Every finding on record at Knolls of Oxford

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, medical record review, incident report review, review of witness statements, staff interview, and review of facility corrective action documentation, the facility failed to ensure residents who require staff assistance and use of a mechanical lift for transfers were safely transferred without injuries. Actual harm occurred to Resident #4 on 07/24/25 when two staff members were transferring the resident using a mechanical (Hoyer) lift, when during the transfer, one of the staff members pressed a wrong button causing the resident to fall out of the lift. Subsequently, Resident #4 sustained a laceration to the back of the right leg which required an emergency room (ER) visit to obtain four internal stitches and 10 external stitches. This affected one (#4) of two residents reviewed for accidents. The census was 44. Findings include:Review of Resident #4's medical record revealed an admission date of 01/11/16. Diagnoses included generalized weakness and unsteadiness on the feet with a need for assistance with personal care.Review of the annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/17/25, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment revealed the resident was dependent on chair-to-bed and bed-to-chair transfers. Review of Resident #4's care plan revealed a focus area revised 11/19/24 which indicated the resident had the potential for harm/injury related to falls. Interventions directed staff to transfer the resident with a mechanical (Hoyer) lift with two staff.Review of Resident #4's progress notes included a health status note dated 07/24/25 which revealed the resident had a fall at 11:15 A.M. while being transferred to the recliner in the Hoyer (lift). The resident was unsure what happened, and the certified nurse aides (CNAs) indicated the resident refused to use proper hand placement within the Hoyer lift. The note indicated Resident #4 was sent to the ER and returned to the facility with 10 external stitches and four internal stitches in the popliteal fossa (back of the knee). Review of an incident report dated 07/24/25 indicated Resident #4 had a fall during a transfer in her room. Licensed Practical Nurse (LPN) #1 was called to the resident's room, and she observed the resident lying on her left side in front of the recliner. Further review revealed a skin tear was observed on the back of the resident's right leg at the popliteal fossa when emergency medical services (EMS) staff were transferring her. The resident was sent to the ER for evaluation of a skin tear to the back of the right knee and received 10 external stitches and four internal stitches. The report indicated recommendations were to encourage and educate the resident on proper hand placement during mechanical lift transfers.Review of CNA #2's witness statement as part of the 07/24/25 incident report revealed she was transferring Resident #4 to the recliner, and the resident did not have proper positioning of her arms in the mechanical lift sling and as a result, the resident slid through the mechanical lift sling. Review of CNA #3's witness statement as part of the 07/24/25 incident report revealed Resident #4 would not put her hands in the proper position in the mechanical life sling, and while moving the resident to the chair, the resident fell through the mechanical lift sling, hitting the floor. During an interview on 12/10/25 at 1:45 P.M., CNA #3 stated she usually worked on the assisted living side but would pull shifts if needed on the long-term care (LTC) side. She stated she never used a mechanical lift before and was training with CNA #2, who told her what to do for the mechanical lift. CNA #3 stated she did what she (CNA #2) told her to do step-by-step, and as they were bringing Resident #4 off the bed to sit in the recliner, the resident flipped backwards. She stated she did not know what happened. During an interview on 12/10/25 at 2:47 P.M., CNA #2 stated when she and CNA #3 went to put Resident #4 in her recliner for lunch, they put the pad under the resident and lifted her. CNA #2 stated while moving the resident to the recliner, she pushed the wrong button which put the resident in a lying position instead of a sitting position, so the resident went back farther and flipped out of the sling. During an interview on 12/11/25 at 9:35 A.M., CNA #2 stated she was very upset when Resident #4 flipped out of the sling, and she must have forgotten she pushed the wrong button until later. CNA #2 stated the resident's arms were in the wrong place because they wanted the resident to hold on to the bar in front of her, but Resident #4 would not, and they went ahead and moved the resident because it was not required for her to hold on to the bar. CNA #2 stated it was her fault for pushing the wrong button and she did not mean to do it and felt really bad that it happened.During an interview on 12/10/25 at 3:12 P.M., LPN #1 stated one of the CNAs said a nurse was needed in Resident #4's room, and she observed the resident on her left side in front of the recliner. LPN #1 stated she assessed the resident for any injuries while calling 911 from the resident's room because she did not want to move the resident. LPN #1 stated once the emergency medical technicians (EMTs) arrived and put a cervical collar on Resident #4, they noticed bleeding to the back of the resident's right leg when they moved the resident and turned her onto her back and saw the tear. LPN #1 stated they determined the laceration was from the sling, and the resident said she thought she caught her leg on the sling. LPN #1 stated when she walked into the room, she was very confused at what happened because Resident #4 was on the floor, but the sling was still attached to the machine. She stated the CNAs told her the resident did not have her arms in the right place and slid out of the sling. During an interview on 12/11/25 at 8:20 A.M., LPN #1 stated she was not told the CNA (#2) pushed the wrong button, and with that information the fall made more sense. LPN #1 stated if she had known, she would have initiated a different intervention of reinstructing the CNAs with a return demonstration. Observation and interview on 12/11/25 at 2:05 P.M., CNA #2 entered Resident #4's room with LPN #1 and LPN #4 to demonstrate how Resident #4 was moved and the placement of the CNAs during the transfer on 07/24/25. CNA #2 stated she was in front of the resident, guiding the machine, and CNA #3 was at the resident's head trying to get the mechanical lift legs to move to get around the recliner. CNA #2 stated she had Resident #4 half-reclined while moving her from the bed to the recliner, and when she went to put the resident in a sitting position for the recliner, she hit the wrong button and the resident started going the other way. Before she realized it, the resident flipped out, and CNA #3 was not able to stop the resident from falling. During an interview on 12/11/25 at 8:54 A.M., the Director of Nursing (DON) stated she had MDS Nurse #10 assess Resident #4's room after the fall. The sling was still attached, and the mechanical lift was working properly. The DON stated she was told the resident did not have her arms in the proper position, and that was the only thing that was out of the ordinary, so that was what the facility put as the cause of the fall, and she ensured they retrained the staff. The DON stated she had not been told the CNA (#2) hit the wrong button, and the fall made more sense after knowing that information. She stated the facility did not have any other incidents or accidents involving a Hoyer lift. During another interview on 12/11/25 at 4:40 P.M., the DON stated if she had known about the CNA pushing the wrong button, she would have written the CNA up, done more extensive training with her with a return demonstration, and would still have educated the rest of the staff. During an interview on 12/11/25 at 4:32 P.M., MDS Nurse #10 stated she went in with the DON to assess the root cause after Resident #4's fall, and remembered the lift was working, it was the appropriate sling, and it was still attached to the lift. She stated she could not remember what they determined was the root cause. MDS Nurse #10 stated if she had known the CNA (#2) pushed the wrong button, they would have implemented different interventions. She stated she would have provided one-to-one training with the CNA with return demonstration and then ensured all the other staff were properly educated. During an interview on 12/11/25 at 4:15 P.M., the Executive Director (ED) stated she felt Resident #4's fall from the mechanical lift was an accident by the information the facility had. She stated the DON and MDS Nurse #10 went in and assessed the situation and determined the lift was working properly, they had the proper sling, and there were two staff present. The ED stated the statements indicated Resident #4's hands were in the wrong position. She stated CNA #2 was very upset by the whole ordeal because she cared for her residents so much and did not mean for it to happen, and it was CNA #3's first day so she was freaked out. The ED stated she was not aware the wrong button was pushed. She stated CNA #2 was one of the facility's best CNAs and was their trainer for the lifts. She stated she was disappointed to hear she did not get the whole story about the incident.Review of a facility policy titled, Lifting Machine, Using a Mechanical, revised 09/23/19, revealed the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device. Included in the steps for the procedure was for staff to test the lift controls, place the sling under the resident, visually check the size to ensure it was not too large or too small, slowly lift the resident, only lift as high as necessary to complete the transfer, and when the transfer destination was reached, slowly lower the resident to the receiving surface.As a result of the deficient practice the facility has implemented corrective action as of 08/01/25 as follows:- During an interview on 12/10/25 at 4:46 P.M., the DON stated she did an in-service on mechanical lift after the incident in July 2025. She stated she contacted the mechanical lift representative, and they sent her a training video that she had all the nursing staff watch. She stated the training started on 07/30/25 and went through 08/01/25.- During an interview on 12/11/25 at 4:15 P.M., the ED stated they did education with the staff after it occurred and it was discussed in Quality Assurance Performance Improvement (QAPI), where they determined that they would have a nurse sign off on the competencies and not just the CNA trainer. She stated they were monitoring monthly in QAPI, and they had not had any further incidents with the mechanical lifts. - After review and verification of the facility's corrective actions, including the facility's investigation, staff education, and interviews with staff, the survey team determined the facility implemented the above corrective actions beginning on 07/30/25.This deficiency represents non-compliance investigated under Master Complaint Number 2680033 and Complaint Number 2615466.

