Every finding on record at Lakes of Monclova Health Campus the

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure residents were treated with dignity. This affected one (Resident #3) of five residents observed during dining. The facility census was 59. Findings include:Review of the medical record for Resident #3 revealed an admission date of 01/11/22 with diagnoses of Alzheimer's disease, dementia, protein-calorie malnutrition, anxiety, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, revealed Resident #3 was rarely/never understood and was dependent on staff for eating assistance.Observation on 04/27/26 at 12:39 P.M. revealed Certified Nurse Aide (CNA) #137 sitting next to Resident #3 and providing meal assistance in the restorative dining room. Four additional residents (Resident #12, Resident #14, Resident #30, and Resident #31) were also present in the dining room. Additionally, CNA #233 and Registered Nurse #126 were present in the dining room. Further observation on 04/27/26 at 12:43 P.M. revealed CNA #137 talking loudly to her co-workers and referring to the residents as feeders. Concurrent interview with CNA #137 confirmed she called the residents feeders and further stated they receive restorative feeding.Follow-up interview on 04/27/26 at 12:55 P.M. with CNA #137 revealed she heard other staff call the residents feeders and picked up the word from them. CNA #137 stated the assistance with eating should really be called restorative care. Interview on 04/29/26 at approximately 4:20 P.M. with the Administrator verified staff should not refer to residents as feeders.Review of the policy titled, Resident Rights Guidelines, revised 05/11/17, revealed residents have a right to be treated with dignity and respect and be treated fairly, courteously and with respect by all staff.

Based on observation, medical record review, and staff interview, the facility failed to ensure food was fed to residents in a sanitary manner. This affected one (#3) of one residents observed receiving meal assistance. The facility identified three (#3, #10, and #17) residents who received meal assistance. The facility census was 59.Findings include:Review of the medical record for Resident #3 revealed an admission date of 01/11/22 with diagnoses of Alzheimer's disease, dementia, protein-calorie malnutrition, anxiety, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, revealed Resident #3 was rarely/never understood and was dependent on staff for eating assistance.Observation on 04/27/26 at 12:39 P.M. revealed Certified Nurse Aide (CNA) #137 sitting next to Resident #3 and providing meal assistance in the restorative dining room. Continued observation on 04/27/26 at 12:43 P.M. revealed CNA #137 stating Resident #3's soup was very hot. CNA #137 scooped a spoonful of soup and blew on it with her mouth to cool it off before offering the spoon to Resident #3. Resident #3 consumed the spoonful of soup. CNA #137 proceeded to scoop a second spoonful of soup, blow on the soup with her mouth to cool it, and offer it to Resident #3. Follow-up interview on 04/27/26 at 2:05 P.M. with CNA #137 verified the soup was often hot and she had to blow on it to cool it.Interview on 04/30/26 at 9:55 A.M. with Assistant Director of Dining Services #179 confirmed the act of blowing on residents' food was not a hygienic practice and staff should not blow on residents' food.

Based on observation, medical record review, review of a diet guide, and staff interview, the facility failed to follow instructions for the preparation and serving of residents receiving pureed textured food to ensure accurate portion sizes. This had the potential to affect three (#3, #17, and #29) of three residents receiving pureed diets. The facility census was 59. Findings include:Observation on 04/28/26 at 11:31 A.M. revealed [NAME] #128 preparing the lunch meal. [NAME] #128 was observed blending goulash mixture and egg noodles together.Interview on 04/28/26 at 11:31 A.M. with [NAME] #128 verified the goulash mixture and egg noodles were blended together.Observation on 04/28/26 at 12:40 P.M. revealed [NAME] #128 plating one, four-ounce scoop of pureed goulash and egg noodle mixture. Further observation revealed [NAME] #128 plating two, four-ounce scoops of mechanical soft goulash and noodle mixture.Interview on 04/28/26 at 12:45 P.M. with [NAME] #128 verified one, four-ounce scoop of pureed goulash and noodle mixture was added to the plate. [NAME] #128 was questioned as to why the mechanical soft plates received two, four-ounce scoops of goulash and noodle mixture while the puree diet plates received only one four-ounce scoop of goulash and noodle mixture. [NAME] #128 stated the noodles for the pureed are more ground down so the one, four-ounce scoop of pureed was equal to two, four-ounce scoops of mechanical soft.Interview on 04/28/26 at 1:20 P.M. with Dining Services Assistant Director (DSAD) #179, during concurrent review of the facility document titled, Diet Guide Sheet, revealed guidance for the preparation and serving of the pureed meal. DSAD #179 confirmed the goulash mixture and egg noodles were to be blended separately and served separately. Review of the Diet Guide Sheet further revealed residents receiving a pureed diet should have received one, four-ounce scoop of goulash mixture and one, three-ounce scoop of egg noodles. DSAD #179 verified residents with a pureed diet did not receive the correct amount of beef goulash mixture therefore the residents did not receive the correct amount of protein.

Based on observation, staff and resident interview, medical record review, and policy review, the facility failed to properly store medications. This affected one (#64) of one residents observed for medication storage in residents' rooms. The facility census was 59. Findings include:Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb and cellulitis of the left lower limb. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact and was assessed with no behaviors. Review of the comprehensive care plan dated 04/28/26 revealed Resident #64 received high risk medications related to congestive heart failure, edema, and hypertension. Interventions included administering medications per physician orders. Observation and interview on 04/27/26 at 8:40 A.M. revealed Resident #64 was awake and lying in bed with her bedside table near her. On the bedside table was a medication cup containing seven medications in tablet form. Resident #64 stated she left her morning medications on the table so she could take them with food.Observation and interview on 04/27/26 at 8:45 A.M. with Licensed Practical Nurse (LPN) #242 confirmed Resident #64 should not have medications at bedside. LPN #242 went into Resident #64's room and asked about the medications. Resident #64 again stated she was waiting to take the medications with food. LPN #242 explained to Resident #64 that medications could not be left at bedside and that she would bring them back when breakfast arrived. Resident #64 was in agreeance. LPN #242 stated Resident #64 had the medications in the hatch (meaning in her mouth) prior to her walking out of the room during morning medication administration. Review of the policy titled, Medication Storage, dated 10/01/23 gave no direction regarding medications being left at bedside.

