impaired safety awareness. The care plan was revised on 01/23/23 to indicate the resident was at increased risk for injury related to osteoporosis. The resident sustained a fall on 01/23/23. An intervention initiated on 01/27/23 was for the resident to have two person assist with care with one on each side of the bed. Review of Resident #57's Kardex (a form which indicates care needs a resident requires) revealed the resident required staff assist of two for bed mobility and hands on care while in bed. Review of Resident #57's progress note revealed on 04/14/24 at 10:15 A.M. Registered Nurse (RN) #602 was called to the resident's room due to the resident rolling out of bed during patient care. The resident rolled over while getting changed and rolled off the bed onto the floor. Resident #57 had an injury to his right elbow and a right knee abrasion. RN #602 notified the physician and an order for an x-ray of the right elbow was given. The x-ray indicated the resident sustained a right shoulder fracture. On 04/18/24 Resident #57 saw the orthopedist who ordered the resident to wear a sling at all times and apply ice to the shoulder for 20 minutes three times a day. A follow-up appointment was scheduled for 05/17/24. Review of the facility's fall investigation for Resident #57's 04/14/24 fall revealed the facility determined the root cause of the fall was he was getting changed. Following the incident the Interdisciplinary Team (IDT) implemented a new fall intervention to obtain a wider bed for the resident and add grab bars to the bed. State tested Nursing Assistant (STNA) #516's written statement regarding the incident dated 04/14/24, revealed she was providing resident care and she rolled Resident #57. STNA #516 said she thought the resident was holding on to the side rail, but he rolled off the bed. STNA #516 stated she first checked the resident and then went and got RN #602. On 04/15/24 STNA #516 was educated on accessing the Kardex and reviewing the resident's mobility status. Interview with Regional Clinical Manager (RCM) #609 on 04/24/24 at 10:15 A.M. regarding Resident # 57's fall on 04/14/24 revealed STNA #516 should have been providing care with another staff member when the resident fell out of bed. The Kardex indicated he was to have an assist of two staff while performing care in bed. Interview with STNA #516 on 04/24/24 at 10:30 A.M. revealed she was the person who was providing care to Resident #57 when he fell out of bed. STNA #516 said the bed was at a normal height. It was not in the high position or the low position. She stated she was changing the resident's fitted sheet when he rolled off the bed. STNA #516 said she had been keeping one hand on him during care except when he rolled over and that was when he fell . She confirmed Resident #57 was supposed to have two staff assist with care while the resident was in bed. STNA #516 confirmed she did not follow the Kardex instructions for care. She said the reason she provided the care alone for the resident was because there was no one available to help her. On 04/24/24 at 10:40 A.M. an observation of Resident #57 revealed he was in bed with a sling to his arm. An interview with the resident at the time of the observation revealed he exhibited confusion and smiled a lot, nodding his head to questions. When asked if he had any pain from the fall he had sustained, the resident stated he was fine. Review of the facility Falls/Accidents/Incidents policy, last revised 07/17/23, revealed the intent of the policy was to ensure the facility provided an environment that was free from accident hazards over which the facility had control and provide supervision and assistive devices to each resident to prevent avoidable accidents. No information was provided on how the facility would accomplish this goal. 39969 2. Review of the medical record for Resident #101 revealed an admitted [DATE]. Diagnoses included muscle weakness, abnormalities of gait and mobility, severe protein-calorie malnutrition, and reduced mobility. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #101 had impaired cognition and had no falls since admission or the prior assessment. Review of the fall risk evaluation dated 03/07/24 revealed a score of nine. Per instructions a total score of 10 or greater, the resident should be considered high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the nurses' note dated 03/31/24 at 8:04 A.M. revealed Resident #101 was observed kneeling on the floor next to the bed holding onto the side rails. Resident #101 stated he was attempting to pick up a pill that he dropped. Resident #101 had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A voicemail was left for the resident's niece. The physician and hospice were notified. Review of the interdisciplinary team (IDT) noted dated 04/01/24 at 11:00 A.M. revealed the IDT team met this morning regarding Resident #101's fall that occurred on 03/31/24. The resident was observed kneeling on the floor next to the bed holding onto the side rails. The resident stated he was attempting to pick up a pill that he dropped. The resident had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A voicemail was left for the resident's niece. The physician and hospice were notified. Risk factors included but were not limited to muscle weakness, communicating hydrocephalus, repeated falls, and reduced mobility. Intervention was to keep bed in lowest position at all times. The care plan and Kardex were updated. Review of the care plan revised on 04/01/24 revealed Resident #101 was at risk for falls related to antidepressant use, history of falls, weakness, episodes of incontinence, balance problem. Interventions included bed in lowest position at all times, and floor mat to left side of the bed while in bed. Observation on 04/22/24 at 3:04 P.M. of Resident #101 in the bed with the bed in the high position with the floor mat folded in corner. Interview at this time with Resident #101 stated he had no concerns with care. Observation on 04/24/24 at 10:55 A.M. of Resident #101 in his room in bed with the bed in high position and no mat to floor. Resident #101 was observed watching tv. Observation on 04/29/24 at 9:42 A.M. of Resident #101 in his room in bed; the bed was not in the lowest position, and there was no mat to the floor next to his bed. Observation on 04/29/24 at 9:58 A.M., with STNA #514 of Resident #101's with the bed not in the lowest position and no floor mat to the floor next to the bed. Interview at this time with STNA #514 verified the observation and pointed to the mat folded in corner near the resident's dresser. Review of the facility policy titled Falls/Accidents/Incidents, revised 07/17/23, revealed the intent of this requirement is to ensure the facility provided an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazards and risks; evaluating and analyzing hazards and risk; implementing interventions to reduce hazards and risk; and monitoring for effectiveness and modifying interventions when necessary. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331.

Based on observation, record review, interview, facility policy and procedure review, Self-Reported Incident (SRI) review and facility investigation review, the facility failed to ensure residents were properly transferred, as per their plan of care and/or physician's order to prevent actual injury and/or potential injury. Actual Harm occurred on [DATE] when Resident #125 who was dependent on staff for activities of daily living (ADL) and required a mechanical lift (device used to transfer a person from one place to another) of two staff assist for transfers was transferred by only one staff, State tested Nursing Assistant (STNA) #614 without a mechanical lift from his bed to his wheelchair. The resident was again transferred on [DATE] by STNA #680 and STNA #685 without a mechanical lift from his wheelchair to his bed. After breakfast on [DATE] STNA #637 pulled back the covers for Resident #125 and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region and yellow tinted bruising to his left rib cage area. STNA #637 revealed the resident was grunting, clenching his teeth and voiced a sound like ouch displaying signs of significant pain. The resident was transferred to the hospital, and diagnosed with a displaced intertrochanteric fracture to his left femur. The injury was determined to have occurred as a result of not being transferred with the mechanical lift on [DATE]. This affected four residents (#15, #33, #80 and #125) of four residents reviewed for accidents/proper transfers. The facility identified 41 residents (#1, #7, #9, #15, #19, #21, #22, #23, #29, #32, #33 #36, #39, #48, #50, #55, #57, #58, #59, #63, #64, #67, #68, #69, #71, #74, #79, #80 #81, #85, #90, #96, #97, #99, #100, #102, #103, #109, #115, #116 and #125) who were dependent on staff or required (staff) assistance with transfers. The facility census was 119. Findings include: 1. Review of the closed medical record for Resident #125 revealed an admitted [DATE]. The resident passed away at the facility on [DATE]. Resident #125 had diagnoses including dementia, hypertension, polymyalgia rheumatica (syndrome with pain or stiffness to neck shoulders and extremities), and fracture of head of left femur diagnosed on [DATE]. Review of the care plan dated [DATE] revealed Resident #125 required assistance with activities of daily living (ADL) related to weakness as he required extensive to total staff assistance with ADL. Interventions included a mechanical lift with two staff assist for transfers and monitor and report changes in physical functioning. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 was cognitively impaired. The assessment revealed the resident was dependent on staff for ADL care including to move from sitting to lying position, and chair to bed/ bed to chair transfers. Review of the undated task bar revealed Resident #125 was to be transferred with a mechanical lift by two staff assist. Review of Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of [DATE] physician's orders revealed Resident #125 had an order dated [DATE] to be transferred with a mechanical lift with two staff assist. He also had an order for Hospice due to Alzheimer's disease dated [DATE]. Review of weight record revealed on [DATE] Resident #125's weight was recorded as 159.6 pounds. Review of nursing note dated [DATE] at 7:12 A.M. and completed by Licensed Practical Nurse (LPN) #629 revealed Resident #125 had purple areas to his left foot near his great toe measuring three centimeters (cm) in length by four cm in width and another area measured two cm in length by one cm in width. The note revealed both areas were blanchable, and the areas were cleansed with normal saline and covered. Primary Care Physician (PCP) #900 was called and a message was left. Review of nursing note dated [DATE] at 9:20 A.M. completed by Registered Nurse (RN) #689 revealed staff had called her to Resident #125's room due to reddened area to his left hip, left pelvis, and left rib cage area. The note revealed the resident was in pain. PCP #900 was notified and ordered to obtain x-rays of the areas. Review of the Bath/ Shower Skin Inspection Sheet dated [DATE] and completed by RN #689 revealed Resident #125 had bruises to his left hip, left side of his pelvis, left side of his ribs, right foot, and right great toe. Review of facility SRI, tracking number 239869 and dated [DATE] revealed the Administrator submitted an SRI for injury of unknown source. The SRI noted on [DATE] Resident #125 had redness near his leg hip, rib, and pelvis area and that he was dependent on staff with mobility. Resident #125 was found to have a closed displaced intertrochanteric fracture of his left hip. The SRI revealed during the investigation the facility concluded the resident was possibly not transferred correctly per care plan, but abuse was not suspected. The facility unsubstantiated the SRI. Review of the nursing note dated [DATE] at 11:01 A.M. and completed by RN #689 revealed the x-ray