Based on observation and staff interview, the facility failed to post nurse staffing information as required. This had the potential to affect all 49 residents residing in the facility. Facility census was 49. Findings include: Observation on 11/30/23 at 11:30 A.M. of the Health Care Pavilion Staffing Guide posted at the nurse station, revealed the posting was dated 05/18/23. Interview on 11/30/23 at 1:31 A.M. the Director of Nursing, (DON) verified the posted Health Care Pavilion Staffing Guide was the facility's daily posting of staffing information for residents and visitors. The DON verified the posting was to completed daily and the last daily staffing information, dated 05/18/23, was posted by the Scheduler #70. The DON had no knowledge of why the daily staffing information had not been posted since May 2023. Interview on 12/04/23 at 10:42 A.M., Scheduler #70 verified the daily staffing information had not been posted since May 2023 and records had not been maintained over the past six months. Scheduler #70 stated she had stopped posting the daily staffing information because it was difficult to adjust the daily staffing numbers when staff did not come to work. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a no smoking/oxygen in use sign was posted for a resident receiving oxygen therapy. This affected one (#46) of one residents reviewed for respiratory care. The facility identified 14 residents receiving oxygen therapy. The resident census was 55. Findings include: Medical record revealed Resident #46 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment revealed she had a cognition impairment and required the assistance of staff with her activities of daily living. Review of physician orders [REDACTED]. Observation on 09/10/18 at 10:45 A.M. revealed Resident #46 was receiving two liters per minute of oxygen therapy via nasal cannula. There was no smoking/oxygen in use sign was not on the door. On 09/11/18 at 3:10 P.M. the resident was sitting in her room chair with the oxygen concentrator beside her. The resident said she last used oxygen at lunch time today and she usually used oxygen at night. On 09/11/18 at 3:30 P.M. Licensed Practical Nurse (LPN) #325 said the resident used oxygen PRN (as needed). The nurse checked the residents' oxygen saturation levels PRN. LPN #325 verified the resident did not have a smoking/oxygen in use sign on her door. LPN #325 said the physician had recently ordered the oxygen therapy. On 09/11/18 at 3:42 P.M. State tested Nurse Aide (STNA) #330 stated the resident used the oxygen at night and sometimes during the day. A review of the Oxygen Administration policy (undated) was conducted. This policy instructed No Smoking/Oxygen in Use signs were to be used.