Based on medical record review, staff interview and policy review, the facility failed to ensure the medical record was complete and accurate when addressing elevated blood sugars. This affected one (#13) of three discharged medical records reviewed for accuracy. The facility census was 54.Findings include:Review of the medical record for Resident #13 revealed an admission date of 07/23/25 and a discharge home on [DATE]. Diagnoses included type one diabetes mellitus and intestinal obstruction. Review of the admission Minimum Data Set (MDS) assessment, dated 07/28/25, revealed Resident #13 had intact cognition and received insulin. Review of the care plan dated 07/28/25 revealed Resident #13 was at risk for hypo/hyperglycemia (low or high blood sugars) due to diabetes mellitus. Interventions included providing medication per orders and monitoring blood sugars per physician order. Review of the physician order initiated 08/05/25 revealed Resident #13 received Novolog mix 70-30 FlexPen U-100 (insulin aspart) insulin pen; 100 units per milliliter (unit/mL) (70-30); nine (9) units, subcutaneous once daily between 3:00 P.M. and 5:00 P.M. Review of the physician order initiated 08/05/25, and discontinued 08/14/25, revealed Resident #13 received Novolog Mix 70-30 FlexPen U-100 (insulin aspart) insulin pen; 100 unit/mL (70-30); eight (8) units, subcutaneous with meals, twice daily, between 6:00 A.M. and 9:00 A.M. and between 11:00 A.M. and 1:00 P.M. Review of the physician order initiated 08/08/25, and discontinued 08/14/25, revealed Resident #13 received insulin glargine 100 unit/mL, five (5) units, injectable, once daily between 6:00 P.M. and 10:00 P.M. Review of a progress note dated 08/13/25 at 9:15 P.M. revealed Resident #13 was slumped over his tray table. His blood sugar was checked with a fingerstick and the results were 568 milligrams per deciliter (mg/dL). The on-call practitioner was notified and provided an order to administer 10 units of Novolog and recheck in one hour. Novolog was given. Review of a progress note dated 08/13/25 at 10:30 P.M. revealed Resident #13's blood sugar was rechecked with a fingerstick with results of 565 mg/dL. The on-call practitioner provided an order for 10 additional units of Novolog. Novolog was given. Review of progress note dated 08/14/25 at 12:37 A.M. revealed Resident #13 had a blood sugar of 481 mg/dL and the on-call practitioner provided a new order for 10 units of Novolog and recheck the blood sugar in one hour. If results were less than 350 mg/dL, leave until the morning. Novolog was given. Review of the interdisciplinary progress note dated 08/14/25 at 9:47 A.M. revealed Resident #13 had an episode of hyperglycemia and new orders were obtained for a one time dose of 10 units of insulin and to recheck blood sugar in one hour. Interview on 09/08/25 at 2:43 P.M. with the Director of Nursing (DON) confirmed Resident #13's progress notes indicated he received three separate doses of 10 units of Novolog insulin. The DON confirmed the nurse should have entered a physician order for the three insulin orders. The DON further confirmed no orders for the insulin doses given on 08/13/25 at 9:15 P.M., 08/13/25 at 10:30 P.M., and 08/14/25 at 12:37 A.M. were entered in Resident #13's physician orders. Additionally, the DON confirmed no follow-up blood sugar was documented as ordered by the physician in the progress note dated 08/14/25 at 12:37 A.M. Interview on 09/08/25 at 3:28 P.M. with Licensed Practical Nurse (LPN) #201, with the DON present, revealed LPN #201 worked the shift on 08/14/25 from 12:00 A.M. until 6:00 A.M. and provided care for Resident #13. LPN #201 stated she checked Resident #13's blood sugar an hour after he received the 12:37 A.M. dose of 10 units of insulin and recalled his blood sugar was 254 mg/dL. LPN #201 confirmed she did not document Resident #13's blood sugar in the electronic medical record. Continued interview with the DON regarding the interdisciplinary team (IDT) progress note documented on 08/14/25 at 9:47 A.M. revealed she became aware of Resident #13's hyperglycemic episode and insulin treatment by reading Resident #13's progress notes; however, the DON confirmed she only read the note dated 08/14/25 at 12:37 A.M. and did not identify Resident #13 received 30 units of insulin for hyperglycemia overnight from 08/13/25 to 08/14/25. Review of the policy titled, Guidelines for Late Entry and Corrections to Medical Record, reviewed 12/17/24, revealed each entry to the medical record shall include the date, time, and signature of the staff member recording the data. Every effort should be made to record the information or event as soon as it is available or occurred. Review of the policy titled, Guidelines for Telephone Orders, reviewed 12/17/24, revealed campuses with electronic medical records shall enter the orders directly into the electronic system which automatically transmits to pharmacy. Additionally, telephone orders shall be countersigned by the physician within 14 days or as applicable by state law of receiving the verbal order. This deficiency represents non-compliance investigated under Complaint Number 2597107.

Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure residents were provided with scheduled bathing. This affected three residents (#20, #35, and #52) of five residents observed for activities of daily living. The facility census was 58. Findings include: 1. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses of osteomyelitis of right ankle and foot, streptococcus, Pseudomonas aeruginosa (P. aeruginosa), unspecified open wound of right foot, peripheral vascular disease, atrial fibrillation, heart disease, heart failure, pericardial effusion, type two diabetes mellitus, nonrheumatic mitral valve insufficiency, nonrheumatic mitral valve insufficiency, protein-calorie malnutrition, low back pain, weight loss, hypertension, anemia, chest pain, cardiomyopathy, tachycardia, hyperkalemia, orthostatic hypotension, embolism and thrombosis of other arteries, stricture of artery, fecal impaction, orphoyngeal dysphagia, hypomagnesemia, malaise, nicotine dependence, urinary retention, hyperlipidemia, hypo-osmolality and hyponatremia, acidosis, pneumonia, and sepsis. Review of the admission Minimum Data Set (MDS) assessment, dated 01/23/25, revealed a Brief Interview of Mental Status (BIMS) score of 06, indicating Resident #20's cognition was severely impaired. Concurrent review of the MDS assessment revealed Resident #20 was dependent for personal hygiene. Review of the facility shower schedule revealed Resident #20 was scheduled to receive showers every Tuesday and Friday in the evening. Review of the facility shower schedule for 01/17/25 through 03/05/25 revealed Resident #20 was scheduled to receive 14 showers/baths. The resident only received showers or baths on seven dates, 01/22/25, 01/31/25, 02/03/25, 02/10/25, 02/13/25, 02/27/25, and 03/03/25 during this time. Interview on 03/05/24 at 2:22 P.M. with the Director of Nursing (DON) and Regional Nurse #241 verified that Resident #20 only received seven baths showers from 01/17/25 through 03/05/25. 2. Review of the medical record for Resident #35 revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, syncope and collapse, dehydration, acute kidney failure, type two diabetes mellitus, dementia, heart disease, occlusion and stenosis of bilateral carotid arteries, aortic valve stenosis, iron deficiency anemia, hypomagnesemia, fall, orthostatic hypotension, hyperlipidemia, hypertension, presence of cardiac pacemaker, old myocardial infarction , dizziness and giddiness, history of falling, thrombocytopenia, Vitamin B12 deficiency, benign prostatic hyperplasia (BPH), and gastro-esophageal reflux disease (GERD). Review of the admission MDS assessment, dated 01/28/25, revealed a BIMS score of 13, indicating Resident #35 was cognitively intact. Concurrent review of the MDS for Resident #35 revealed he was dependent for personal hygiene. Review of the facility shower schedule revealed Resident #35 was supposed to receive showers every Monday and Thursday in the evening. Review of the facility shower schedule for 01/22/25 through 03/05/25 revealed Resident #35 was supposed to receive 12 showers or baths. The resident only received showers or baths on eight dates, 01/24/25, 01/30/25, 02/26/25, 02/28/25, 02/18/25, 02/27/25, and 03/03/25 during this time. Interview on 03/05/24 at 2:22 P.M. with the Director of Nursing (DON) and Regional Nurse #241 verified that Resident #35 only received eight baths or showers from 01/22/25 through 03/05/25. Interview on 03/05/25 at 2:45 P.M. with Resident #35 revealed he does not feel that he received adequate baths or showers. Resident #35 states he would prefer to have showers, but he receives baths more often than showers. 3. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses of hypertensive heart disease, acute kidney failure, peripheral vascular disease, pleural effusion, protein-calorie malnutrition, anemia, chronic respiratory failure, rheumatoid arthritis, atrial fibrillation, generalized muscle weakness, hypomagnesemia, and heart failure. Review of the most recent quarterly MDS assessment, dated 02/14/25, revealed a BIMS score of 13, indicating Resident #52 was relatively cognitively intact. Concurrent review of the MDS assessment revealed Resident #52 required substantial/maximal assistance with showers/bathing. Review of the facility shower schedule revealed Resident #52 was supposed to receive showers every Monday and Thursday in the morning. Review of the facility shower schedule for 01/01/25 through 03/05/25 revealed Resident #52 was supposed to receive 18 showers or baths. The resident only received showers on 15 dates, 01/02/25, 01/06/25, 01/10/25, 01/13/25, 01/16/25, 01/20/25, 01/22/25, 01/23/25, 01/27/25, 01/30/25, 02/03/25, 02/06/25, 02/10/25, 02/13/25, 02/24/25, 02/27/25, and 03/03/25 during this time. Review of the facility shower schedule revealed Resident #52 did not receive a shower or a bath for 9 days during the period of 02/14/25 through 02/23/25. Interview on 03/05/25 Interview on 03/05/24 at 2:22 P.M. with the Director of Nursing (DON) and Regional Nurse #241 verified that Resident #52 only received 15 showers from 01/01/25 through 03/05/25 and that Resident #52 went 9 days between showers form 02/14/25 through 02/23/25. Review of the facility policy titled, Guidelines for Bathing Preference, dated 05/11/16, revealed the resident shall determine their preference for bathing upon admission. Bathing shall occur at least twice a week unless resident states otherwise. This deficiency represents non-compliance investigated under Complaint Number OH00158264.

Based on observation, staff interview, review of the medical record, and review of facility policy, the facility failed to ensure there were appropriate receptacles placed inside of the doorway to resident rooms to doff (remove) personal protective equipment (PPE) into. This affected two residents (#7 and #20) who were in Enhanced Barrier Precaution (EBP) isolation of five residents reviewed for isolation. The facility identified 11 residents (#1, #3, #5, #6, #7, #10, #16, #20, #24, #35, #52) residents in EBP isolation. The facility census was 58. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses of dementia, Alzheimer's disease, bipolar disorder, protein-calorie malnutrition, hypertensive chronic kidney disease (CKD), anxiety, hyperlipidemia, Vitamin D deficiency, white matter disease, seizures, restlessness and agitation, weakness, benign prostate hyperplasia (BPH), edema, malaise, dry eye syndrome, insomnia, difficulty in walking, and generalized muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was unable to be obtained due to Resident #7 being unable to complete the interview. Observation on 03/05/25 at 8:14 AM revealed a sign outside Resident #7's room indicating the resident was in EBP. Observation on 03/05/25 at 8:14 A.M. of Resident #7's room revealed there was no receptacle inside to discard used PPE into. Interview on 03/05/25 at 8:18 A.M. with LPN #158 verified there was no receptacle in Resident #7's room to discard used PPE into. 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses of osteomyelitis of right ankle and foot, streptococcus, pseudomonas aeruginosa (P. aeruginosa), unspecified open wound of right foot, peripheral vascular disease (PVD), atrial fibrillation, heart disease, heart failure, pericardial effusion, type two diabetes mellitus, nonrheumatic mitral valve insufficiency, nonrheumatic mitral valve insufficiency, protein-calorie malnutrition, low back pain, weight loss, hypertension (HTN), anemia, chest pain, cardiomyopathy, tachycardia, hyperkalemia, orthostatic hypotension, embolism and thrombosis of other arteries, stricture of artery, fecal impaction, oropharyngeal dysphagia, hypomagnesemia, malaise, nicotine dependence, urinary retention, hyperlipidemia, other signs and symptoms concerning food and fluid intake, hypo-osmolality and hyponatremia, acidosis, pneumonia, and sepsis. Review of the admission MDS assessment, dated 01/23/25, revealed a BIMS score of 06, indicating Resident #20's cognition was severely impaired. Observation on 03/05/25 at 7:09 A.M. revealed a sign outside Resident #20's room indicating the resident was in EBP. Observation on 03/05/25 at 7:47 A.M., when exiting Resident #20's room, revealed there was no receptacle to discard used PPE into. Interview on 03/05/25 at 7:47 A.M. with Licensed Practical Nurse (LPN) #175 verified there was no receptacle in Resident #20's room to discard used PPE into. Interview on 03/06/25 with Registered Nurse (RN) #151 revealed staff is required to doff PPE prior to exiting a resident's room who is in isolation. Concurrent interview with RN #151 revealed there should be a receptacle inside of every resident who is in isolation to doff used PPE into. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 04/01/24, revealed EBP will be in place during high-contact care activities for residents with the following conditions: - all residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. - all residents with indwelling medical devices, including but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes.