company was unable to obtain x-rays and PCP #900 was notified and ordered to send Resident #125 to the hospital emergency room . Review of the After Visit Summary dated [DATE] revealed emergency room (ER) Physician #708 had evaluated Resident #125 and noted in the summary the reason of the visit was due to a fall. The resident had a closed displaced intertrochanteric fracture of his left femur. He was to follow up with Physician #709 and received orders for pain medications. Review of the nursing note dated [DATE] at 6:49 A.M. completed by LPN #704 revealed at approximately 8:00 P.M. the hospital called and reported Resident #125 was returning to the facility with a new diagnosis of left femur fracture. The note revealed no intervention would be done because the resident was contracted per the orthopedic physician at the hospital. The note revealed Resident #125 was nonverbal throughout the night but grimaced in pain while transferring from gurney to bed. PCP #900 was notified and ordered pain medication, and his family was notified. Review of the Skin Observation Tool dated [DATE] and completed by RN #670 revealed Resident #125 had bruising to his left trochanter area that measured 16 cm in length by 5.2 cm in width. The area was described as redness noted with dark purple area to center of his boney prominence. Review of the nursing notes dated [DATE] at 11:28 A.M. and completed by Social Service Director (SSD) #622 revealed Resident #125's daughter had spoken with PCP #900 and they both agreed to have Hospice services initiated due to his decline in health. Review of the Witness Statement dated [DATE] and completed by STNA #680 revealed she had come on duty on [DATE] at approximately 8:30 P.M. to 9:00 P.M. and STNA #685 asked for assistance to transfer Resident #125 to his bed as he was not on a Hoyer sling (designed to be suspended from a swivel bar on a mechanical lift to transfer a person) in his wheelchair. The statement revealed that this had happened several times. The statement revealed the only available Hoyer sling was not suitable for the current mechanical lift. The statement revealed she and STNA #685 armed and leg him into his bed and then she left the room. Review of the Witness Statement dated [DATE] and completed by STNA #615 revealed she had gotten Resident #125 up on [DATE] and that she was not aware he was to be transferred with a mechanical lift. Review of nursing notes dated [DATE] at 8:15 A.M. and completed by RN #670 revealed Resident #125 had expired at the facility. Interview on [DATE] at 2:39 P.M. with RN #689 revealed (on [DATE]) at approximately 9:00 A.M. STNA #637 notified her Resident #125 had something on his left hip. She revealed she immediately evaluated and noted a softball size red hard area to his left hip over his boney prominence. She revealed he also had bruising to his left pelvic area, and on his left rib cage. She revealed she notified PCP #900, and he ordered an in-house x-ray, but the x-ray company was unable to obtain good imaging due to the resident's contractures. She revealed PCP #900 ordered the resident to be sent to the hospital for an evaluation. Interview on [DATE] at 2:44 P.M. with STNA #630 revealed she worked day shift on [DATE] and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. Interview on [DATE] at 3:05 P.M. with STNA #665 revealed she had worked on [DATE] on day shift and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. She revealed she had seen this happen a few times before as well. She revealed Resident #125 was to be transferred by a mechanical lift and did not know how staff were transferring him without use of a mechanical lift as he was contracted, heavy, and not able to assist by bearing any weight. Interview on [DATE] at 3:20 P.M. with STNA #685 revealed on [DATE] she had worked 7:00 P.M. to 7:00 A.M. and when she came in, Resident #125 was sitting in his wheelchair without a Hoyer sling underneath him. She revealed she told LPN #629 the resident was not on a Hoyer sling as this had happened several times before. She revealed LPN #629 stated that she would communicate again that staff were still getting him up without a Hoyer sling. She revealed she and STNA #680 got on each side of him and transferred him by getting under his arms and grabbing the back of his pants. She revealed she felt the transfer was completed in a safe manner. She revealed he already had a gown on and that she just removed his sweat pants. She revealed since he had a urinary catheter and was not incontinent of bowel that she did not remove his incontinent product and/or lift his gown. She revealed she did not notice any bruising. Attempts to interview STNA #615 on [DATE] at 3:36 P.M. and on [DATE] at 8:42 A.M. were unsuccessful as she did not return the calls. Interview on [DATE] at 3:38 P.M. with STNA #680 revealed on [DATE] she came in at 7:00 P.M. and noticed Resident #125 was not on a Hoyer sling. She revealed she went to laundry to retrieve a sling to place underneath him, but there was only one available. She verified she had not notify LPN #629 that he was not on a Hoyer sling and that she was unable to locate a sling to transfer him with. She revealed she and STNA #685 were strong and transferred him under his arms and grabbed his pants. She verified she did not utilize a gait belt during the transfer. She revealed she left the room after the transfer but felt the transfer was done in a gentle manner. During the interview, she revealed first shift staff continued to get up residents , including Resident #81 and #119 without a mechanical lift as she frequently came in and they did not have a Hoyer sling underneath them despite orders to be transferred with a mechanical lift. Interview on [DATE] at 3:42 P.M. with LPN #629 revealed she was the nurse on duty [DATE] from 7:00 P.M. to 7:30 A.M. but was not notified by the staff that Resident #125 did not have a Hoyer sling underneath him and/or that they transferred him without a mechanical lift. She revealed on [DATE] she was completing the treatment on his foot and noticed he had new dark purple areas to the inside of his right foot. She revealed she did not know if the areas were pressure and/or bruise and passed on the areas in report. Interview on [DATE] at 3:48 P.M. with STNA #637 revealed she worked on [DATE] and after breakfast she pulled back Resident #125's covers and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region, and yellow tinted bruising to his left rib cage area. She revealed he was grunting, clenching his teeth together, and voicing a sound like ouch showing he was in significant pain. She revealed RN #689 was notified. She revealed she had worked on [DATE] and felt STNA #615 had gotten Resident #125 up all by herself as she was working the same hall as her, and she had not asked her to help transfer him. Interview on [DATE] at 4:12 P.M. with [NAME] President (VP) of Clinical Services #711 verified STNA #615 revealed during the investigation that she had gotten Resident #125 up by herself without a mechanical lift on [DATE]. She also verified that the facility only had a policy regarding transfer with a mechanical lift but did not have a policy regarding one or two persons transfer assistance. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #125 was to be transferred with a mechanical lift with two staff assist per his physician order dated [DATE]. Also, they verified on [DATE] STNA #615 had transferred him by herself without the use of a mechanical lift from his bed to his wheelchair and on [DATE] STNA #680 and #685 had transferred him without a mechanical lift from his chair to his bed. They verified per STNA #680's witness statement she had stated the only available Hoyer sling was not suitable for the mechanical lift so they armed and leg transferred him. 2. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including congestive heart failure, lymphedema, and morbid obesity. Review of the care plan dated [DATE] revealed Resident #33 required assistance with ADL related to weakness and morbid obesity. Interventions included he was to be transferred by use of mechanical lift and two staff assist. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #33 was cognitively impaired as his Brief Interview for Mental Status Score (BIMS) was a 12. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the [DATE] Physician Orders revealed no orders regarding utilizing a mechanical lift to transfer. Review of the weight record revealed on [DATE] Resident #33's weight was 335.2 pounds. Review of the Kardex as of [DATE] revealed Resident #33 was to utilize a mechanical lift with two staff assist with transfers. Interview on [DATE] at 7:38 A.M. with Resident #33 revealed he was to be transferred with a mechanical lift in and out of bed but that it was hard as sometimes staff would not transfer him back into bed when he wanted as there was not enough staff. He revealed this caused him to sit up in his wheelchair for a long time causing his legs and buttocks to hurt. He revealed staff sometimes had no choice but to only use one staff to transfer him back to bed as he stated there were not enough staff. He revealed there was one aide and described the aide: African American and that she had told him she was [AGE] years old but could not remember her name had gotten him up and put him back to bed with the mechanical lift by herself on several occasions. He revealed it was not her fault as there just were not enough staff. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #33 was to be transferred utilizing a mechanical lift with two staff. 3. Review of medical record for Resident #15 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, and major depression. Review of the care plan dated [DATE] revealed Resident #15 was at risk for falls related to impaired mobility. Interventions included transfer by use of a mechanical lift and two staff assistance. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. Review of annual MDS assessment dated [DATE] revealed Resident #15 had significant cognitive impairment. Review of the [DATE] physician orders revealed Resident #15 had an order dated [DATE] to be transferred with a mechanical lift by two staff. Review of the Kardex dated as of [DATE] revealed Resident #15 was to be transferred using a mechanical lift and two staff assist. Observation on [DATE] at 7:26 A.M. revealed STNA #600 and STNA #710 transferred Resident #15 with a mechanical lift with no concerns. She was unable to be interviewed due to cognitive ability. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. 4. Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including unspecified psychosis, abnormalities with gait and mobility, osteoporosis, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed she was cognitively intact and required extensive assist of two staff with transfers. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on all the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 3:09 P.M. with Resident #80 revealed she was unsure how and how many staff usually assisted in transferring her to her bed to chair and/or her chair to her bed. Review of the Kardex dated [DATE] Resident #80 was to be transferred with two staff assist. Observation on [DATE] at 10:02 A.M. revealed STNA #632, and STNA #665 transferred Resident #80 with no issues. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the facility policy labeled; Mechanical Lift, dated [DATE], revealed the purpose of the policy was to transfer a dependent resident safely. The policy revealed to confirm a mechanical lift was to be used. There was nothing in the policy regarding how many staff were to assist during a transfer with a mechanical lift. Review of the undated policy labeled, Freedom from Abuse and Neglect revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, and emotional stress. This deficiency represents non-compliance investigated under Complaint Number OH00147411. This deficiency is an example of continued non-compliance from the survey completed on [DATE].