Based on record review and staff interview, the facility failed to implement timely interventions for a resident with a significant weight loss. This affected one (#17) out of two residents reviewed for nutrition. The facility census was 55. Findings include: Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #17's Comprehensive Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident has severe cognitive impairment and requires extensive assist with all activities of daily living including dressing, toilet use, personal hygiene and eating. Review of the resident's weight log revealed the resident's weight on 08/06/18 was 167.4 pounds and on 09/03/18 the residents weight was 157.6 pounds indicating a weight loss of 5.85% in twenty-eight days. Further review of Resident #17's medical record revealed no documentation related to the significant weight loss, from 09/03/18 to 09/12/18. On 09/12/18 at 9:04 A.M., during an interview Licensed Practical Nurse (LPN) #301 revealed the Licensed Dietician Registered Dietician (LDRD) #200 was in the facility on 9/11/18 and requested the resident be re-weighed, no new orders for dietary interventions were given for Resident #17 at that time. LPN #301 stated the resident was re-weighed on 09/12/18 and weighed 157.8 pounds, LDRD #200 was notified and new orders were given for two nutritional supplements for Resident #17: Ensure Plus 120 milliliters (mls) twice daily, and Magic Cup with lunch and dinner. Review of the Clinical Notes dated 09/12/18 at 10:18 A.M., LDRD #200 documented Resident reviewed, resident re-weight obtained today at 157.8 pounds which verifies weight of 157.6 pounds obtained on 09/03/18 and indicates a significant weight loss of 5.7% in one month. Current body Mass Index (BMI) of 30.9 indicating obesity. On 09/13/18 at 10:54 A.M. during an interview LDRD #200 confirmed nutritional interventions for Resident #17 were not implemented on 09/03/18 when the significant weight loss was discovered.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure one residents's (#34) glucometer was cleansed and disinfected appropriately. This occurred when the glucometer was cleansed with an alcohol pad after use. This affected one resident (#34) of one sampled residents for glucometer cleansing. This had the potential to affect three (#34, #3 and #45) residents who had glucometer monitoring on the Memory Support Unit and shared the device. The facility census was 55. Findings include: Review of Resident #34's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 09/12/18 at 4:20 P.M. Licensed Practical Nurse (LPN) #301 removed a bag from the medication cart that contained alcohol pads and the residents' glucometer. The nurse said she cleansed the glucometer after use with an alcohol pad. LPN #301 conducted a fingerstick blood glucose sample from Resident #34 finger. At 4:33 P.M. when she went to clean the glucometer prior to putting it back into the medication cart, the nurse wiped it down with an alcohol pad. On 09/12/18 at 4:35 P.M. an interview with the Director of Nursing (DON) revealed the glucometer should have been cleaned after use with the disposable germicidal cleansing wipes. He affirmed the facility policy for Glucometer Cleaning attested to this instruction. The facility confirmed this had the potential to affect the three (#34, #3 and #45) residents who share the glucometer. A review of the Glucometer Cleaning Policy dated 10/15/17 was conducted. The policy instructed the glucometers used for testing (active) residents' blood sugars will be cleansed after each use with the disposable germicidal cleansing wipes. The procedure instructed to wipe the exposed surfaces of the glucometer using the disposable germicidal surface wipes for four minutes. Allow the meter to dry on a clean surface.

Based on observation, record review, staff list review and staff interviews, the facility failed to ensure staff education and follow up was provided to nursing staff after an infection trend was identified. The facility also failed to ensure clean and dirty linen was kept separated to lower the risk of cross contamination and separate biohazard material from clean linens. This had the potential to affect 49 of 49 residents. Findings include: 1. Review of Facility Infection Control Tracking forms from September 2016 through September 2017 revealed three E-Coli (a bacterium that lives in intestines) urinary tract infections (UTI) listed in the month of August 2017 and four in September 2017. Interview with Licensed Practical Nurse (LPN) #98 on 11/07/17 at 11:45 A.M. stated all facility infections were listed on the Infection Control Tracking Forms. The information was obtained from facility morning meetings and weekly Interdisciplinary Team meetings. Interview on 11/08/17 at 11:50 A.M. with Registered Nurse (RN) #16 reported she provided staff education and revealed the last infection control education was held in February 2017. RN #16 denied knowledge of monthly infection tracking log and reported she does not attend Quality Assurance meetings. Interview with the Director of Nursing (DON) on 11/08/17 at 12:00 P.M. stated a nursing in-service on perineal care was held on 09/01/17 due to Quality Assurance Committee (QA) identified infection trend caused by E-Coli. The DON provided Chapter 16 Perineal Care form dated 09/01/17, which revealed 18 sets of initials whom the DON reported were the initials of the state tested nursing assistants (STNA's) whom attended the in-service. The DON verified four E-Coli UTI's were identified in September after his in-service and stated no further education or follow up was done. Review of Human Resource - Employee Listing found 17 LPN's and 37 STNA's worked at the facility. 2. During tour of the facility laundry rooms on 11/08/17 at 12:20 P.M. with the DON, observation was made of washers and dryers sitting side by side in laundry rooms on South hall, West hall, and in the Memory Care unit. Each laundry room had a small flat surface with clean and dirty clothes present. A small refrigerator with a biohazard sticker on the door was located in the west hall laundry room. Isolation carts were observed in laundry rooms on South hall and Memory Care which the DON reported were stored and brought out for use as needed for residents on isolation precautions. Interview with the DON, at the time of the observation, verified housekeeping staff brought dirty linen into the laundry room in bags and fold or hang clean clothes in same area without a separate area used. The DON also stated personal laundry from an isolation room was laundered the same as all other personal clothes without additional precautions. The DON reported the refrigerator with the biohazard sticker in the west hall laundry room was for potentially infectious specimens awaiting lab pickup.