Based on record review of staff schedules, review of posted staffing, and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 56 residents residing in the facility. The census was 56. Findings include: Review of facility staffing schedules and posted staffing information from 05/02/24 to 06/02/24 revealed there was no Registered Nurse (RN) coverage in the facility on 05/18/24 or 05/19/24. Interview on 06/06/24 at 2:04 P.M., with the Director of Nursing (DON) verified there was no RN on duty in the facility on 05/18/24 and 05/19/24. The DON reported they had RN's on call but not in the facility. This deficiency represents non-compliance investigated under Complaint Number OH000154300.

Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure personal protective equipment (PPE) was worn by staff while performing care for a resident in contact precautions. This affected one (#307) of one resident reviewed for transmission based precautions and had the potential to affect all residents on the 100-hall (#20, #30, #39, #41, #47, #311, #312, #313, and #314). Additionally, the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted appropriately for residents. This affected one (#26) of four residents reviewed for EBP. The facility census was 56. Findings include: Review of the medical record for Resident #307 revealed an admitted [DATE], with a diagnosis of Clostridium difficile (C. diff). Review of the Admission Observation and Data Collection completed 05/28/24 revealed Resident #307 was alert and oriented to person, place and time and had no impaired cognition. Further review revealed Resident #307 was continent of bladder and bowel. Review of the baseline careplan dated 05/28/24 revealed Resident #307 had a current infection of C. diff and was in isolation for C. diff and isolation precautions would be implemented. The type of isolation (contact/droplet) was not identified on the assessment. Review of the physician order dated 05/29/24 to 06/03/24 revealed Resident #307 was in contact precautions due to C. diff. Observation on 06/03/24 at 8:40 A.M., revealed Resident #307's room with a Contact Precautions sign posted outside the room and a plastic PPE cart was outside the room next to the doorway. The Contact Precautions sign stated providers and staff must put on gloves before room entry, put on gown before room entry and discard gloves and gown before exiting the room. Further observation revealed Licensed Practical Nurse (LPN) #460 in Resident #307's room not wearing PPE. LPN #460 exited the room and used hand sanitizer. Interview on 06/03/24 at 8:42 A.M., with LPN #460 confirmed Resident #307 was in contact precautions for C. diff and further stated no PPE was required when providing care unless staff were coming in contact with areas that may have been soiled by stool, such as bedding or brief changes. LPN #460 confirmed he was in Resident #307's room to provide her a glass of water and was not wearing PPE. LPN #460 further confirmed the expected hand hygiene after exiting her room was hand sanitizer. Observation on 06/03/24 at 9:03 A.M., revealed State tested Nurse Aide (STNA) #445 in Resident #307's room. Resident #307 was dressed and sitting in a chair with her breakfast tray on the overbed table in front of her. STNA #445 was not wearing PPE in the room while she removed a napkin from Resident #307's lap, moved her meal tray from the overbed table to the dresser, moved her tray table, picked up Resident #307's tennis shoes and tied the shoes on Resident #307's feet. STNA #445 then brought Resident #307's walker within reach and stood by while Resident #307 walked to the bathroom, entered the bathroom alone and closed the door. Interview on 06/03/24 at 9:06 AM., with STNA #445 confirmed Resident #307 was in contact precautions. STNA #445 confirmed she did not wear any PPE while providing assistance to Resident #307. STNA #445 stated PPE was only required when providing toileting hygiene assistance to Resident #307. Upon prompting by the surveyor during the interview, STNA #445 performed hand hygiene by using hand sanitizer. Observation on 06/03/24 at 3:04 P.M., revealed Resident #307 in her room with Occupational Therapy Assistant (OTA) #630. A Contact Precautions sign and PPE cart remained outside Resident #307's room. OTA #630 was not wearing PPE in the room. Interview on 06/03/24 at 3:05 P.M with OTA #630 confirmed Resident #307 was in contact precautions, and confirmed she did not wear PPE while providing care to Resident #307. OTA #630 stated PPE was only required if staff provided care after Resident #307 had a bowel movement. Observation on 06/04/24 at 5:52 A.M., revealed STNA #511 in Resident #307's room, not wearing PPE. A Contact Precautions sign and PPE cart was outside Resident #307's room. STNA #511 closed the door. Continued observation at 6:02 A.M., revealed STNA #511 exited Resident #307's room carrying a bag of trash. STNA #511 confirmed she did not wear PPE when providing care to Resident #307. STNA #511 stated she touched Resident #307's hand to assist her up to her walker, then Resident #307 walked herself to the bathroom and was in the bathroom during the interview. STNA #511 confirmed Resident #307 was in contact precautions and stated PPE was only required when providing care after a stool. STNA #511 carried the trash to the soiled utility room. STNA #511 confirmed she had not washed her hands since exiting Resident #307's room and proceeded to the bathroom on the 100-hall nurses station to wash her hands. Interview on 06/04/24 at 7:42 A.M., with the Assistant Director of Nursing (ADON)/Infection Preventionist confirmed Contact Precautions means a gown and gloves should be donned prior to entering the room for any reason. Additionally, hand hygiene after potential contact with C. diff should be soap and water, not just hand sanitizer. Review of policy titled, Guidelines for Contact Precaution, revised 02/28/24, revealed Contact Precautions are indicated to prevent and control transmission of C. diff, among other healthcare-associated infections. PPE guidance included wearing gloves before contact with the resident or environmental objects. Hands should be washed after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects. Additionally, a fluid resistant gown should be worn when entering the room when there is likelihood that organisms from blood, urine, stool or wound drainage may be on surfaces or items in the resident's room. 35033 2. Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included congestive heart failure, type two diabetes mellitus with foot ulcer, atrial fibrillation, malignant neoplasm of the colon, and hypertension. Review of plan of care dated 05/03/24 revealed the resident required enhanced barrier precautions during high-contact care related to presence of wound with dressing change. Review of a physician order dated 05/03/24 revealed staff to use enhanced barrier precautions, wear a gown and gloves at minimum during high-contact care activities. Observation on 06/03/24 at 12:42 P.M., revealed Resident #26 had no enhanced barrier precaution sign posted on her door or in her room. Interview on 06/03/24 at 12:57 P.M., with Registered Nurse (RN) #485 verified Resident #26 was on enhanced barrier precautions and no sign was posted regarding the enhanced barrier precautions. Review of the policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, last revised 04/02/24, revealed no guidelines for sign placement for a resident on enhanced barrier precautions.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of medication administration records, review of staffing assignments, and review of Certified Registered Medication Aide (CRMA) licenses, the facility failed to ensure licensed staff were administering medications. This affected 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) of 24 residents reviewed for medication administration. The facility census was 56. Findings include Review of the CRMA licenses for State tested Nursing Assistant (STNA) #433 and STNA #407 revealed their CRMA licenses for administering medications had expired on [DATE]. Review of the staff assignment sheets revealed STNA #433 administered medications with an expired license on [DATE], [DATE], [DATE], and [DATE]. STNA #407 administered medications with an expired license on [DATE], [DATE], [DATE], and [DATE]. Review of the medication administration records for 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) revealed STNA #433 and/or STNA #407 had administered the residents' medications while working with expired medication certification licenses. Interview on [DATE] at 8:44 A.M., the Administrator revealed the facility had identified the two medication technicians working with expired licenses. Interview on [DATE] at 11:40 A. M.,with Regional Clinical Support Registered Nurse (RCSRN) #610 revealed the facility reviewed all events for all the residents, removed the two medications technicians from the schedule for administering medications, and verbally educated the two staff members to renew their licenses. RCSRN #610 revealed ongoing assessments of residents were completed by the nurses and a daily check of the administration compliance report for all residents showed no medication errors. As a result of the incident, the facility took the following actions to correct the deficient practice by [DATE]: On [DATE], STNA #433 and STNA #407 were removed from the schedule as administering medications and remain of the CRMA schedule. On [DATE], the Director of Nursing assessed the 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) and there were zero change in condition events. On [DATE], all CRMA licenses were verified to be active on [DATE], by the staffing scheduler. Beginning on [DATE], the staffing scheduler/designee would verify via the Ohio Board of Nursing all CRMAs licenses were active monthly. The Director of Nursing will be mointoring this to ensure it is completed monthly. On [DATE], review of the CRMA licenses for the four medication aides in the facility revealed the licenses for STNA #433 and STNA #407 remained expired. Review of the licenses for CRMA #436 and CRMA #480 were active through [DATE]. On [DATE] at 1:09 P.M., interview with STNA #433 revealed she had been educated by the facility to renew her medication administration certification license. STNA #433 verified she had administered medications with an expired license. On [DATE] at 12:08 P.M., interview with STNA #407 verified she had administered resident medications with an expired license. STNA #407 verified the facility had educated her to renew her medication administration certification license. This deficiency represents non-compliance investigated under Complaint Number OH000154300.