Based on observation, interview, and record review, the facility failed to treat potentially contagious/communicable rashes per physician orders, failed to timely implement transmission-based precautions to prevent spreading the rash to other residents, failed to implement exposure control measures, failed to educate and in service staff on infection control relative to preventing the spread of potentially contagious/communicable rashes, failed to report the outbreak to the local health department, and failed to prohibit State tested Nursing Assistant (STNA) #373, who exhibited signs of a potentially communicable/contagious rash, from direct resident contact. Actual Harm occurred on 07/26/23 when Resident #61, who was evaluated for a body rash by his Primary Care Physician (PCP) #400 on 07/25/23 and ordered permethrin cream (a topical treatment used to treat scabies caused by the itch mite Sarcoptes scabiei which is a highly contagious skin condition) to be administered on 07/26/23 to treat the body rash, did not get the treatment of permethrin cream as ordered by the physician until the permethrin cream was reordered on 08/03/23. This resulted in seven residents (#26, #36, #54, #61, #62, #96 and #103) developing a rash with resulting severe itching, intense scratching, bleeding of rash areas, severe discomfort with statements including but not limited to feeling like their skin was on fire, felt she was dying, it is miserable, it is burning demonstrating psychosocial harm due to anxiety, disrupted routine sleep and/or hospitalization to the emergency room for worsening rash symptoms. Additionally, the facility did not exclude STNA #373 from providing direct resident care after she told a nurse on duty she had developed the rash to her arms, legs, and abdomen approximately one week ago. Instead, the nurse gave her permethrin cream to use and had her continue to work her shift. On 08/25/23 STNA #373 revealed she went to Physician #901 and was diagnosed with scabies. This affected 20 residents (Residents #12, #17, #19, #26, #27, #31, #36, #42, #45, #48, #50, #54, #62, #63, #69, #96, #102, #103, #104 and #118) who developed a rash, and/ or received permethrin treatment out of 41 residents (Resident #5, #6, #9, #12, #17, #19, #24, #26, #27, #31, #36, #40, #42, #45, #46, #48, #50, #54, #55, #57, #60, #61, #62, #63, #69, #76, #78, #82, #80, #87, #88, #90, #96, #102, #103, #104, #108, #111, #115, #117, #118) residing on the secured unit and had the potential to affect all 117 residents residing at the facility as STNA #373 had worked other units other than the secured unit in the last two weeks. Findings included: 1. Review of the medical record for Resident #61 revealed an admitted [DATE] and diagnoses included psychosis, dementia, and chronic obstructive pulmonary disease. Resident #61 lived on the secured unit of the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/23, revealed Resident #61 was cognitively impaired. He required supervision only with bed mobility, transfers, and ambulation. Review of a nursing note dated 07/21/23 at 11:27 A.M. and completed by Licensed Practical Nurse (LPN) #341 revealed Resident #61 complained of dry, itchy skin to arms and legs. The note revealed PCP #400 was notified and ordered [NAME] lotion (an anti-itch lotion). Review of a nursing note dated 07/25/23 at 7:05 P.M. and completed by LPN #341 revealed Resident #61 was seen per Primary Care Physician (PCP) #400 due to re-occurring rash to body and she referred to dermatologist and ordered permethrin treatment. Review of the July 2023 Medication Administration Record (MAR) revealed Resident #61 had an order to receive permethrin external cream five percent apply all over body topically one time on 07/26/23 for re-occurring rash and shower off on 07/27/23. The MAR was blank on 07/26/23 indicating the treatment was not completed as ordered by the physician. Review of the July 2023 Treatment Administration Record (TAR) revealed Resident #61 was placed on contact isolation precautions from 07/27/23 through 07/31/23 when the contact precautions were discontinued. There was no evidence on the TAR to indicate Resident #61 was placed on contact isolation precautions on 07/25/23 when PCP #400 ordered the permethrin treatment and there was no evidence of contact isolation precautions on 07/26/23. Review of the August 2023 MAR and TAR revealed on 08/03/23 at 10:38 P.M. Resident #61 received permethrin cream five percent topically all over his body due to re-occurring rash. This was his first treatment of permethrin cream, since it had not been given on 07/26/23 per physician order. There was no order for Resident #61 to be on contact isolation precautions from 08/01/23 to 08/03/23 per the TAR. Review of nursing notes dated from 07/25/23 to 08/03/23 revealed there was no documentation PCP #400 was notified Resident #61 had not received his one-time permethrin cream ordered for 07/26/23 and he had not received the treatment until 08/03/23. Review of nursing notes also revealed no evidence Resident #61 was on contact isolation on 07/25/23 and 07/26/23 after PCP #400 had ordered permethrin for potential scabies on 07/25/23. There was also no documentation per the nursing notes that he was on contact isolation from 08/01/23 to 08/03/23. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #61 had a red rash to his body. The assessment revealed PCP #400 was notified and ordered permethrin cream to be applied and then to repeat the treatment in one week. Review of the resident census revealed Resident #61 received a roommate (Resident #9) on 07/28/23 and continued to live as roommates despite Resident #61 not receiving the permethrin cream (scabies treatment) as ordered for 07/26/23. Review of Physician Progress Note dated 08/01/23 and completed by PCP #400 revealed Resident #61 continued to have an itchy rash to arms, neck, abdomen, and he was treated with permethrin and had a dermatology appointment. There was no documentation PCP #400 was aware Resident #61 missed his permethrin treatment on 07/26/23. Interview and observation on 08/23/23 at 11:34 A.M. with Resident #61 revealed he had a rash in his groin, around his legs and just about everywhere. He revealed it itched especially all night which kept him up at night. He stated, it is miserable. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing (DON) verified Resident #61's permethrin cream was not documented as given on 07/26/23 as well as he was not on contact isolation for the entire duration of the rash after the permethrin cream was ordered on 07/25/23 until it was finally given on 08/03/23. Review of Dermatopathology Report, dated as collected on 08/15/23 and reported on 08/22/23, revealed Resident #61 had a biopsy to left forearm showing irregularly acanthotic and spongiotic epidermis with dermal inflammatory reaction. The report's comments section documented a medication reaction and spongiotic dermatitis were not ruled out. It is to be noted the biopsy was completed after permethrin cream was administered to Resident #61 on 08/03/23. 2. Review of the medical record for Resident #62 revealed an admitted [DATE] and diagnoses included dementia, and hypertension. Review of the annual MDS dated [DATE] revealed Resident #62 was cognitively impaired and required supervision with most her activities of daily living. Review of Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review dated 07/26/23 and completed by Unit Manager/ LPN #344 revealed Resident #62 had a rash to her bilateral arms and legs with scabs. Review of Skin Observation Tool dated 07/28/23 and unauthored revealed Resident #62 had a dry rash to her body with some scabbed areas. Review of July MAR and TAR for Resident #62 revealed she had an order for contact precautions dated to start 07/27/23 at 7:00 P.M. and was treated with permethrin external cream for her rash on 07/28/23. There was no evidence contact precaution started on 07/26/23 when on the shower review it was documented she had a rash (as well as other residents in the secured unit had a rash and being treated with permethrin cream). Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. Interview and observation on 08/23/23 at 3:01 P.M. of Resident #62 revealed she was sitting in the lounge and a visible red splotchy rash noted to her bilateral arms with dry flaky skin. She was unable to provide any information during the interview except that she had a rash. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim DON verified the facility had no documentation Resident #62 was placed on transmission-based precaution before 07/27/23. 3. Review of medical record for Resident #54 revealed an admitted [DATE] and diagnoses included dementia, and hypertension. Review of quarterly MDS dated [DATE] and revealed she had impaired cognition. Review of July 2023 physician orders revealed Resident #54 had an order dated 07/21/23 for [NAME] lotion as needed to apply to itchy skin. She then had orders dated 07/26/23 to be placed on contact isolation and permethrin external cream. Review of nursing notes dated 07/21/23 at 5:50 P.M. and completed by LPN #343 revealed PCP #400 was in facility and notified of new red itchy areas and new orders were received. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #54 had a rash to her stomach area that was acquired on 07/26/23. The assessment revealed PCP #400 ordered permethrin and to repeat the cream in one week. Interview and observation on 08/22/23 at 7:54 P.M. revealed Resident #54 sitting in her chair in her room and when asked if she had a rash she stated, it was burning and was red. She then proceeded to show this surveyor a rash to her chest and arms as she pulled down her shirt. She revealed the rash just does not go away. She revealed the rash was uncomfortable and that it does keep her up at night as the rash was itchy. She revealed she had the rash a long time but was unable to provide details to how long and was unsure if she seen a physician for the rash as she stated that was why she was at the facility as she was unable to remember things. Review of nursing notes dated from 07/27/23 to 08/22/23 revealed no other documentation regarding her rash and/ or physician notification that the rash continued as observed on 08/22/23. 4. Review of medical record for Resident #96 revealed an admitted [DATE] and her diagnoses included Alzheimer's disease, hypertension, and diabetes. Review of quarterly MDS dated [DATE] revealed Resident #96 had impaired cognition and required supervision only with most her activities of daily living. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed on 07/26/23 Resident #96 had a rash to her body. PCP #400 was notified and ordered permethrin cream topically and repeat in one week. Interview and observation on 08/22/23 at 7:58 P.M. with Resident #96 revealed she had a rash all over but mainly her back. She revealed it itched all the time. She showed this surveyor her bilateral arms and a red rash with scratch marks noted to her bilateral arms. She revealed the rash itched and sometimes woke her up at night causing her not to sleep well. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed several residents had rashes on the secured unit and recently Resident #96 was in her room when she was passing out the mail and she was digging and scratching hard at her leg intensely causing her leg to bleed all over. She revealed she felt bad as she seemed very uncomfortable as well as several other residents. 5. Review of medical record for Resident #103 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, diabetes, anxiety, and hypertension. A diagnosis of scabies on 08/10/23 was added to her medical diagnosis list. Review of care plan dated 07/21/23 revealed Resident #103 was at risk for actual and/ or potential skin impairment as on 07/27/23 she was receiving treatment due to roommate's rash. Intervention included treatment as ordered, skin check weekly, and observe skin during care. Review of unauthored Skin Observation Tool dated 07/25/23 revealed a second skin check was completed and skin was intact with no areas noted. Review of Skin Monitoring: Comprehensive CNA Shower Review dated 07/26/23 completed by Unit Manager/ LPN #344 revealed skin was clear. There were no additional skin observations noted as completed from 07/25/23 to 08/10/23. Review of July 2023 MAR revealed Resident #103 received permethrin external cream five percent apply to neck to toes topically times one dose and then shower and remove on 07/27/23. Review of nursing notes dated 07/27/23 to 08/23/23 revealed no documentation regarding Resident #103's rash and/ or notification to the Power of Attorney (POA) regarding the permethrin cream ordered on 07/27/23. Review of nursing note dated 08/08/23 at 4:53 P.M. and completed by LPN #343 revealed staff notified the nurse that Resident #103 felt itchy on her thighs and small raised areas were noted. The note revealed Resident #103 denied pain just felt itchy. The note revealed PCP #400 was notified and ordered [NAME] (anti-itch moisturizing lotion) lotion five percent as needed for areas. Review of nursing note dated 08/10/23 at 2:32 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103's daughter was in concerned about the itchy areas to her inner thighs. The note revealed her daughter wanted her sent to the emergency room (ER) for an evaluation. Review of nursing note dated 08/10/23 at 4:35 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103 returned from the emergency room with a diagnosis of scabies and new orders. Review of After Visit Summary dated 08/10/23 and completed by ER Physician Assistant #900 revealed Resident #103 was seen due to rash. Resident #103 was provided information regarding scabies and nonspecific rash. She was ordered hydrocortisone ointment 2.5 percent to apply to affected areas twice a day for `14 days and permethrin five percent to apply to affected area times one dose for pruritic (itchy) rash. Observation on 08/22/23 from 7:30 P.M. to 8:25 P.M. revealed Resident #103 was unable to be interview due to cognitive ability and no signs of a rash were visibly seen. 6. Review of the medical record for Resident #36 revealed an admitted [DATE] and diagnoses included dementia, anxiety, and diabetes. Review of the significant change MDS dated [DATE] revealed she was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of a nursing note dated 07/26/23 at 7:15 P.M. and completed by Unit Manager/ LPN #344 revealed Resident #36's power of attorney (POA) was notified she received permethrin cream as preventative and had a possible exposure to scabies and was asked if the resident was itching or had a rash and the POA stated not at this time. Review of nursing notes dated 08/08/23 at 1:39 P.M. and completed by LPN #341 revealed during Resident #36's shower she had small red spots/ rash noted to lower back along with some scratch marks. The note revealed she stated it itched sometimes. The note revealed PCP #400 was notified and ordered [NAME] anti-inch lotion since she was treated with the permethrin cream on 07/26/23. Interview on 08/22/23 at 7:30 P.M. with Resident #36 revealed she had a rash as well as all the residents on the unit had a rash. She revealed her rash was on her chest and she had the rash for two to three weeks. She revealed she felt it was caused by staff washing all their clothes together and not keeping it separate. Observation revealed during the interview she was itching her bilateral arms and the sides of her abdomen. 