Based on observations, review of the dietary spreadsheet/menu, review of a dietary listing and staff interview, the facility failed to ensure the pre-planned spreadsheet/menu included portion sizes for mechanically altered meat affecting 20 residents (#6, #7, #18, #24, #27, #31, #35, #36, #38, #40, #44, #45, #48, #49, #60, #64, #68, #72, #78 and #98) who received mechanically altered diets. Additionally, the facility failed ensure residents on regular and mechanical diets received the preplanned portion sizes of the main entree at lunch affecting four (#35, #58, #64 and #65) of eleven residents on the secure memory care unit. Facility census was 49. Findings include: 1. Observation on 11/07/17 at 1:39 P.M. revealed Server #402 served cheese coneys at the lunch meal. Server #402 plated the food for the mechanically altered diets with three ounces of the mechanically altered meat. Review of the Diet Spreadsheet dated 11/07/17 that was used by Server #402 to plate the food listed the hot dog portion for the regular diet as 1 & 1 oz C. The pureed and ground coneys also listed 1 & 1 oz C. During an interview on 11/07/17 at 1:39 P.M., Director of Food Service #94 reported the amount served for the lunch meal was one hot dot with one ounce of coney sauce. Director of Food Service #94 confirmed the spreadsheet, prepared by the dietician, did not contain the amount of mechanically altered meat to be served with the meal and stated the staff were instructed to just serve three ounces. Review of a dietary list revealed 20 residents (#6, #7, #18, #24, #27, #31, #35, #36, #38, #40, #44, #45, #48, #49, #60, #64, #68, #72, #78 and #98) received mechanically altered diets. 2. During observation of lunch service in the Memory Unit on 11/06/2017 at 12:55 P.M. staff member #75 served entrees to four residents (#35, #58, #64 and #65). Staff member #75 stated she used a #12 scoop for the vegetable lasagna entrée and replied she just guessed when asked how she knew which scoop she was to use when interviewed on 11/06/17 at 1:00 P.M. The interview with staff member #94 on 11/06/17 at 1:05 P.M. revealed the four residents (#35, #58, #64 and #65) served with #12 scoop had diet slips indicating six ounces of entrée were to be served. Staff member #94 verified a # 12 scoop was only three ounces and two scoops were to be served to each resident. Review of facility Dietary Spreadsheet Fall/Winter Week 5 revealed six ounces of Lasagna-vegetable was indicated for regular, regular mechanical, and pureed diets.

Based on record review and staff interview, the facility failed to ensure residents were provided with a two day notice when Medicare skilled services were terminated. Additionally, the facility failed to issue a resident the Skilled Nursing Advanced Beneficiary Notice (SNFABN) or one of the five denial letters when a resident was cut from Medicare skilled services and the resident remained in the facility. This affected one (#13) of three resident medical records reviewed. The facility identified two current residents receiving skilled Medicare services. The facility census was 49. Findings include: Review of Resident #13's medical record revealed the resident was admitted on [DATE] and received skilled care. [DIAGNOSES REDACTED]. Further review of Resident #13's medical record revealed a Notice of Medicare Non-Coverage with a signature of Resident #13 dated 08/08/17. The medical record indicated Resident #13's last cover day for Medicare was 08/09/17 and the resident remained in the facility after skilled service ended on 08/09/17. Further review revealed Resident #13 was not issued the SNFABN or one of the five denial letters giving the resident the right to a demand bill. Interview with Facility Staff #102 on 11/08/17 at 9:02 A.M., verified Resident #13 had remained in the facility after skilled services were completed. Facility Staff #102 states Resident #13 had Part A days remaining and was discharged due to plateau of progress. Staff person #102 denied presence of any other notices provided to Resident or their representative. Facility Staff #102 also confirmed the resident was not provided with a two notice prior to the cut in services.

Based on observation, record review, resident and staff interviews, the facility failed to ensure and provide adequate supervision for one resident who had behavior occurrences. This affected one (#41) of three residents reviewed for supervision. The current census was 49. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Plan of Care (P(NAME)) initiated 09/14/17, identified Resident #41 as wandering into other's rooms and getting into their belongings. Interventions included take resident to a quiet area for one on one interactions to reduce stimulation, encourage use of distraction, techniques one on one activity, food, fluids, music, and television, allow resident to vent feelings as needed, praise resident for positive behaviors, redirect resident out of others' rooms as needed; offer snacks, reading material or old movies and listening to old county music and observe Resident #41 whereabouts frequently during shift. Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #41's Brief Interview of Mental Status (BIMS) Summary Score of 4 which indicated the resident had severe cognitive impairment. Resident #41 required extensive assistance with bed mobility, transfer and toileting; and one-person physical assistance with personal hygiene and dressing. Review of clinical notes dated 06/23/17, revealed Resident #41 was going into another residents' room but was effectively redirected. On 09/05/17, clinical notes revealed Resident #41 was trying to pull flowers off the nurse's station counter and took her wheel chair to tried to run over another resident's toes, Resident #41 also took binder off nurse's station and ripped pages out of it and would not give the book back to staff. On 11/04/17, Resident #41 wandering up and down hallways and was easily redirected. On 11/05/17 at 12:20 A.M., Resident #41 was being pulled out of another resident's room. On 11/05/17 at 11:23 P.M., revealed the resident went into room 113. Resident in room 113 stated her clock was missing. Observation on 11/07/2017 at 2:56 P.M., revealed Resident #41 in wheelchair going into another resident's room. Licensed Practical Nurse (LPN) #30 wheeled Resident #41 out of room and gave her a baby doll. Observed on 11/07/2017 at 3:03 P.M., revealed Resident #41 was following LPN #20 and LPN # 30 but went into another resident's room. Activity Staff #40 wheeled resident to the activity room. Interview on 11/09/17 at 3:00 P.M. with State tested Nursing Assistant (STNA) #303, revealed Resident #41 appears to be confuse and disoriented. She seems to be lost. STNA #303 stated there are about three residents that have been complaining about Resident #41 coming into their rooms. The facility has put up a mesh stop signs across those residents' doors to keep Resident #41 out. STNA #303 has witnessed Resident #41 in one of the resident's room about two weeks ago with the mesh stop sign on the side of the door. STNA #303 has not seen Resident #41 physically take the sign off the door. STNA #303 stated Resident #41 is easily to be redirected but it does not last long. Interview on 11/07/17 at 12:08 P. M., with Resident #13 revealed she has been complaining to the facility about Resident #41 entering her room without permission. Resident #13 stated she has brought her concerns up with Administrator and Director of Nursing (DON). Resident #13 believes that the facility is not protecting her things. Resident #13 stated she has witness Resident #41 take down the mesh stop sign and proceed on into their rooms. Interview on 11/08/17 at 11:35 A. M., with the Administrator and the DON revealed they are aware of the situation with Resident #41 wandering into other residents' rooms. The facility has a Memory Unit but family is apprehensive of placing Resident #41 there due to memories of spouse passing away in that unit.