Based on observation, staff interview, review of resident diet list, and review of the menu spreadsheet, the facility failed to provide adequate portions of protein and mashed potatoes to residents on a mechanical soft diet. This had the potential to affect all 10 residents on a mechanical soft diet (#10, #16, #19, #20, #27, #30, #44, #262, #309, and #310). Additionally, the facility failed to provide adequate portions of protein and vegetables to residents on a pureed diet. This affected all four residents on a pureed diet (#4, #18, #37, and #40). The facility census was 56. Findings include: Observation during meal service on 06/04/24, between approximately 12:00 P.M. and approximately 12:25 P.M., revealed staff used a #12 scoop (2 2/3 ounce) to serve mechanical soft Salisbury steak, pureed Salisbury steak, and mashed potatoes. Further observation revealed staff used a #16 scoop (2 ounce) for pureed peas. Review of the the menu spreadsheet revealed the mechanical soft Salisbury steak portion should be 5 1/3 ounces and the mashed potatoes portion should be 4 ounces. The pureed Salisbury steak portion should be 4 ounces and the pureed peas portion should be 3 ounces. Review of a facility provided list of diets revealed 10 residents (#10, #16, #19, #20, #27, #30, #44, #262, #309, and #310) were on a mechanical soft diet and 4 residents (#4, #18, #37, and #40) on a puree diet. Interview on 06/04/24 at approximately 12:33 P.M., with the Director of Food Service (DFS) #459 confirmed the scoops sizes used to serve the mechanical soft and pureed Salisbury steak, and the mashed potatoes were 2 2/3 ounces and the scoop used to serve the pureed peas was 2 ounces. Further interview and concurrent review with the the menu spreadsheet revealed the mechanical soft Salisbury steak portion should be 5 1/3 ounces and the mashed potatoes portion should be 4 ounces. Additionally, DFS #459 confirmed the pureed Salisbury steak portion should be 4 ounces and the pureed peas portion should be 3 ounces.