7. Review of medical record for Resident #26 revealed an admitted [DATE] and diagnoses included psychosis, bipolar disorder, and dementia. Review of the quarterly MDS dated [DATE] revealed Resident #26 had cognitive impairment. Review of August 2023 Physician Orders and TAR revealed no evidence Resident #26 was placed on contact isolation after she was found to have a rash on 08/13/23 and was ordered to be treated with permethrin cream. Review of a nursing note dated 08/13/23 at 12:37 P.M. with LPN #377 revealed Resident #26 was complaining of itching and the nurse examined noting a rash to her torso and extremities. PCP #400 was notified and ordered permethrin cream and repeat the cream in seven days. Observation on 08/22/23 at 7:36 P.M. revealed Resident #26 was in her room without a shirt on attempting to make her bed. She was observed with a red rash covering her back, chest, abdomen, and bilateral arms and had multiple scratch marks that were scabbed from previous scratching. She was observed to intensely dig at her back making red marks and removing previous scabbed scratches causing areas to bleed. While scratching she was observed making facial grimaces as she was trying to reach the middle of her back. She was unable to be interviewed due to cognitive ability. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing verified no evidence Resident #26 was placed on transmission-based precautions. 8. Interview on 08/24/23 at 3:35 P.M. and 4:18 P.M. with STNA #373 revealed she worked 5:00 P.M. to 5:00 A.M. usually on the secured unit but floated to other units in the facility. She revealed approximately one week ago she got a rash to her arms, legs, and abdomen that looked like what the residents had on the secured unit. She revealed she told a nurse (but did not want to get the nurse in trouble so would not provide her name) about her rash and the nurse gave her permethrin cream to apply to the rash and the nurse had stated the rash was scabies. She revealed she remained on duty and worked having direct contact with the residents despite having the rash, as the nurse did not send her home. She revealed she was upset as she felt the facility should have told the staff the rash was contagious and what should have been done to prevent the rash from spreading amongst the staff. She revealed she was concerned bringing the contagious rash home to her family. She revealed she felt this was a contamination issue especially because she worked on other units and with how many residents had the rash on the secured unit, she was concerned about spreading to the other units. She revealed she did not tell the interim DON instead she told the nurse on duty. STNA #373 explained she knew the interim DON was aware, as the interim DON had contacted her today (08/24/23) and told her she needed to repeat the permethrin treatment. STNA #373 revealed she was not sure how the interim DON thought she would get the cream but probably the interim DON assumed she would get it from the nurse who gave it to her the first time. She then revealed the interim DON called her back later and told her she was being removed from the schedule until she got a doctor's release. Interview on 08/25/23 at 3:56 P.M. with STNA #373 revealed she went to Physician #901 today (08/25/23) and she was diagnosed with scabies. She revealed the physician had told her she had burrowing to her skin which was a classic sign of scabies. She revealed she was ordered permethrin cream to be applied and was to remain off work until 08/27/23. She revealed she was notifying the facility. Review of the staffing schedule and interview on 08/24/23 at 8:31 A.M. with Scheduler/ STNA #372 revealed the following staff from 08/07/23 to 08/20/23 had worked the secured unit as well as other units in the facility during this time frame including STNA #373 as well as LPN #377, STNA #319, #322, #335, #340, #349, #351, #358, #365, #367, and #375. 9. Interview on 08/22/23 at 7:22 P.M. with STNA #351 revealed on the secured unit there was tons of residents with rashes. She revealed she usually worked on the secured unit but today, 08/22/23, she was on a different unit. She revealed just more and more residents keep getting it and nobody seems to be doing anything about it. She revealed she felt bad as the residents constantly are itching and scratching at their skin and seemed to be uncomfortable. She revealed she was concerned about what the rashes were as she had heard it was scabies, but that management was not telling the staff. She revealed she had never received any in services regarding the rashes and precautions to take. Interview on 08/22/23 at 7:39 P.M. with STNA #375 revealed he routinely worked the secured unit and there were several residents with rashes on the unit. He revealed the rashes were bad as residents were itching so bad it felt like they cannot take it anymore as the residents had the rashes a long time approximately two months it seemed. He revealed management had not communicated what the rashes were and/ or given any training regarding precautions they should be doing. Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she routinely worked the secured unit and was upset as nobody had told the staff what the rashes were, and she felt the staff had a right to know especially that so many residents had rashes and that more keep on getting a rash. She revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. She revealed Resident #61 always complained and appeared in a lot of discomfort. She revealed she had not received any training regarding the rashes and/ or precautions to take. She revealed staff member, STNA #373, now had the rash and stated most likely because nobody was telling them what the rashes really were and any special instructions that they should be taking to prevent the spread. Interview on 08/22/23 at 8:25 P.M. with Agency STNA #403 revealed several residents had rashes on the secured unit. She revealed she had not received any in-services regarding the rashes and/ or precautions to take. Interview on 08/23/23 at 9:37 A.M. with the Interim DON verified per the list the facility submitted there were 17 residents currently with rashes on the secured unit. She verified all 17 residents appeared to have the same type of rash and revealed I am assuming it is contagious because one person is getting it then the next person also getting it. She revealed the facility could not state the rash was scabies but verified PCP #400 was ordering permethrin cream which was a treatment to treat scabies. She was asked what infection control plan the facility had initiated, and she revealed once the rash was found on a resident, the resident was placed on contact isolation and permethrin cream was ordered and applied and then washed off after 12 hours. When the Interim DON was asked if any further plans regarding the outbreak, she stated why would I have to have any other plan or such, we see the rash, we call the doctor, we get the cream, and they wash it off. She verified the facility had not contacted the local health department regarding the outbreak of rashes. She was asked if she felt the facility was having an outbreak of rashes and she stated yes. She verified the facility did not have any formal training of staff regarding infection control measures regarding the outbreak of rashes and then asked, what am I supposed to educate on a rash?. She verified the facility completed only one skin sweep on 07/26/23 and revealed if the staff find a rash, they already know they were to report it but verified she had no education evidence she educated the staff regarding reporting of rashes. Interview on 08/23/23 at 10:38 A.M. with Local Health Department Epidemiologist #405 revealed they had not been contacted by the facility regarding the outbreak of rashes that potentially may be scabies since the physician was treating the rashes with permethrin cream. He revealed anytime there was two or more cases including rashes that they needed to be reported by the facility. He revealed if they have 17 rashes or possibly more confined to one unit this was a contagious outbreak and needed to be reported. He revealed the local health department would try to figure out the exact diagnosis and/ or confirm if it was scabies, work with the medical team at the facility, implement isolation exposure guidelines as usually they would send the facility immediate guidelines to implement and coordinate a host of infection control measures to stop and prevent further spread/ outbreak. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed she was upset as the facility does not share anything about what the rashes were and what the staff should do. She revealed the facility had not in serviced and/ or provided any education regarding precautions to take. She revealed she was concerned as she did not want to take anything home to her kids so felt the facility should educate especially since almost all the residents on the secured unit have the rash. Interview on 08/23/23 at 3:38 P.M. with PCP #400 revealed about a month ago Resident #61 started to have a rash as she felt he was the first resident on the secured unit to have. She revealed at first, she treated with triamcinolone cream as she felt it was allergic dermatitis. She revealed the rash did not improve and the rash looked like possibly scabies. She revealed she ordered him to be treated with permethrin cream and had referred him to a dermatologist. She revealed she seen him recently and felt his rash had improved and felt it was because he had received permethrin cream for the scabies. She revealed she had received further calls regarding other residents having the same type of rash, so she instructed them to treat as well with permethrin cream and repeat the cream in one week. She revealed she also ordered the facility to treat the resident's roommate as well as precaution. She revealed she did not realize there was currently 17 total residents with rashes as she stated, not aware of 17 did not think that many but that she received a lot of calls so could be that many as she did not keep track. She revealed there were only a few contagious rashes with severe itching with scabies being one of them and that was why she treated the rashes with permethrin cream. Review of a list provided by the facility on 08/22/23 of residents with current rashes on the secured unit included 17 residents: Resident #9, #12, #17, #19, #26, #36, #42, #45, #48, #54, #61, #62, #63, #69, #96, #103, and #104. Review of Infection Control Log from 07/01/23 to 08/22/23 revealed the following 20 residents on the secured unit currently or had rashes and/ or were treated with permethrin cream: on 07/26/23 Residents #12, #17, #31, #54, #96, on 07/27/23 Resident #36, #42, #50, #62, on 08/08/23 Resident #19, #27, #48, #102, on 08/09/23 Resident #63, #69, #118, on 08/10/23 Resident #103, on 08/13/23 Resident #26, and on 08/20/23 Resident #45, and #104. Review of Know Your ABC's: A Quick Guide to Reportable Infectious Disease in Ohio dated 08/01/19 included the facility would report an outbreak, unusual incident, or epidemic of other disease such as histoplasmosis (fungal infection, pediculosis (lice), scabies) by the end of the next business day to the local health department. Review of facility policy labeled, Scabies identification, Treatment and Environmental Cleaning dated August 2016 revealed the purpose of this procedure was to treat residents infected with and sensitized to scabies and to prevent the spread of scabies to other residents and staff. The policy revealed scabies was an itching skin irritation caused by a microscopic human mite which burrows into the skin's upper layers and eventually causes itching, tiny red lines just above the skin and an allergic rash. The incubation period was two to six weeks and persons who had been previously infected develop more rapid symptoms one to four days after re-exposure. The policy revealed symptoms include severe itching which worsens at night and spreads by skin-to-skin contact or through contact with bedding, clothing, privacy curtains and furniture. Residents should remain on contact precaution 24 hours after the treatment and any staff members should report any rashes that developed on their bodies to the Infection Preventionist or Director of Nursing. The policy revealed during a scabies outbreak the Infection Preventionist or committee would coordinate an effective treatment program. The policy revealed infected employees can return to work after treatment was completed but should use gowns and gloves for direct resident care to prevent reinfestation until all control measures for affected areas have been completed. This deficiency represents non-compliance investigated under MASTER Complaint Number OH0000145650, Complaint Number OH00145621, OH00145594, OH00145593, OH00145536, OH00145524, and OH00145303 and is an example of continued noncompliance from the survey dated 07/20/23.