Based on observation and staff interview, the facility failed to ensure expired milk was discarded and to change gloves in between contaminated surfaces and food. This had the potential to affect 54 of 54 residents who receive meals from the facility kitchen in a census of 55. Findings include: 1. Observation on 08/22/16 at 9:47 A.M. of the refrigerator in the kitchen revealed there were 18 one pint containers of white milk with an expiration date of 08/21/16. Further observation on the skilled unit in the refrigerator revealed there were nine one pint containers of chocolate milk with an expiration date of 08/21/16. Observation on the memory care unit in the refrigerator, there were five one pint containers of chocolate milk with an expiration date of 08/21/16. Interview with the Dietary Manager (DM) #12 on 08/22/16 at 10:00 A.M. verified the milk in the kitchen refrigerator, skilled unit and memory care unit had expired on 08/21/16 and should have been discarded. 2. Observation on 08/24/16 at 9:13 A.M. of the tray line on the memory care unit, revealed kitchen worker (KW) #17 washed her hands when coming into the kitchen and applied gloves. She proceeded to unload the hot cart with gloved hands and placed the hot items into the steam table, she then proceeded to use an alcohol swab to clean off the probe of the thermometer and take the temperatures of the steam table food and used her gloved hands to write the temperatures on the temperature log. KW #17 continued to have her same gloved hands to handle the plates, getting jelly packets out of drawers, and placed her gloved hands on the counter tops of the the kitchen. She took her same gloved hands and removed four slices of wheat bread out of the package and placed them into the toaster. KW #17 proceeded to take the four pieces of wheat toast out of the toaster and placed them on a plate. KW #17 used a knife to cut the toast in half with the same gloved hands. Interview on 08/24/16 at 9:30 A.M. with KW #17 verified she did not change her gloves in between touching contaminated surfaces and food that was being prepared for the residents.

Based on observation, interview, and policy review, the facility failed to ensure cooking utensils were stored clean, in a clean environment and that staff observed hand washing and changing soiled gloves when handling food items. This affected all 54 residents receiving nutrition from the kitchen. Findings include: On 11/05/12 at 8:45 A.M. an initial tour of the facility's main kitchen was done with the Director of Food Service (DFS) #8. He explained the facility has three dining rooms that are served from the main kitchen. Observation of the inside of a utensil drawer containing scoops and serving utensils was found to be sticky with dried substances and dried residue of food particles. A second drawer containing scoops and serving utensils revealed the utensils were wet and tan colored water had collected in the corner of the drawer. Observation of 2 stacks of aluminum pans revealed 4 pans were stacked wet, with visible droplets of water inside the pans, 4 aluminum stock pans were heavily dented, one of which had hardened food inside of it. These observations were made with the DFS #8 who verified them. A cart of clean dishes was verified as being placed next to dirty dishes in the dirty area. Tour of the skilled dining room pantry area revealed a tray of clean coffee cups in the dirty area, one of which had been soiled with coffee. Observation of the memory units juice machine revealed the tray assembly area was dirty and the area behind the tray had a build up of slimy like debris. On 11/0712, at 8:30 A.M. the memory unit breakfast meal was observed. The two servers #9 and #14 were observed applying gloves after washing their hands. As the meal service progressed, server #9 was observed wearing the same gloves to open cabinets and drawers in order to get dishes, utensils, and bowls, and then picking up a Danish from a box with his gloved hand and placing them on the individual plates. The second server #14 was observed leaving the kitchen area with her gloves on, putting in the code on the pantry door, going in to get items from the pantry and refrigerator, and then returning to the kitchen. Without removing her gloves, she reached inside the bread container, placed the bread in the toaster, and handled it with the same gloves she had on earlier. She also was observed to get a jar of peanut butter from the cabinet, pick up the bread, and prepare a peanut butter sandwich with the same gloves on she had been wearing during the whole breakfast server. The two servers left the memory unit, and entered the north dining room after the service was over. Prior to entering the north dining room both servers removed their gloves and washed their hands. In setting up the north dining room for breakfast, the two servers put gloves on and began to set up the area to serve the breakfast meal. The north dining room meal service was also observed with dietary staff #15. She verified the servers were opening drawers, going into the pantry via the coded door, and upon returning handling bread with the same gloves on. She acknowledged they had no utensils to pick up the food items, and were using their gloved hands. Interview with server # 9 verified he was using his gloved hand to pick up Danish rolls, and was not changing his gloves and washing his hands when he went from one task to another. Review of the facility gloves policy indicated gloves will be worn to maintain safe and sanitary food preparation, and proper utensils will be used for food handling.