Based on medical record review, interview of nephrology clinic staff, review of fax confirmation, and staff interviews, the facility failed to timely notify the nephrologist of abnormal laboratory test as ordered by the primary care physician. This affected one (#25) of two residents reviewed for hospitalization . The facility census was 56. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE], with diagnoses of type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease stage 3, and hypokalemia (low potassium). Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 had severely impaired cognition and required supervision or touching assistance for eating, and substantial/maximal assistance for all other activities of daily life. Review of a progress note dated 05/10/24, by Certified Nurse Practitioner (CNP) #600, revealed Resident #25 was evaluated after a fall without injury or pain and after recently elevated blood sugars, and CNP #600 requested laboratory (labs) tests thyroid stimulating hormone (TSH), hemoglobin A1c (HbA1c), complete blood count (CBC) and a comprehensive metabolic panel (CMP). Review of a physician order dated 05/12/24 revealed a Comprehensive Metabolic Panel (CMP) laboratory test was ordered for Resident #25. Review of a progress note dated 05/16/24 by CNP #600 revealed the laboratory tests were still pending. Review of a progress note dated 05/21/24, by CNP #600, revealed the laboratory tests ordered 05/10/24 had not been drawn. Further review revealed CNP #600 reminded the facility to draw labs ordered 05/10/24: HbA1c, TSH, CMP, CBC. Review of a physician order dated 05/21/24 revealed a CMP laboratory test was ordered for Resident #25. Review of the CMP laboratory test drawn 05/28/24, with results available on 05/30/24, revealed Resident #25's BUN was critically high at 78 milligrams per deciliter (mg/dL) (normal range of 6-21 mg/dL), her creatinine (an indicator of kidney function) was high at 2.4 mg/dL (normal range 0.5-0.9 mg/dL) and her potassium was high at 5.6 millimoles per liter (mmol/L) (normal range of 3.5-5.1 mmol/L). Review of a physician order dated 05/30/24 revealed Resident #25's order for bumetanide was on hold. The order was discontinued on 06/02/24. Review of a progress note dated 05/31/24 at 7:13 A.M., by CNP #600, revealed Resident #25's laboratory tests were reviewed, and CNP #600 requested the facility send the laboratory tests with medication list and vital signs to Resident #25's nephrology clinic. Review of a handwritten physician order dated 05/31/24 revealed Resident #25's laboratory tests, vital signs, and medication list should be sent to the nephrology clinic. Review of a fax confirmation dated 05/31/24 revealed the facility sent a 31-page document to a nephrology clinic. Interview on 06/05/24 at 11:03 A.M., with CNP #600 revealed she was aware of Resident #25's elevated laboratory values dated 05/28/24 and requested the laboratory results be sent to her nephrology clinic. CNP #600 stated she hand writes her orders on paper and hands them to staff and discusses her orders with the nurse. CNP #600 wanted the nephrology clinic notified the day she wrote the order, 05/31/24. A further interview with CNP #600 revealed she believed the nephrology clinic was notified and was addressing Resident #25's abnormal laboratory test results. Review of progress note dated 06/05/24, (a late entry dated 05/31/24), revealed the facility faxed Resident #25's laboratory results, medication list and face sheet to the nephrology clinic. Telephone interview on 06/05/24 at 11:35 A.M., with Medical Assistant (MA) #615 at Resident #25's nephrology clinic revealed no laboratory tests were received from the facility on 05/31/24. Further interview with MA #615 confirmed Resident #25 was a patient at their clinic. Telephone interview on 06/05/24 at 2:48 P.M. with Office Manager #620 at the nephrology clinic identified by the facility as the recipient of Resident #25's laboratory tests on 05/31/24, revealed the nephrology clinic does not provide care for Resident #25 and further could not confirm receipt of the laboratory tests faxed on 05/31/24. Interview on 06/05/24 at 3:08 P.M., with the Director of Nursing (DON) revealed she faxed the laboratory test results to the nephrology clinic on 05/31/24. The DON stated she did not follow up with the nephrology clinic to verify the laboratory test results were received. Interview on 06/06/24 at 8:25 A.M., with the DON revealed she identified Resident #25's nephrology clinic by referring to Resident #25's current orders. The DON stated there was an order to fax all laboratory tests to the nephrology clinic, but no fax number was in the order. The DON stated she had to look up the fax number on the internet. Concurrent review of the record with the DON confirmed she sent Resident #25's laboratory test results to the wrong nephrology clinic. Interview on 06/06/24 at 1:38 P.M., with Medical Assistant #635 at Resident #25's nephrology clinic revealed the nephrologist would have treated Resident #25's elevated potassium of 5.6 mmol/L in light of the elevated creatinine of 2.4 mg/dL, if they had received the laboratory test results.

Based on medical record review and staff interviews, the facility failed to timely obtain laboratory test as ordered by the physician. This affected one (#25) of two residents reviewed for hospitalization . The facility census was 56. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE], with diagnoses of type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease stage 3, and hypokalemia (low potassium). Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 had severely impaired cognition and required supervision or touching assistance for eating, and substantial/maximal assistance for all other activities of daily life. Review of a progress note dated 05/10/24, by Certified Nurse Practitioner (CNP) #600, revealed Resident #25 was evaluated after a fall without injury or pain and after recently elevated blood sugars, and CNP #600 requested laboratory tests thyroid stimulating hormone (TSH), hemoglobin A1c (HbA1c), complete blood count (CBC) and a comprehensive metabolic panel (CMP). Review of a physician order dated 05/12/24 revealed a Comprehensive Metabolic Panel (CMP) laboratory test was ordered for Resident #25. Review of a progress note dated 05/16/24 by CNP #600 revealed the laboratory tests were still pending. Review of a progress note dated 05/21/24, by CNP #600, revealed the laboratory tests ordered 05/10/24 had not been drawn. Further review revealed CNP #600 reminded the facility to draw labs ordered 05/10/24: HbA1c, TSH, CMP, CBC. Review of a physician order dated 05/21/24 revealed a CMP laboratory test was ordered for Resident #25. Review of the CMP laboratory test drawn 05/28/24, with results available on 05/30/24, revealed Resident #25's BUN was critically high at 78 milligrams per deciliter (mg/dL) (normal range of 6-21 mg/dL), her creatinine (an indicator of kidney function) was high at 2.4 mg/dL (normal range 0.5-0.9 mg/dL) and her potassium was high at 5.6 millimoles per liter (mmol/L) (normal range of 3.5-5.1 mmol/L). Review of a physician order dated 05/30/24 revealed Resident #25's order for bumetanide was on hold. The order was discontinued on 06/02/24. Review of a progress note dated 05/31/24 at 7:13 A.M., by CNP #600, revealed Resident #25's laboratory tests were reviewed, and CNP #600 requested the facility send the laboratory tests with medication list and vital signs to Resident #25's nephrology clinic. Interview on 06/05/24 at 3:08 P.M., with the Director of Nursing (DON) revealed the laboratory tests ordered on 05/12/24 and 05/21/24 for Resident #25 were not entered into the electronic system correctly and therefore were not drawn as ordered.

Based on medical record review, resident interview, staff interviews, and policy review, the facility failed to ensure a resident was provided with showers per their preference. This affected one (#48) of one resident reviewed for choices. The census was 56. Findings include: Review of Resident #48's medical record revealed an admitted [DATE], with diagnoses of atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertensive heart disease with heart failure, acute on chronic congestive heart failure (CHF), bilateral lower extremity (BLE) edema, and weakness. Review of the admission Minimum Data Set (MDS) Assessment, dated 05/30/24, revealed the resident had moderate cognitive impairment. The resident required substantial assistance for bathing. Interview on 06/03/2024 at 10:11 A.M., with Resident #48 revealed only receiving one shower since admission. Further interview with Resident #48 revealed that prior to admission, they took three showers per week at home. Interview on 06/04/24 at 8:12 A.M., with State tested Nursing Assistant (STNA) #446 revealed Resident #48 was scheduled to receive showers in the evening, but they were not certain regarding the scheduled days. Review of the shower schedule revealed Resident #48 was scheduled to receive showers two times per week, on Tuesday and Friday in the evening. Review of the bathing documentation revealed Resident #48 had only received showers on two of their scheduled days on 05/03/24 and 05/24/24. The resident had not received showers as scheduled on 05/07/24, 05/17/24, 05/21/24, 05/28/24, and 05/31/24. The resident had received a bed bath instead of his choice of a shower. The resident refused a shower on 05/14/24. Review of the nurses' notes dated 04/30/24 through 06/01/24 revealed no documentation the resident was offered a shower or had refused a shower on 05/07/24, 05/17/24, 05/21/24, 05/28/24, and 05/31/24. Interview on 06/04/24 at 10:32 A.M., with Registered Nurse (RN) #485 revealed if a resident was offered a shower and they refused, staff was then required to get the nurse to enter the resident's room and verify the refusal. Further interview with RN #485 revealed the documentation of a refused shower was required in the nurse's notes as well as in the caregiver charting in the electronic medical record. Continued interview with RN #485 revealed they have encountered several residents who stated they were dissatisfied with not getting showers and who were not offered showers and staff were instead documenting the residents refused their showers. Interview on 06/04/24 at 3:26 P.M., with the Director of Nursing (DON) and Regional Clinical Support Registered Nurse (RN) #610 revealed Resident #48 has had two showers since his admission on 04/30/24. Review of policy titled, Guidelines for Bathing Preference, revised on 12/31/23, revealed bathing would occur at least twice a week unless resident preferences stated otherwise.