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 tracking log, review of facility policies, observations, interviews with the local health department (LHD), staff and residents and record review the facility failed to conduct consistent and appropriate screening for visitors upon entering the facility and failed to implement appropriate infection control practices including quarantine of exposed residents and appropriate use of personal protective equipment (PPE). This resulted in Immediate Jeopardy on 08/06/21 when the facility failed to implement effective practices to prevent the spread of COVID-19 to residents in the facility after the family member of Resident #11 entered the facility while ill and requested a COVID-19 test which was positive. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 100. On 08/26/21 at 11:14 A.M. the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #202, Unit Manager (UM)/LPN #223 and the Regional Vice President of Clinical Services (RVPCS) #224 were notified that Immediate Jeopardy began on 08/06/21 when the family member of Resident #11 entered the facility with no evidence of being screened for signs and symptoms of COVID-19. While visiting with Resident #11, she text-messaged Admissions/LPN #211 requesting a COVID-19 test ahead of her trip the following week and disclosed she had been ill with [CONDITION(S)]. The family member subsequently tested positive for COVID-19. The facility conducted one round of staff outbreak testing which identified Physical Therapy Assistant (PTA) #206 had tested positive on 08/07/21 but failed to quarantine exposed residents. Immediate Jeopardy continued on 08/23/21 when PTA #205 tested positive for COVID-19 and the facility failed to again quarantine exposed residents. The Immediate Jeopardy was removed on 08/27/21 when the facility implemented the following corrective actions: · On 08/25/21 at 5:00 P.M. education began for all employees by the LNHA, UM/LPN #223 and Night Shift Supervisor (NSS)/LPN #228 that includes: donning and doffing PPE, handwashing, types of isolation including quarantine, donning mask appropriately and eyewear to include a post test. Any employee that is on vacation, short term disability or other leave will have education and competencies completed upon return to work. New employees will complete education and competencies upon hire as part of their new hire orientation. Education has been ongoing and provided to staff based on their schedules. Training sessions have been held 08/25/21, 08/26/21, 08/27/21, 08/28/21, 08/29/21 and 08/30/21. Any staff member that has not completed education will be removed from schedule until education has been completed. The Director of Nursing (DON), ADON/LPN #202 and UM/LPN #223 will complete random rounds on all shifts for the next seven days to ensure that all staff are wearing appropriate PPE and to monitor infection control practices. One on one education will be provided as needed. Daily infection rounds will then be completed by UM/LPN #223 for one month to ensure sustained compliance. Results will be forwarded to the Quality Assurance and Performance Improvement (QAPI) committee for any further recommendations and or resolution. · On 08/25/21 at 5:00 P.M. a screening calendar was put into place by the LNHA and education was provided to department managers Social Service Designee (SSD) #214, ADON/LPN #202, UM/LPN #223, Business Office Manager (BOM) #216, Scheduler/State tested Nursing Assistant (STNA) #225, Licensed Social Worker (LSW) #201, Admissions/LPN #211, Activities Director (AD) #229 and Human Resources Director (HRD) #230 on how to appropriately screen visitors. Managers listed above along with the LNHA will be covering visitor screening Monday through Friday from 8:30 A.M. to 5:00 P.M. while doors are unlocked. Doors will remain locked after hours and on weekends. All the listed managers above will screen employees after hours. The schedule is as follows: Monday through Friday a screener will be assigned from 5:00 A.M. to 8:00 A.M., normal coverage from 8:00 A.M. to 5:00 P.M., 6:30 P.M. to 7:30 P.M. and 10:30 P.M. to 11:30 P.M. The schedule for Saturday and Sunday will be 5:00 A.M. to 8:00 A.M., 2:30 P.M. to 3:30 P.M., 6:30 P.M. to 7:30 P.M. and 10:30 P.M. to 11:30 P.M. If staff arrives outside of these hours, they will be screened by floor nurses on duty who are being trained by UM/LPN #223 and ADON/LPN #202, both who are infection preventionist (IP) trained. The facility will implement a full-time schedule of coverage when outbreak mode is completed on or around 09/10/21. · On 08/25/21 at 5:00 P.M. the RVPCS #224 provided reeducation to the LNHA regarding reporting requirements of contacting the local Health Department with any positive COVID-19 results for a resident or a staff member and the requirements for tracking county positivity rate to determine frequency of testing and PPE requirements based current positivity rate. · On 08/26/21 at 9:00 A.M. a COVID-19 binder was started to include company policies and procedures, CMS guidance, CDC recommendations, county local health department contact information and any guidance offered. The binder will be maintained by the DON and UM/LPN #223 and updated as new policies, procedures and guidance are released. Binder will be reviewed during outbreak zoom calls by RVPCS #224, Senior Vice President of Clinical Services (SVPCS) #232, Regional Vice President of Clinical Education (RVPCE) #233 and Senior Vice President of Operations (SVPO) #234 to ensure any new company policies and procedures, CMS and CDC changes have been added to the binder. · On 8/26/21 at 2:00 P.M. ADON/LPN #202 and UM/LPN #223 reviewed all residents that were exposed by PTA #206 on 08/07/21. Residents #1, #3, #11, #12, #28, #40, #42, #50, #56, #64, #72, #82, #97 and #104 have had their daily COVID-19 evaluations and vital signs reviewed with no negative findings. Residents #101, #102, #103 and #105 no longer reside at facility. Residents exposed on 08/07/2021 are past the 14-day exposure and there is no need for quarantine. All of these residents have tested negative for COVID-19 on 08/07/21, 08/09/21, 08/23/21 and 08/26/21. · On 08/26/21 at 2:00 P.M. ADON/LPN #202 and UM/LPN #223 reviewed the residents that were exposed by positive employee PTA #205 on 08/23/21. Residents # 5, #11, #12, #23, #30, #32, #38, #40, #50, #56, #68, #72, #81, #92 and #96 have had their daily COVID-19 evaluations and vital signs reviewed with no negative findings. Resident #102 no longer resides at facility. ADON/LPN #202, UM/LPN #223 and Minimum Data Set (MDS)/Registered Nurse (RN) #231 will continue to review these evaluations daily through 09/06/21 to monitor for any signs or symptoms (cough, fever, sore throat, or shortness of breath) that may be associated with COVID-19. · On 08/26/21 at 2:00 P.M. the RVPCS #224 provided additional reeducation to the LNHA on company policies, LHD guidelines, and CDC guidelines regarding isolation of new admissions to the center; quarantine of potentially exposed residents per LHD guidelines; wearing the appropriate PPE during outbreak testing and current county positivity rate; the responsibilities of the IP to include providing oversight of all infection control activities; the frequency needed for testing when facility is in outbreak mode and visitor screening protocol to ensure screening tool is completed with all questions answered and date and time and temperature completed. · On 08/26/21 at 2:30 P.M. the residents that were exposed on 08/23/21 (Residents #5, #11, #12, #23, #30, #32, #38, #40, #50, #56, #68, #72, #81, #92, and #96) were placed in quarantine by Scheduler/STNA #226 and Scheduler/STNA #225. Resident #102 no longer resides at the facility. · On 08/26/21 at 2:30 P.M. MDS/RN #231 wrote contact and droplet isolation orders for Residents #5, #11, #12, #23, #30, #32, #38, #40, #50, #56, #68, #72, #81, #92, and #96 placed in quarantine. Care plans were updated for these residents regarding COVID-19 risk and isolation. · On 08/26/21 at 4:00 P.M. MDS/RN #231 reviewed all residents' COVID-19 evaluations and vitals to ensure no change of condition had been identified. · On 08/26/21 at 4:45 P.M. Medical Director (MD) #227 was made aware of resident's exposure on 08/07/21 and on 08/23/21 to COVID-19 positive staff members. · Outbreak testing has been completed on the following dates with no positive residents: all residents and staff (08/07/21); all residents and staff (08/09/21); unvaccinated staff were tested twice weekly the weeks of 08/09/21, 08/16/21 and 08/23/21; all residents and staff (08/23/21). Another round of rapid testing was completed for all residents on 08/26/21 and is scheduled the week of 08/30/21 and will continue until facility has reached compliance with no positive staff or residents for 14 days with an end date estimated to be 09/10/21. DON/IP will validate all testing has been completed for both staff and residents by cross referencing COVID-19 testing log with employee roster and resident census. This audit will be completed going forward with each round of testing for both staff and residents. · The LNHA will immediately notify RVPCS #224, SVPCS #232 or SVPO #234 whenever a staff/resident/visitor test positive to ensure that all the appropriate steps are followed. If a staff/resident/visitor test positive, a daily call will be initiated to ensure all task are completed and follow up is complete. This will continue with every positive staff/resident/visitor and will be ongoing for any outbreak at the facility. Monitoring will take place via a daily Zoom (teleconferencing application) call each time the facility has an outbreak and will continue for the duration of the outbreak, that will include the LNHA, DON, UM/LPN #223 and/or ADON/LPN #202. RVPCS #224 will schedule the daily Zoom call. Invitees will also include RVPCE #233, SVPCS #232 and SVPO #234. Education tasks to be monitored include quarantine of affected residents, appropriate intervals for outbreak testing, review of county positivity rate, LHD notification, appropriate visitation and PPE usage. · On 08/26/21 at 5:00 P.M. a call em all (which is a type of communication used to inform both staff and families of any changes at the facility) went out to all staff to alert staff that they must see a department head who has been competency tested for any rapid COVID-19 test. A list of all staff that have been trained to conduct COVID-19 rapid tests has been developed and will be placed at screening table upon entrance and at the employee time clock. · On 08/27/21, RVPCS #224 remained on site and reviewed facility visitor logs. Visitor logs will be scanned weekly on Fridays to RVPCS #224 for review to ensure accuracy and completion and to verify no visitors were in the center that did not meet compassionate care criteria if facility is in outbreak testing. The DON and/or LNHA will be responsible to scan visitor logs to RVPCS #224 weekly for one month, then monthly for three months if an outbreak occurs. · On 08/27/21 at 12:00 P.M. a formal Ad Hoc QAPI meeting was conducted with MD #227, LNHA, Admissions/LPN #211, SSD #214, ADON/LPN #202, UM/LPN #223, BOM #216, HRD #230, MDS/RN #231 and RVPCS #224 to ensure no further changes need to be made to the plan. · On 08/27/21 at 3:30 P.M. Department managers Admissions/LPN #211, BOM #216, SSD #214, HRD #230, and the LNHA were all re-competency tested by UM/LPN #223 and ADON/LPN #202 who are IP certified. · On 08/30/21 the DON was educated by RVPCS #224 on the role of the IP, COVID-19 policies and procedures, isolation practices to include new admissions/readmissions, resident exposure to COVID-19 and subsequent quarantine, county positivity rates, LHD notification criteria, and appropriate PPE during an outbreak. The DON will oversee the IP program and coordinate all infection control activities per CMS, CDC, state and local guidelines to prevent and control the spread of an infection to include COVID-19. RVPCS #224 and/or SVPCS #232 will hold daily calls with the facility to ensure all steps have been followed for any staff, resident or visitor who test positive for COVID-19 during outbreak testing. Daily calls will continue as long as facility remains in outbreak testing mode. · On 09/02/21 the LHD will be onsite at the facility to provide guidance and education to LNHA, DON, UM/LPN #223 and ADON/LPN #202 related to COVID-19. LHD recommendations will be shared with the DON, LNHA and RVPCS #224 to ensure that any further education and or follow up is completed. · The following corporate staff will rotate facility visits weekly for the next month to ensure ongoing compliance then will evaluate frequency of needed visits: RVPCS #224, SVPCS #232, RVPCE #233, SVPO #234 and Regional Vice President of Operations (RVPO #235). RVPCS #224 remains on site through 09/02/21. RVPO #235 will be on site at facility the week of 09/07/21. A further schedule will be developed the week of 08/30/21. · On 09/01/21 from 10:42 A.M. until 11:56 A.M. interviews with RN #26, Housekeeper #237, Housekeeper #222, the DON and the Director of Rehabilitation #220 indicated they had been trained on appropriate infection control including PPE use, quarantine, isolation and COVID-19 testing. Staff verified appropriate screening were taking place at the facility. Although the Immediate Jeopardy was removed on 08/27/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. During the onsite investigation beginning on 08/24/21 at 9:07 A.M. the LNHA shared the facility was currently in outbreak status as PTA #205 had tested positive for COVID-19 on 08/23/21. Observation upon entrance revealed staff were wearing surgical masks and no N95 masks or eye protection were noted. On 08/24/21 from 10:11 A.M. to 11:21 A.M. environmental tour with Director of Housekeeping (DOHK) #200 further revealed no residents were observed to be on quarantine or isolation precautions. Staff observed during the tour only had surgical masks on with no N95s or eye protection noted. Residents were not observed wearing masks or being encouraged to wear a mask if they were outside of their rooms. Interview on 08/24/21 at 11:33 A.M. with the LNHA revealed the facility utilized the CMS memorandum QSO-20-39-NH as the basis for infection control policy and procedure. The LNHA stated the QSO was grey regarding handling a staff positive for COVID-19 and the LNHA's thought was as long as there were no COVID-19 positive residents in house, an N95 mask was not required. On 08/25/21 from 7:40 A.M. to 8:00 A.M., from 12:08 P.M. to 12:17 P.M. and from 2:00 P.M. to 2:04 P.M. additional observations revealed residents were not wearing masks outside of their rooms and staff were not wearing protective eyewear with their N95 masks. Interview on 08/25/21 at 8:25 A.M. with the LNHA acknowledged staff were wearing N95s today as they were more appropriate due to the facility's outbreak status. Phone interview on 08/25/21 at 11:03 A.M. with Local Health Department Epidemiologist (LHDE) #215 revealed it was inappropriate for staff to only wear a surgical mask if the facility was in outbreak status. Interview on 08/25/21 at 11:30 A.M. with BOM #216 indicated after the family and staff positive case on 08/06/21 and 08/07/21 staff had only worn N95s for four days during the last outbreak status. Interview on 08/25/21 at 12:59 P.M. with UM/LPN #223 indicated the facility staff had not been wearing N95s on 08/23/21 when PTA #205 had tested positive and the facility went into outbreak status. Phone interview on 08/25/21 at 4:36 P.M. with PTA #205 indicated after the family member tested positive on 08/06/21, staff were tested and only wore N95s for a few days. Review of a facility notification to families script dated 08/10/21 revealed the facility was out of outbreak mode and the same rules applied as before. All employees can go back to blue [surgical] masks and visitation resumed as normal. Review of a facility notification to families script dated 08/23/21 indicated one staff member had tested positive for COVID and all staff and residents were being tested . Visitation was stopping until further notice. Everyone can remain in blue [surgical] masks until given other directive. Review of CDC guidance, Infection Control for Nursing Homes, updated 03/29/21, revealed because of the high risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any healthcare personnel (HCP) or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Recommended precautions should be continued for residents until no new cases of [CONDITION(S)]-CoV-2 infection have been identified for at least 14 days. 2. Observations on 08/24/21 at 12:29 P.M., 3:24 P.M. and 3:28 P.M. revealed LPN #210 was at the nurses' station with her mask below her nose. Interview on 08/24/21 at 4:40 P.M. with the LNHA indicated the facility had completed training on appropriate mask usage and was aware LPN #210 did not wear her mask appropriately. Interview on 08/24/21 at 5:02 P.M. with LPN #210 with the LNHA and ADON/LPN #202 present verified she was to always wear a mask appropriately and there was nowhere to not wear a mask in the facility. Review of staff training and competencies dated 09/07/20, 09/08/20, 02/04/21 and 06/22/21 indicated LPN #210 had received training on PPE, including mask usage. 3. Interview on 08/24/21 at 2:01 P.M. with the LNHA indicated the facility had had two recent cases where a staff member had tested positive for COVID-19 with PTA #206 on 08/07/21 and PTA #205 on 08/23/21. When asked if the facility utilized a line list to track infections, the LNHA stated the line list had not been utilized since approximately March 2021. The LNHA indicated some outbreak testing had been completed for residents and staff and showed the surveyor stacks of tests with binder clips. The LNHA verified residents exposed by both PTA #206 and PTA #205 were mostly vaccinated and not quarantined due to exposure. Interview on 08/24/21 at 2:35 P.M. with ADON/LPN #202 with the LNHA present revealed on 08/23/21 residents that had been assisted by PTA #205 were identified as having been exposed and all residents had tested negative for COVID-19. ADON/LPN #202 stated they were screened for COVID-19 and had vitals done daily but verified residents were not quarantined after the exposure to COVID-19 positive staff. ADON/LPN #202 indicated she thought they followed QSO-20-39-NH for guidance and stated while she had the Infection Preventionist (IP) training, she was not responsible for tracking COVID-19 at the facility but helped do COVID-19 testing. Review of the facility's line list file revealed the most recent information was from 03/01/21 and was not up to date at the time of the survey. a. Review of infection control documentation dated 08/07/21 revealed an email from Director of Rehab #220 indicating that PTA #206 tested positive that day and had treated 18 residents in the last 14 days (Residents #1, #3, #11, #12, #28, #40, #42, #50, #56, #64, #72, #82, #97, #101, #102, #103, #104 and #105). Time sheet data indicated PTA #206 left the facility immediately after the positive result. PTA #206's staff screening on 08/06/21 and 08/07/21 indicated no triggers for concern regarding COVID-19 symptoms. Record review for Residents #1, #3, #11, #12, #28, #40, #42, #50, #56, #64, #72, #82, #97, #101, #102, #103, #104 and #105 indicated they were not quarantined after the facility had identified the residents had been exposed to PTA #206 in the last 14 days. No nurses' notes were available in the medical records indicating residents had been exposed or were quarantined as a result of the exposure. Review of COVID-19 evaluations for the above residents on 08/07/21 and on 08/08/21 revealed no mention of the exposure to COVID-19 positive staff. b. Review of infection control documentation dated 08/23/21 revealed an email from Director of Rehab #220 indicating PTA #205 tested positive that morning and did not go beyond the testing room. PTA #205 had treated 16 residents in the last 14 days (Residents #5, #11, #12, #23, #30, #32, #38, #40, #50, #56, #68, #72, #81, #92, #96 and #102). Time sheet data indicated PTA #205 did not even clock in and had not worked since 08/20/21. Staff screening on 08/20/21 and 08/23/21 indicated no triggers for concern regarding COVID-19 symptoms. Record review for Residents #5, #11, #12, #23, #30, #32, #38, #40, #50, #56, #68, #72, #81, #92, #96 and #102 indicated they were not quarantined after the facility had identified the residents had been exposed to PTA #205 in the last 14 days. No nurses' notes were available in the medical records indicating residents had been exposed or were quarantined as a result of the exposure. Review of COVID-19 evaluations for the above residents on 08/23/21 and on 08/24/21 revealed no mention of the exposure to the COVID-19 positive staff. Phone interview on 08/25/21 at 8:52 A.M. with Local Health Department Nurse (LHDN) #213 revealed exposed residents should be quarantined in one area. Phone interview on 08/25/21 at 11:03 A.M. with LHDE #215 indicated when a staff tested positive for COVID-19, the facility was to identify the exposed residents, ensure they were tested and utilize full PPE for the room and quarantine them to their rooms. LHDE #215 stated this was important regardless of vaccination status due to breakthrough COVID-19 cases. Interview on 08/25/21 at 12:59 P.M. with UM/LPN #223 verified all the residents that had been in contact with PTA #205 had not been placed into quarantine on 08/23/21. The LNHA and RVPCS #224 were made aware of the absent documentation related to exposure status during a phone interview on 08/31/21 at 8:22 A.M. Review of the facility policy, COVID-19: Identification and Management of Ill Residents, revised July 2020 revealed residents who may have been exposed to someone with COVID-19 were monitored closely and not placed with unexposed residents or until status of COVID-19 was determined. The policy did not further elaborate on quarantine requirements. Review of CDC guidance, Infection Control for Nursing Homes updated 03/29/21 revealed residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Residents in quarantine should be placed in a single-person room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter-in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2 infection. HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. 4. Interview on 08/24/21 at 4:40 P.M. with the LNHA revealed PTA #206's positive test was discovered as the facility was doing testing in response to a positive family member. The family member of Resident #11 came in before going on a trip out of the country, had symptoms and bypassed entry screening. The LNHA stated SSD #214 had been out at lunch when the family member visited. The LNHA stated the family member felt a little ill and staff [not identified in the interview] had asked her why she had come to the facility sick. The family member had [CONDITION(S)] and then tested positive on 08/06/21. The next day, PTA #206 tested positive for COVID-19. The LNHA verified there was no documentation for surveyor review regarding the family member. Interview on 08/25/21 at 8:09 A.M. with Admissions/LPN #211 revealed she had been in her office when Resident #11's family member entered the facility on 08/06/21 and did not see anything. Admissions/LPN #211 explained all of the families had the managers' cell phone numbers and explained Resident #11's family member had text messaged her from Resident #11's room. The family member had asked for a COVID-19 test and was nervous since she was going to Europe on the following Tuesday; she was supposed to get a COVID-19 test that Monday and was currently on antibiotics for [CONDITION(S)]. Admissions/LPN #211 took her to the testing room and tested the family member with facility testing supplies, and it was positive for COVID-19. Admissions/LPN #211 stated she'd never had a positive test result before so she did a second test on the family member and it was positive. She got the LNHA who came in and told the family member she had to leave and the family member was crying and left. Admissions/LPN #211 did not know if the family member had screened in and stated the facility did not have a full-time receptionist at the front desk. Interview on 08/25/21 at 8:39 A.M. with STNA #212 revealed on 08/06/21 Resident #11's family member came in and visited with the resident in her room and left 30 minutes after that. STNA #212 recalled the facility went into COVID protocol with testing. STNA #212 did not know if the family member had been screened when she entered the facility or not. Phone interview on 08/25/21 at 8:52 A.M. with LHDN #213 revealed she expected all staff and visitors to be screened for signs and symptoms upon entry to a facility. LHDN #213 confirmed if anyone such as a family member did not feel well, they should not have been able to enter the facility. Interview on 08/25/21 at 9:31 A.M. with SSD #214 indicated she worked on 08/06/21 and did not remember screening Resident #11's family member. SSD #214 indicated if she was not up front by the entrance then BOM #216 or another manager would have screened the family member. SSD #214 indicated while the family member had not come back to the facility after the incident, if someone did not feel well they should not have been allowed in the building. Interview on 08/25/21 at 9:47 A.M. with the LNHA revealed he was not in his office and he did not know who would have screened the family member of Resident #11 on 08/06/21. The LNHA stated management staff were supposed to look at the visitor logs and ensure visitors take their temperature with the thermometer on the wall but staff would not ask visitors the questions out loud and rather relied on the visitor to self-screen into the facility. The LNHA stated the corrective action to the issue on 08/06/21 was to start shifts of managers at the front desk to screen staff in but this had not started yet. The LNHA verified his planned corrective action was not timely in relation to the issue with Resident #11's family member on 08/06/21. The LNHA provided a photocopy of a visitor screening sheet to the surveyor with the date 08/06/21 written across the top and this sheet indicated Resident #11's family member had signed in at 11:15 A.M. The sheet was signed off by Former Human Resources Director (FHRD) #219. Phone interview on 08/25/21 at 11:03 A.M. with LHDE #215 indicated the facility needed to screen all visitors and ensure they were not sick before allowing entry. Interview on 08/25/21 at 11:30 A.M. with BOM #216 revealed she had not seen the family member of Resident #11 enter the facility on 08/06/21. BOM #216 stated FHRD #219 was supposed to screen people and if she was not around then other managers would screen visitors in to the facility. Phone interview was attempted with FHRD #219 on 08/25/21 at 11:55 A.M. No return call was