Based on record review and staff interview, the facility failed to ensure one (#60) resident of ten residents reviewed for unnecessary medications received insulin as ordered resulting in a significant medication error. The resident received insulin for over 4 months at bedtime without an order. The facility identified fourteen residents who were prescribed insulin. The census was 54. Findings include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 06/28/12, 06/29/12, 07/01/12 thru 07/30/12, 08/01/12, 08/03/12 thru 08/31/12, 09/01/12 thru 09/30/12, 10/01/12 thru 10/31/12 and 11/01/12 thru 11/04/12 at 10:00 P.M. without a physician's orders [REDACTED]. During interview on 11/08/12 at 11:40 A.M., the Director of Nursing (DON) confirmed Resident #60 received [MEDICATION NAME] R Insulin at bedtime during the period 06/28/12 until 11/05/12 without a physician's orders [REDACTED]. The DON explained that the nurse who transcribed the [MEDICATION NAME] Regular Insulin order's on 06/28/12 from the physician's admission orders [REDACTED]. The DON confirmed the physician admission order's dated 06/28/12 indicated Resident #60 was supposed to receive [MEDICATION NAME] Regular Insulin coverage before meals only and not at bedtime. Review of Medication Error Report indicated that on 11/06/12 Registered Nurse #10 reported the error to the DON. The DON confirmed he was unaware of the medication error until it was found by the surveyor. The DON explained that a nurse was assigned the responsibility to check each new month's MAR indicated [REDACTED]. The DON confirmed the nurses responsible for changeover in June, July, August, September, October and November 2012 had not ensured the monthly electronic MARs were correct.

Based on record review and staff interviews, the facility failed to accurately assess residents for hospice care. This affected three (#43, #39, and #46) of four residents sampled for hospice care. The facility identified five residents currently on hospice care in the facility. Findings include: 1. Record review revealed Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was admitted to Hospice care on 05/20/08. A review of the Activity of Daily Living Plans of Care revealed care was provided by the Hospice Aide two days a week. The Annual Minimum Data Set ((MDS) dated [DATE] contained no assessment for Hospice care. On 07/21/11 at 12:33 A.M., an interview with Registered Nurse (RN) # 45 confirmed the Hospice part of the MDS should have been completed for Hospice services. She confirmed the resident was a recipient for Hospice services. 2. Record review revealed Resident #39 was admitted with [DIAGNOSES REDACTED]. The resident was admitted to Hospice care on 01/02/10. A review of the Activity of Daily Living and Psychosocial Plans of care addressed the services provided by Hospice. The last two Annual MDS assessments dated 07/01/10 and 06/01/11 contained no assessment for Hospice care. On 07/21/11 at 12:33 P.M., an interview with RN # 45 confirmed the MDS were not completed with the Hospice assessment. RN #45 stated both MDS should have the Hospice assessment completed since the resident was a Hospice recipient. 3. Record review revealed Resident # 46 was admitted with [DIAGNOSES REDACTED]. The resident was admitted to Hospice care on 05/23/11. A Plan of Care dated 05/23/11 was in place. A review of the significant change MDS assessment dated [DATE] contained no assessment for Hospice care. On 07/21/10 at 12:30 P.M., an interview with RN #45 confirmed the Significant change MDS dated [DATE] was completed when the resident became a recipient of Hospice care. RN #45 confirmed the assessment for Hospice care was blank. RN #45 revealed the Hospice assessment was missed on the residents and was not marked in error.

Based on record review, observations, staff and resident interview, the facility failed to ensure Resident # 24 received an eye drop ordered by her physician after a surgical procedure was performed to the eye. This resulted in a significant medication error for one (#24) of two residents who received eye drops during medication pass. The facility identified twenty residents receiving eye drops. Findings include: Review of Resident # 24 accumulative [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] revealed the resident was mildly cognitively impaired and required extensive assistance of one staff with all care. Review of the physician's progress notes dated 02/01/11 documented the resident had an intravitreal injection of a medication to help to correct age related [MEDICATION NAME] degeneration. Review of the nurses notes for 04/21/11 documented the resident went out with her son to the eye doctor to have the surgical procedure to her eye. The nurses notes dated 04/21/11 at 6:23 P.M. documented the resident returned with a physician's orders [REDACTED]. The order was faxed to the pharmacy. Review of the physician's orders [REDACTED]. Review of the April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Observation of Resident # 24 07/20/11 at 2:30 P.M. revealed she was seated in her recliner in her room. The resident stated she had the procedure on her eyes and the nurses forgot to give her eye drops. Interview with the Director of Nursing (DON ) 07/20/11 at 3:00 P.M. revealed the resident did not get her eye drops as ordered . The DON noted it was a transcription error and was never put on the MAR. He stated the eye doctor was notified on 04/25/11 of the omitted eye drops and stated if the resident had no signs and symptoms of infection, they could discontinue the eye drop order. He noted the physician was called and stated if no signs or symptoms of infection were present to stop the order Review of the medication error investigation 07/20/11/ at 3:15 P.M. documented the error was not found until second shift on 04/24/11. The resident did not receive any of the antibiotic eye drops as ordered. This deficiency substantiates Complaint Number OH 663.