Based on observation, review of resident council minutes, resident and staff interviews, the facility failed to ensure residents were served meals on nondisposable dishes, glasses/cups and silverware, to promote a homelike environment. This had the potential to effect 51 of the 52 residents in the facility. Resident #11 received nothing by mouth. The facility census was 52. Findings include: Observation on 09/27/21 at 12:00 P.M., revealed residents seated in the dining room being served a variety of beverages in disposable Styrofoam cups. The meals were served on disposable thin plastic plates. Subsequent observation at 1:00 P.M., of hall trays delivered revealed the same disposable dinnerware was served to the residents in their rooms. The plates were wrapped in clear cellophane wrap and were on trays placed in an insulated cart. Random interviews on 09/27/21, during the screening process, with Residents (#14, #17, #19, #23, #25, #31, #36, #40, #45, #48, and #255) revealed the food is cold when delivered and they feel it is more related to the plastic plates. Interview on 09/27/21 at 3:40 P.M., with Executive Director revealed the facility had been using disposable dishes and flatware for approximately two months citing lack of sufficient dietary staff to timely cleanse dishware. ED went on to state the facility was serving the assisted living residents on china but determined, with the numbers, to continue to use disposable dishware and flatware for the long term residents. The ED stated they have a policy to allow the use of disposable dishes. Interviews on 09/28/21 at 12:10 P.M., with various random residents, seated in the dining room, revealed they had been eating off of disposable plates and using plastic cutlery for quite some time. It is difficult at times to cut foods with plastic knife, the staff will assist but if resident had a regular knife could have cut the meat by themselves. Interview on 09/29/21 at 10:00 A.M., with Resident Council members Resident #2, #9, #30, and #48 revealed concerns related to the disposable plates and utensils. Resident #30 referred to the dinnerware as picnic supplies. Residents reports they do not like them because the plates and utensils are disposable, the knives do not work, the food does not stay hot, and condensation from the cover makes the food wet. Interview on 09/29/21 at 11:06 P.M., with Activities #370 verified residents have made complaints about disposable plates and utensils. Review of Resident Council Meeting Minutes, dated 06/22/21, revealed residents voiced concerns with plastic silverware stating they are unable to cut meats and food being cold when passed in the hall. Residents present included Resident #9, #10, #19, #30, #37, #38, #44, and #48. Review of Resident Council Meeting Minutes, dated 07/27/21, revealed residents voiced concerns with plastic silverware. Residents present included Resident #5, #13, #10, #19, #38, #44, and #48. Review of Resident Council Meeting Minutes, dated 08/25/21, revealed residents voiced concerns with cold food. Residents present included Resident #2, #9, #30, #38, and #48.

Based on observation and staff interview; the facility failed to ensure a resident's environment was free from electrical wires being exposed. This affected one (#33) of 24 residents observed for the environment. The census was 52. Finding include: Observation on 09/27/21 at 3:25 P.M., of Resident #33 and the resident's room revealed wires were coming out of a hole in the wall in the resident's room. The hole in the wall and exposed wires appeared to be in the spot were a call light box and call light cord should be located. There was a bell placed on the resident's bed side table. Interview on 09/30/21 at 10:34 A.M., with the Director of Maintenance (DOM) verified there were wires hanging out of a hole in the wall in Resident #33's room. The DOM revealed the wires were for the call light box, which, should be affix to the exterior of the wall. The DOM revealed the call light box was laying on a shelf next to the wall and the call light cord was wrapped around the side rail on the resident's bed. The DOM reported call lights were a priority to be fixed. The DOM reported he/she was not notified of Resident #33's call light being broken.

Based on resident record review, observation, and staff interview; the facility failed to ensure fall interventions were in place in accordance with the plan of care. This affected one (#37) of three resident's reviewed for falls. The census was 52. Findings include: Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anorexia, [CONDITION(S)], chronic obstructive pulmonary disease, heart disease, and hypertension. Review of a document titled, 48 Hour Baseline Care Plan dated 05/21/21, revealed Resident #37 was at risk for falls or lacks safety awareness. The history/observed triggers included placement in a new environment, takes medications that could potential adverse effects such as cathartics, analgesics, [CONDITION(S)], and/or hypoglycemic agents, diagnoses of disease or condition that increases risk for falls, and requires staff assistance and/or assistive devices for safe transfers and mobility. Interventions include assess for fall risk at admission and as needed until comprehensive care plan completed, provide assistive devices and ensure accessibility, keep call light within reach and encourage use of it, observe medications for side effects that could affect balance, cognition, or gait, and encourage and educate resident to utilize safety measures if applicable. Review of a physician order dated 05/27/21, revealed Resident #37 was not to be left unattended in the bathroom. Review of a care plan dated 06/04/21, revealed Resident #37 was at risk for falls related to assistance needed for transfers and a history of falls. Interventions included dycem to wheel chair, perimeter mattress to bed, ensure the floor is dry after shower. Observation on 09/27/21 at 4:54 P.M., of fall interventions for Resident #37, revealed the resident was sitting up in the wheel chair. There was no dycem located in the resident's wheel chair. Further observation revealed there was no perimeter mattress on the residents bed. Observation on 09/28/21 at 9:55 A.M., revealed Hospice Employee (HE) #369 was in the bathroom with Resident #37, assisting the resident with care. Continued observation revealed the HE #369, exited the bathroom leaving the resident in the bathroom, closed the door, and exited the resident's room. The HE #369 entered the hallway and walked down towards the nurse station to find a facility staff member to assist with the resident care. HE #369 and a staff member returned to Resident #37's room , entered the bathroom, and closed the door. Interview on 09/28/21 at 9:59 A.M., with HE #369 revealed HE #369 was in the bathroom with Resident #37 to assist the resident with a shower. HE #369 reported the resident was left unattended in the bathroom while the staff left the room to find someone to assist with transferring the resident off of the toilet. Continued interview with the staff revealed the reason HE #369 needed help with the transfer was because the drain on the bathroom floor was not draining the shower water very fast and the floor was covered with water, pooling in some areas. Further interview with HE #369 revealed the staff had attempted to dry the bathroom floor but there was to much water and the floor was not able to be dried properly. Interview with HE #369 verified Resident #37 was left unattended in the bathroom with a wet floor. Observation on 09/28/21 at 10:02 A.M., of Resident #37's bathroom/shower area revealed the drain for the shower was located towards the middle of the room. The area of the shower was wet, there was water pooling in front of the sink, and the floor was wet surrounding the toilet. Interview and observation on 09/28/21 at 10:04 A.M., with Licensed Practical Nurse (LPN) #335 of Resident #37 revealed the resident was sitting in a broda wheel chair, there was no dycem in the wheel chair. Continued observation revealed there was no perimeter mattress on the residents bed. LPN #335 verified there was no dycem on the broda chair, on the standard wheel chair, or on the resident's recliner chair. An attempt was made to verify the type of mattress on the resident's bed but the LPN did not know if the mattress was a perimeter mattress or a regular mattress. Interview on 09/28/21 at 10:08 A.M., with Assistant Director of Nursing (ADON) #368 and observation of Resident #37's mattress verified the current mattress on Resident #37's bed was not a perimeter mattress.