received. Phone interviews were attempted with the family member of Resident #11 on 08/25/21 at 4:34 P.M. and on 08/26/21 at 9:17 A.M. No return call was received. Interview on 08/26/21 at 2:16 P.M. with the LNHA discussed the differing staff recollections regarding Resident #11's family member and how originally he had told the surveyor the family member was not screened but then had a provided a screen. The original screening sheets for July and August 2021 were reviewed with the LNHA present and he verified none of the screening sheets reviewed had dates on them until 08/24/21. When asked how one could use the screening sheets to track infections without dates on them, the LNHA stated he knew what order they were in by month. Review of visitor screening sheets identified by the facility as being from July 2021 revealed Resident #11's family member visited the facility four times. No dates were indicated on the screening sheets. Review of visitor screening sheets identified by the facility as being from August 2021 revealed Resident #11's family member visited the facility eight times. There were no dates indicated on the visitor screening sheets until 08/24/21. An original for the screening sheet previously given to the surveyor as a photocopy surrounding the concerns with Resident #11's family member could not be found. It could not be determined from facility documentation if Resident #11's family member had been screened on 08/06/21. Review of the facility policy, COVID-19 Infection Prevention and Control Measures, revised July 2020 indicated anyone entering the facility including staff was screened and triaged for signs and symptoms of COVID-19 infection. Symptoms were listed. Anyone with a fever, signs/symptoms of illness or those had been advised to self-quarantine due to exposure were not allowed to enter the facility. Review of CDC Guidance, Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, updated 04/27/21 revealed visitors should be screened and restricted from visiting, regardless of their vaccination status, if they have: current [CONDITION(S)]-CoV-2 infection; symptoms of COVID-19; or prolonged close contact (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection in the prior 14 days or have otherwise met criteria for quarantine. Visitors should be counseled about recommended infection prevention and control practices that should be used during the visit (e.g., facility policies for source control or physical distancing). Facilities should have a plan to manage visitation and visitor flow. This deficiency substantiates Master Complaint Number OH 440 and Complaint Number OH 890.

Based on staff interview, observation of tray line service and review of the facility ' s policy and procedure, the facility failed to ensure chicken was cooked thoroughly and foods were held at the proper temperatures when served from the tray line to prevent food borne illness. This resulted in Immediate Jeopardy for seven residents, (Residents #52, #54, #55, #56, #57, #58 and #59) on the secured dementia unit, who were served and consumed bone-in chicken thighs that were undercooked. Licensed Practical Nurse (LPN) #30 cut into a chicken thigh and it was pink and seeped blood. This affected seven of 44 residents residing in the secured dementia unit (ACU). The facility census was 120. The administrator, Food Service Director (FSD) #21 and the Director of Nursing (DON) were notified on 03/18/16 at 3:10 P.M. that Immediate Jeopardy began on 03/09/16 when seven residents residing in the ACU received undercooked chicken. The Immediate Jeopardy remained ongoing due to the lack of interventions put into place to ensure no other potentially hazardous foods left the kitchen at an unacceptable temperature. The Immediate Jeopardy was abated on 03/20/16 at 12:18 P.M., when all food temperatures were taken prior to starting tray line and all potentially hazardous foods were within acceptable temperature limits to prevent food borne illness. The facility also initiated the following corrective actions: · On 03/18/16, a commercial oven company inspected the oven to ensure adequate heating temperatures and found no malfunction with the oven. The company suggested monitoring the product and shifting trays during the cooking process. · On 03/18/16 Registered Dietitian (RD) #42 in-serviced Cook #20 regarding calibration of the thermometer, recording the food temperatures and ensuring foods were served at safe and proper temperatures. · On 03/20/16 Consultant Chef #28 in-serviced Cooks #22 and #25 regarding calibration of the thermometer, recording food temperatures and ensuring foods were served at safe and proper temperatures. · Beginning 03/20/16 FSD #21 will audit all meals for three weeks and randomly after to ensure potentially hazardous foods are within acceptable temperatures to reduce the potential for food borne illness. · Beginning 03/20/16 the administrator will monitor daily for three weeks and randomly thereafter to ensure compliance with acceptable food temperatures of potentially hazardous foods. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility continued to complete audits and verify the corrective action taken was effective. Findings include: Review of the investigation completed by the DON on 03/11/16 revealed on 03/09/16 Cook #20 served undercooked chicken to the residents on the ACU. Residents #52, #54, #55, #56, #57, #58 and #59 consumed part or the entire undercooked chicken thighs. There was no evidence the temperature of the chicken thigh was taken at any point while in the kitchen or before leaving the kitchen. Those residents identified were monitored for signs and symptoms of nausea, vomiting, fever and diarrhea for 72 hours. The resident ' s physician was notified and informed a Quality Assurance Plan for Improvement (QAPI) had been implemented by FSD #21. Further review of the 72 hour monitoring revealed there was no evidence any residents displayed any signs or symptoms of food borne illness. On 03/18/16 at 11:20 A.M., observations of the kitchen revealed Cook #20 had already taken the food temperatures. Cook #20 stated that there was no food temperature log when requested at the time of the kitchen observation. Cook #20 then stated he remembered the temperatures and wrote the temperatures on the spread sheet. Cook #20 stated that sometimes the temperatures were put on the spread sheet. The spread sheets for March 2016 were reviewed with Cook #20. The attached spread sheets for March 2016 revealed no evidence of any food temperatures being recorded. The food temperature logs for March 2016 were requested. Cook #20 verified he did not use food temperature logs. The FSD #21 was present during the interview and indicated he provided the cooks with the temperature log but was unable to locate it in the kitchen On 03/18/16 at 11:30 A.M., FSD #21 was interviewed and verified he was not able to find any food temperature logs for 2016 and the most recent logs were from June 2015. FDS #21 was asked if there had been any concerns regarding undercooked chicken. FSD #21 verified Cook #20 undercooked chicken on 03/09/16 and it was served to residents in the ACU. On 03/18/16 at 11:40 A.M., Cook #20 was interviewed regarding the undercooked chicken. He stated there was a problem with the convection oven. The left side of the oven would overcook the food and the right side would not get up to temperature. Cook #20 verified FSD #21 was made aware of the concern with the convection oven. The temperature of the country fried steak was taken at this time on the steam table. Cook #20 lifted the layers of steak and placed the tip of the thermometer on the bottom piece of steak. The notch for the thermometer was not in the meat and the temperature read 140 degrees Fahrenheit (F). Cook #20 then put the notch of the thermometer in the top layer of steak, after surveyor intervention, and the steak registered at 155 degrees F. Cook #20 stated the temperature for the food on the steam table should be between 135 and 140F. Cook #20 stated that about 10 pieces of undercooked bone in thighs were served to residents on 03/09/16 during the lunch meal. Cook #20 verified that all of the residents were on the ACU unit. Cook #20 verified he was not able to provide evidence he took the temperatures of the bone-in chicken thighs. On 03/18/16 at 12:05 P.M., interview with FSD #21 verified Cook #20 was a dishwasher until about five months ago. FSD #21 verified the most recent in-service related to food safety was 02/12/15 and Cook #20 did not attend the in-service. FSD #21 stated he watched Cook #20 prepare the chicken breast on 03/09/16 for lunch. The boneless chicken breasts were placed in the cooler for three days prior to use to defrost. The bone-in chicken thighs were taken right out of the freezer on 03/09/16, I think he panicked and did not think he was going to have enough chicken. I was notified of the undercooked chicken when the care staff was cutting them up and they observed the inside not cooked all the way. I went over to the building. The chicken thigh was brown on the outside but when I cut into it, it was not done, it was red with blood. FSD #21 stated 36 to 39 chicken thighs were sent to the ACU on 03/09/16. FSD #21 verified he did not have any documentation of any type of corrective action but planned some action by Tuesday 03/22/16. On 03/19/16 observations were made of the kitchen at 4:35 P.M. Cook #25 verified he already took the food temperatures for the hot foods and was not going to retake the temperatures prior to starting tray line. He stated all hot food temperatures were to be above 165 degrees F. He verified he had not documented the food temperatures for many months including today ' s dinner. Upon surveyor request, Cook #20 was asked to retake the food temperatures. He verified he did not take the cold food temperatures and was not sure who was responsible for taking the cold food temperatures. He stated the alternate was a tuna salad sandwich and the tuna salad was still in the cooler. At 5:05 P.M., the tuna salad was placed in a pan with two inches of ice at the base of the pan. Cook #25 verified he had taken all the food temperatures and was ready to start tray line. At 5:08 P.M., Cook #20 started tray line and was stopped due to the temperature of the tuna salad not being obtained. At 5:10 P.M., the cook took the temperature of the tuna salad which was 48 degrees F; both RD #42 and FSD #21 were present at the time the temperature was taken. There was no acknowledgement that the 48 degrees F. was above the acceptable 41 degrees F and the cook proceeded with tray line. At 5:45 P.M., the first tray for alternate (tuna salad) was announced. The tray was observed being prepared by RD #42 with the tuna salad. The tray was then placed in the cart to be delivered to Resident #49. It was verified at this time that the tuna salad registered 48 degrees at 5:10 P.M. and it was requested that the temperature of the tuna salad be retaken. RD #42 took the temperature which read 45 degrees F. which was verified by Cook #25 who stated it was okay to be served. Cook #25 was interviewed regarding the appropriate temperature cold foods before leaving the kitchen. Cook #25 stated 35 degrees F. He stated he made the tuna salad on 03/19/16 at 11:00 A.M. On 03/20/16 at 2:40 P.M., interview with LPN #30 verified he was the one who first identified the chicken was undercooked on the ACU unit. He stated he served two tables and the chicken appeared okay then he went to the third table and cut into a piece of chicken and it was pink with some blood coming out of it. He stated all the chicken was immediately removed from the residents but some residents had already eaten part or all of the chicken. Review of the facility ' s dining services policy and procedure on infection control for cooking, holding and serving foods, dated 2011, revealed raw poultry was to be cooked to an internal temperature of 165 degrees Fahrenheit (F) for 15 seconds. Improper holding temperatures were contributing factors of foodborne illness. The holding temperatures of all hot and cold items must be taken and recorded after full preparation and immediately before starting meal service. Monitor temperatures at the end of cooking to assure the correct internal cooking temperature was reached before putting on serving line and shortly before the start of meal service to assure food was being served at correct and safe temperatures. Do not place food on the steam table more than 30 minutes before the meal service. It stated to hold hot foods at a continuous temperature of 140 degrees F or above on the serving line or according to state regulations. Cold foods should not be placed on the serving line or steam table more than 15 minutes prior to the start of mealtime. Hold potentially hazardous cold foods at a continuous temperature of 41 degrees F or below. Hold all potentially hazardous cold items on ice during service. Take and record temperature to assure all items were at 41 degrees F or below. Review of the most recent in-service related to food temperatures, dated 02/12/15, revealed it was facility policy, effective 02/12/15, to hold hot foods at a continuous temperature of 135 degrees or above on the serving line or according to the state regulations; to monitor temperatures at the end of cooking to assure the correct internal cooking temperature was reached before putting on serving line and to monitor shortly before the start of the meal serve to assure food was being served at correct and safe temperatures. Cook #20 was not identified as part of the in-service. Review of the 01/07/16 resident council meeting minutes revealed 24 residents attended. There were concerns raised regarding hot foods being served cold in the main dining room. There was no evidence the concern was addressed.