Based on observation and interview, the facility failed to ensure that water temperatures on the Memory Care unit and the Rehabilitation Unit were maintained below 120 degrees Farenheit. This affected two (Memory Care and Rehabilitation) of four hallways and and one room, on the Rehabilitation Unit. This had the potential to affect four (#9,#10,#4,#5) of twelve residents that resided on the memory care unit and one resident (#20) of twelve that resided on the Rehabilitation Unit. Findings include: During the general environmental tour on 05/19/10 11:15 A.M. the water temperature on the Memory Care Unit in the bathroom sink of room 232 and in the kitchenette sink measured 130 degrees Farenheit. Maintenance staff #25 arrived and measured the temperature in the kitchenette sink with his laser thermometer. He measured 124 degrees Farenheit. He verified that the thermometer used by the surveyor was calibrated at the time of the measurements and read 32 degrees Farenheit in a slurry of cold water mixed with crushed ice and that the calibrated thermometer read 130 degrees Farenheit under the hot running water in the kitchenette sink. He placed his hand under the water and stated that it felt hot. Observation of the boiler room and the hot water heater and holding tanks on 05/19/10 at 11:35 A.M. revealed that the hot water tank was in the service hallway next door to the Memory Care Unit and between the Memory Care Unit and the Rehabilitation Unit. The hot water heater temperature gauge read by Maintenance staff #25 was 130 degrees Farenheit and the holding tank temperature gauge read 170 degrees. Measurement of the water temperature in bathroom sink in room 135 on the Rehabilitation Unit on 05/19/10 at 11:40 A.M. revealed 128 degrees Farenheit,. and the Spa room next to Resident room 116 measured 124 degrees Farenheit in the sink at 11:45 A.M. Review of the manufacturers specifications and the attached cover letter received 05/19/10 from the application engineer for Instrument regarding the Raytek MT4 laser thermometer (used by the facility), stated the Raytek MT4 had an emissivity of .95 and water had an emissivity of .93 making it suitable for measuring the temperature of water, assuming the spot size was appropriate for the surface being measured. Maintenance staff #25 did not explain the statement or comment on "spot size". On page two, under the heading Introduction, it stated to aim, pull the trigger and read current surface temperatures in less than a second. It went on to state that you could safely measure surface temperatures of hot, hazardous, or hard to reach objects without contact. Under the heading How It Works, it was written that infrared thermometers measure the surface temperature of an object. Interview of Maintenance staff #25 at the time of the observations revealed that he monitored water temperatures randomly three times a week and had not obtained measurements above 120 degrees Farenheit. He stated that the temperatures were not recorded and no log was available for review. He stated that he always used the laser thermometer and was not aware of any discrepancies in it's measurement. He aimed and measured the water temperature at different heights in the stream of water and received readings that varied from 112 degrees to 124 degrees Farenheit. Interview of Licensed Practical Nurse #11 on 05/19/10 at 11:15 A.M. revealed that the Memory Care Unit had a census of 12 residents. She stated that no residents were observed near the sinks and no residents had suffered from burns. She verified that two current residents (#9, #10) were ambulatory and that two (#4, #5) were able to propel themselves about the unit and had access to the water in resident bathrooms and the kitchenette sink. Interview of the Administrator on 05/20/10 at 8:35 A.M. confirmed that one of two boilers had been shut down on 05/19/10 and the temperatures had improved measuring from 110-112 degrees Farenheit on the evening shift of 05/19/10 and the morning of 05/20/10. He verified that logs of the boiler temperatures were kept but no room temperatures were logged prior to 05/19/10. He stated that there was a ten degree difference in temperature measurements between the facility's laser thermometer and the facility's digital thermometer and the laser thermometer was no longer in use.

Based on observation, staff interview, review of the manufactures recommendations for cleaning glucometer, review of the Centers for Disease Control (CDC), recommended Infection Control Safe Injection Practices to Prevent Patient to Patient Transmission of Blood Borne Pathogens, review of the facility's policy on Fingerstick glucose Level and review of the Journal of Diabetes Science and Technology, the facility failed to clean and disinfect glucometers between resident use to prevent the potential transmission of disease and exposure to blood-borne pathogens. This involved two (#16, #15) of nine residents identified with [DIAGNOSES REDACTED]. Findings include: Review of physician orders [REDACTED]. Resident #15 with [DIAGNOSES REDACTED]. Observation on 05/18/10 at 9:00 A.M., Licensed Practical Nurse (LPN) #10 removed a soft sided, zippered case, containing a glucometer along with test strips and lancets from a drawer of the medication cart. LPN #10 inserted a test strip into the glucometer and with the lancet took them into Resident #16's room. LPN #10 donned a pair of gloves, cleaned the resident's finger with an alcohol pad and fanned the finger dry with her gloved hand. LPN #10 then pricked the resident's finger with a lancet. LPN #10 squeezed the resident's finger and expressed a droplet of blood. She touched the test strip to the droplet of blood and waited for the results of the blood sugar. Once the results of the blood sugar was displayed in the glucometer, LPN #10 removed the test strip from the glucometer and returned the glucometer to the soft sided zipped case. She placed the case back in the medication cart. She did not clean and disinfect the glucometer. At 11:30 A.M., LPN #10 was observed to remove the same soft sided, zippered case from a drawer on her medication cart. She repeated the same procedure on Resident #15. She used the same glucometer used on Resident #16. LPN #10 did not clean and disinfect the glucometer prior to using it on Resident #15. When questioned about when and who cleans the glucometer LPN #10 stated they are cleaned on third shift when they calibrate them. LPN #10 stated she was unaware of what was used to clean the glucometer. LPN #10 confirmed that she used the same machine on both residents and did not clean or disinfect them between residents. Review of the instructions care for the glucometers stated the meter should be cleaned with a clean, lint-free cloth damped with one of the following , OSHA approved disinfectant or 10% bleach and water. The Manufacture did not state when to clean the glucometer. According to CDC Safe Injection Practices to Prevent Resident to Resident Transmission of Blood borne Pathogens, updated 2005: Glucometers should be assigned to individual patients. If a glucometer that has been used for more then one patient must be reused for another patient, the device must be cleaned and disinfected. Review of the Journal of Diabetes Science and Technology, Volume 3, Issue 2, march 2009 revealed an article titled "Eliminating the Blood: Ongoing Outbreaks of Hepatitis B Virus Infection and the Need for Innovative Glucose Monitoring Technologies." The article reviewed and summarized reports of Hepatitis B (HBV) infection outbreaks in the United States that have been attributed to blood glucose monitoring practices, primarily affecting long term care residents with diabetes. The predominant unsafe practices included sharing of blood glucose testing meters (glucometer) without cleaning and disinfection between uses. Review of the facility's policy, 06/03/08, stated the Glucometers are disinfected daily by the 11:00 P.M. -7:00 A.M. shift. The Glucometers were to be disinfected with an approved surface disinfectant or per manufacture's recommendation. On 05/19/10 at 11:20 A.M., interview with the Director of Nursing (DON) revealed she was the infection control nurse for the facility and was responsible for the implementation, monitoring and staff education related to the infection control program. The DON stated she was unaware of the glucometer guidelines.