Based on observation, interview and record review, the facility failed to ensure necessary care and services were provided to Resident #138 in a manner to prevent harm, which resulted in a fractured left arm. The facility also failed to ensure care and services were provided to prevent falls for Resident #31 and Resident #165. This affected three of six resident investigated for accidents. The facility census was 157 residents. Findings include: 1. Resident #138 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] indicated the resident had physical behavioral symptoms directed towards others (hitting, pushing, scratching, and grabbing) which occurred one to three days of the assessment period. Under the area of verbal behavioral symptoms directed towards others, the behavior of this type also occurred one to three days of the assessment period. The resident was also noted to require extensive assistance of two staff for dressing, mobility, and transfers. The care plan indicated the resident was resistive to care, blind, and had impaired communication. Interview with Licensed Practical Nurse (LPN) #202 on 05/18/2014 at 2:36 P.M. revealed the resident sustained [REDACTED]. Review of the 'Verification of Investigation" dated 05/03/14 at 10:00 A.M. revealed '"R" (resident) during HOC (hands on care) shaking/swinging BIL (bilateral) arms vigorously at staff members while attempting to put shirt on. STNA (state tested nursing assistant) at this time noted to hear a loud cracking in left arm. STNA's immediately stopped care and got both nursing staff on unit to assess "R"." The resident sustained [REDACTED]. The two STNA's involved in the incident were STNA's #205 and #206. Review of the personnel record for STNA #205 revealed a 05/07/14 "Separation Action Form" with the reason of "incomplete certified nursing assistant training." Further comment indicated the STNA took the certification test three times and did not pass. The STNA had been hired on 01/18/14, after successfully completing nurse aide training on 01/16/14. Interview on 05/20/14 at 2:00 P.M. with the DON (director of nursing) revealed there was no continuing education or inservicing for the STNA's that were involved in the incident. on how to assist resident who resist care. Review of inservices on resident care for resistive residents revealed the facility had conducted a training on 04/24/14 titled "Bathing The Difficult Patient" the sign in sheet had STNA #206 designated as "termed" (verified by the DON who stated the staff person is still employed). The signature for STNA #205 stated "terminated" (DON verified that the staff person had been terminated). Review of the grievance log dated 05/02/14 indicated the family of resident #138 no longer wanted the STNA's to work with the resident after the fracture occurred. The staff failed to follow facility policy and the residents care plan that indicated when the resident is resistive to care the staff are to stop providing care, and alert the nurse to the behavior. The STNA's continued care of the resident which resulted in a fracture left femur. 2. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] indicated the resident required a two person extensive assistance with transfers. On 05/18/14 at 2:40 P.M., interview with the charge nurse revealed the resident had sustained a fall within the past thirty days. Review of the residents care plan indicated the resident was at risk for falls related to impaired mobility, impaired decision making, and impaired safety awareness. The intervention was to transfer with two persons. The "Fall investigation" dated 11/05/13 which indicated the resident sustained [REDACTED]. There were no apparent injury. The investigation indicated the STNA was re-inserviced. Interview on 05/20/14 at 3:00 P.M. with the DON revealed no inservice could be found. On 05/20/14 at 9:51 A.M., interview with STNA #204 revealed the resident required transfers with the assist of one or two staff members. The surveyor asked the STNA when two staff should transfer the resident. She stated when she takes her to the bathroom, she can't always stand and hold the handrail so she needs two staff. The STNA seemed to be unaware of the comprehensive assessment, and care plan that indicated the resident requires two staff for transfers. Resident #31 was transferred with one staff person and sustained a fall. 3. Review of the record revealed that Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was assessed as a fall risk on 09/27/13 due to impairments in cognition, decision making, and vision. He was to be a mechanical lift for transfers, and a care plan dated 10/02/13 revealed impaired decision making and communication was due to impaired cognition, inattention and disorganized thinking. He also had a care plan for falls, dated 09/27/13 and updated through 06/29/13, which revealed interventions to use a mechanical lift for transfers; the call light to remain within reach; and the environment to be well lit and free from clutter. The resident also had an order for [REDACTED]. Review of a nursing note dated 04/25/14 at 6:20 P.M. revealed the resident was found on the floor laying on the left side parallel to the bed. Review of the investigation of the incident revealed that he had been ordered to have side rails in place on his bed but they had not been applied to the bed as ordered. The resident had rolled out of his bed onto the floor. The intervention to prevent further falls was that the side rails were to be installed on the bed as previously ordered. Interview with the director of nursing on 04/20/14 at 4:00 P.M. verified the side rails were not in place as ordered prior to the resident being found on the floor on 04/25/14.

Based on observation, record review and staff interview, the facility failed to ensure staff applied compression stockings safely and conducted wheelchair transfers safely for Resident #149. Two separate incidents resulted in Resident #149 being sent to the hospital within 14 days to have seven stitches to a lower left leg laceration and seven stitches to a lower right leg laceration. This affected one of three residents reviewed for accident hazards. Findings include: Resident #149, a [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #149 used a wheeled-walker for supervised ambulation. Review of the physical therapy evaluation dated 08/09/11 revealed Resident #149 was referred to physical therapy related to increased difficulty with ambulation after the resident's lower leg split open in the shower room requiring seven stitches. Review of the nurses notes dated 07/27/11 revealed on 8:45 A.M., Resident #149 was in the shower room and State tested Nursing Assistant (STNA) #100 was attempting to apply compression stockings (TED hose) to the right lower leg. The resident was assessed to have three-plus [MEDICAL CONDITION] of the right lower leg and when STNA #100 tried to apply the TED'S, the skin split, measuring seven centimeters in length. The resident was transferred to the hospital and received seven stitches to the right lower leg. Review of an incident report dated 07/27/11 verified a three-inch laceration to the right shin occurred when TED'S were being applied to Resident #149. STNA #100 reported she applied lotion to legs prior to applying TED'S. Review of the occupational therapy evaluation dated 08/12/11 revealed Resident #149 sustained a left leg injury on 08/11/11 after staff transferred her from her wheelchair. The resident was transferred to the hospital and received seven stitches to the left lower leg. Review of the nurses notes dated 08/11/11 revealed at 3:02 P.M., STNA #101 reported Resident #149 bumped her left lower leg on her wheelchair footrest. The charge nurse used six steri strips to close the laceration and then the resident was transferred to the hospital and received seven stitches to the left lower leg. Review of the incident report dated 08/11/11 revealed STNA #101, an agency STNA, was transferring the resident from the wheelchair to the commode. The lower left leg bumped the footrest causing a five centimeter laceration. On 08/30/11 another incident report identified STNA #103 was removing Resident #149's TED hose and re-opened the left leg wound. The nurses assessed the opening to be 1.5 centimeters by 1.0 centimeters, with [MEDICAL CONDITION], drainage, red and warm to the touch. The physician ordered antibiotics and a new treatment was ordered for a self-adhesive absorbent dressing (Mepore). Review of the treatment administration records revealed one or both leg wounds were under treatment from 07/27/11 through 09/29/11. On 10/31/11 at 11:33 A.M., Resident #149 reported she was currently in therapy and used the wheelchair to move about the unit. Resident #149 was observed on 11/01/11, 11/02/11, and 11/03/11 self-propelling her wheelchair to and from the dining room for breakfast between 7:30 A.M. and 8:30 A.M. On 11/02/11 at 4:30 P.M. the director of nursing verified no investigations were conducted regarding the above two incidents nor any staff education/training initiated. On 11/03/11 at 7:30 A.M., assistant director of nursing (ADON) was interviewed regarding the two incidents. She reported no investigations or facility inservicing/education was conducted following either incident. Also, the wheelchair transfer on 08/11/11 occurred with an STNA who was from an agency. The ADON reported the facility no longer uses agency personnel. On 11/03/11 at 9:20 A.M., STNA #100 was interviewed. She confirmed she had given Resident #149 a shower. Then she applied lotion to her legs and when attempting to apply the TED hose, her skin split open. She stated her legs were extremely [MEDICAL CONDITION] at the time. When asked if it was standard protocol to apply lotion before applying TED hose, she stated, "I don't know, I just do it. Some aides apply powder." She confirmed no additional training or inservicing followed after the incident. Review of the personnel file for STNA #100 revealed she had been employed at the facility for [AGE] years and had not had any corrective action since 2003. On 11/03/11 at 11:30 A.M., the director of clinical education (DCE) was interviewed. She reported the facility did not conduct any inservice education regarding application of compression stockings. She reported they were not trained to apply power or lotion before application of the stockings. Also, the DCE reported STNA should have the nurses assess resident to see if compression stockings may need to be replaced with ace wraps to address excessive lower extremity [MEDICAL CONDITION]. The DCE was not aware of any inservicing on resident transfers following the incident on 08/11/11.