Based on record review and staff interview revealed that the facility failed to ensure a physicians order for an bronco [MEDICATION NAME] was administered as ordered to one resident with several hospitalization s for [MEDICAL CONDITION] and pneumonia. After not receiving the ordered [MEDICATION NAME] [MEDICATION NAME] the resident was sent back to the hospital for a third admission with pneumonia. This involved one (#56) of six residents reviewed for medications. The facility census was 53. Finding include: Resident #56 was admitted to the facility, 04/26/10, from the hospital with [DIAGNOSES REDACTED]. Included in the admission orders [REDACTED]. Review of the nursing documentation 04/29/10 at 3:00 P.M., revealed the resident was coughing up yellow colored phlegm was congested but cleared when he coughed. At 7:00 P.M., the resident was very hard to arouse. 12:20 A.M., the physician was notified of the residents status. A chest x-ray was ordered. The chest x-ray revealed that the resident had vascular congestion or plural effusion. The resident was transferred to the hospital and admitted with an [DIAGNOSES REDACTED]. On 05/07/10 at 7:30 A.M., the physician was notified Resident #56 was having an increase in congestion, his lungs when ausculted had Rhonchi. Oxygen saturation was 74% on five liters of oxygen respirations were 32 and his pulse was 113. At 7:40 A.M., the resident was administered 40 mg of [MEDICATION NAME] (diuretic) IM and sent to the emergency room . At 3:00 P.M., the hospital called the facility to inform them the resident had been admitted with an [DIAGNOSES REDACTED]. On 05/14/10 Resident #56 was sent back to the facility from the hospital. On the admitting orders was [MEDICATION NAME]/Atrovent ([MEDICATION NAME][MEDICATION NAME]) per a hand held nebulizer (machine that vaporizes liquid medication into a fine mist to be inhaled into the lungs via a mouthpiece or mask.) four times a day and as needed. A review of the medication administration record (MAR) for May revealed the resident did not receive the physician ordered [MEDICATION NAME][MEDICATION NAME]. The May MAR indicated [REDACTED].M., 12:00 P.M., 6:00 P.M., and 12:00 A.M. on 05/14/10, 05/15/10 and 05/16/10. The MAR indicated [REDACTED].M. 05/17/10 at 10:00 A.M., the nursing documentation stated the resident was having difficulty holding up his head, was a bit lethargic, his oxygen saturation level was 82% on 3.5 liters of oxygen. Coughing up green thick mucous, Rhonchi throughout all lung fields. At 1:45 P.M., the resident was not as alert and the physician was notified. The resident was again transferred back to the hospital. At 6:56 P.M., the facility was notified by the hospital the resident had been readmitted due to pneumonia. On 05/20/10 at 10:00 A.M., during a interview with the Director of Nursing (DON) it was confirmed the resident did not receive the physician ordered [MEDICATION NAME]/Atrovent HHN four times a day due to the order was transcribed on the as needed sheet for medications instead of the scheduled medications sheet. A medication error report was completed on 05/17/10 and stated the adverse reaction to the medication was a decrease in oxygen saturations and increase in shortness of breath. This deficiency substantiates complaint number OH 515.

Based on review of the facility Medicare cut letters and staff interview, the facility failed to ensure two of two residents' (#61,#62) cut letters contained specific notification of discontinuation of skilled services. The finding could potentially affect 18 residents receiving Medicare services. Findings include: Review of the Medicare cut letters provided to residents when skilled services were discontinued was completed on 05/24/10. The letters were noted to lack notification of the specific skilled services discontinued for Residents #61 and #62; the letters stated "current skilled services" will end. Resident #61 was discontinued from therapy on 05/11/10 and Resident #62 was discontinued from therapy on 05/21/10. Interview with Social Worker #45 on 05/24/10 at 3:10 P.M. verified the specific services or therapies no longer to be covered were not communicated to Residents #61 and #62. She confirmed the lack of written notification of the specific skilled services.

Based on review of the resident trust fund record and interview, the facility failed to convey funds to the Treasurer of the State of Ohio within 30 days of death for one (#60) resident. This affected one (#60) of one resident trust account reviewed for a recently deceased resident. Findings include: Review on [DATE] of one resident trust fund record for a recently deceased (Resident #60) revealed that the resident had passed away on [DATE]. A check was written by the facility on [DATE] to the State Treasurer for balance of the residents trust. During an interview on [DATE] at 11:25A.M. Business Office Staff #40 revealed that Resident #60 had passed away on [DATE] but the facility had not sent the remaining balance back to the state until [DATE]. During a second interview on [DATE] at 2:50 P.M.Business Office Staff #40 stated the facility had not sent the money back within thirty days because they believed they had the sixty days that the Ohio Revised Code allows.

Based on observation and interviews the facility failed to post the required information concerning staffing levels for Registered Nurses, Licensed Practical Nurses and Nurse Aids at the beginning of each shift and failed to maintain a record of the staffing levels as required. This had the potential to affect all 53 residents currently residing in the facility. Findings include: During the general environmental tour with the Housekeeping Manager #35 and Director of Environmental Services #30 on 05/19/10 at 2:00 P.M., posting of nurse staffing hours was not observed. Both stated that they were unaware of what was being asked. Upon request, the Assistant Director of Nursing was asked to provide the location of the nursing staff required posting. She proceeded to a chalk board that contained the names of the current staff on duty. Interview of the Assistant Director of Nursing on 05/19/10 3:20 P.M. revealed that the staff names were placed on the chalk board each shift on the Nursing Unit and on the white board on the Memory Care Unit. She stated that she was not aware of a requirement to post actual hours for specific classifications of nursing staff. She stated that daily staffing sheets were available at the nurses station but not posted for public viewing. She verified that no records had been retained that provided the required information.