Based on medical record review, resident and staff interviews, the facility failed to ensure a resident was seen by a physician as required. This affected one (#38) of three residents reviewed for physician visits. The facility census was 52. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 08/27/21, revealed Resident #38 was moderately cognitively impaired. Review of physician visits revealed Resident #38 met with a nurse practitioner monthly but has not met with a physician since 01/26/21. Interview on 09/28/21 at 9:32 A.M., with Resident #38 revealed the resident had not met with a primary care physician. Resident #38 stated he meets with a nurse practitioner but has not met with a physician at the facility. Interview on 09/29/21 at approximately 3:00 P.M., with the Director of Nursing verified Resident #38 has not met with physician since January 2021.

Based on record review, observation, staff interview, review of manufacturer guidelines, interview with manufacturer representative, policy review and review of the Ohio Department of Health form named Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, the facility failed to ensure proper hand hygiene was performed during a clean dressing change for one resident (#55) of one dressing change observed. The facility also failed to report an outbreak of gastroenteritis to the local/state health department in a timely manner. This affected 23 of 55 residents. The facility census was 55. Findings include: 1. Observation of Licensed Practical Nurse (LPN) #152 providing the treatment to Resident #55's left heel ulcer. She entered the room, washed her hands and donned gloves. She removed the top border of the Allevyn dressing while the bottom border was attached to the resident's heel. While LPN #152 was removing the top border of the dressing, the resident was complaining of severe pain. There was a dime sized area of serosanguineous drainage (yellow liquid) with a brown border around the drainage on the dressing. The wound on with the left heel appeared to have an open area with no evidence of eschar or slough. LPN #152 applied skin prep to the entire area on the left heel. She allowed the skin prep to air dry and reapplied the soiled dressing. She removed her gloves, donned new gloves, and applied skin prep to the right heel . The right heel was intact with no skin breakdown. Interview on 03/20/19 at 2:10 P.M. with LPN #152 verified the dressing to the resident's left heel was soiled with drainage. When asked why she did not change the soiled dressing to Resident #55 heel she stated she could have but verified she did not. Interview with Director of Nursing on 03/20/19 at 2:15 P.M. she stated that is the purpose of the Allevyn dressing to absorb drainage from wounds and did not need to be changed for three days. Review of the manufactures instructions for Allevyn dressings under the heading of precautions stated the Allevyn dressing is a single use product. During a phone interview with Product Representative #300 for Allevyn on 03/21/19 at 2:00 P.M. verified the Allevyn dressing was a single use product. She stated the dressing could be pulled back and reapplied if the wound was dry without drainage as it serves a protective barrier to prevent infection. She verified if the wound was open and and there was drainage on the dressing, it should not be peeled back and reapplied due to risk of infection. Review of the undated facility policy titled Dressing Changes under step eight, nine and 10 stated to dispose of gloves, wash hands with soap and water, and put on a second pair of gloves after discarding a soiled dressing. 2. Review of the facilities Long Term Care Acute Gastroenteritis Surveillance Line list revealed the first resident to have Gastrointestinal symptoms was on 03/01/19 and the last resident to have symptoms was on 03/18/19, with a total of 23 residents. The first staff member to have gastrointestinal symptoms was on 03/06/19 and the last to have symptoms was on 03/14/19 for a total of 15 staff affected by the outbreak. The facility did not report the gastrointestinal outbreak until 03/19/19. Interview on 03/21/19 at 11:16 A.M. with the Director of Nursing (DON) verified the facility did not test any of the resident's or staff for norovirus and reported to the health department on 03/19/19 of the gastroenteritis outbreak. Interview on 3/21/19 at 2:05 P.M. with the(NAME)County Health Department Supervisor verified the facility did not report the gastrointestinal outbreak at the facility until 03/19/19. Review of the Ohio Department of Health form titled Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, from the Ohio Administrative Code Chapter 3701-3; Effective (MONTH) 22, (YEAR), revealed facilities should report when they suspect an outbreak within the next business day. Review of the policy titled Infection Prevention and Control General Guidelines, dated 11/10/17, revealed the facility shall establish an infection prevention and control program that enables the facility to analyze patterns of known infections. Review of the policy titled Infection Prevention and Control Program, dated 11/10/17, revealed the Infection Prevention and Control Program designee should report communicable disease that are reportable to the local/state public health authorities. This deficiency substantiates Complaint Number OH 295.

Based on review of the facility menu and spread sheets, observation, and staff interview, the facility failed to provide the appropriate portion sizes for therapeutic diets as ordered by the physician for five residents (#6, #11, #16, #17, and #214) of 36 residents who were served lunch in the dining room. Findings include: Review of the menu for lunch on 03/20/19 revealed main entree was fried shrimp, cauliflower, and peach cobbler. Review of the spread sheet for lunch on 03/20/19 revealed residents on carbohydrate consistent diets prescribed by their physician were to receive a half portion of the peach cobbler. Observation of the dessert cart located in the dining room during lunch on 03/20/19 revealed dishes with peach cobbler. All of the cobblers appeared to be the same size. Observation and interview on 03/20/19 at 12:55 P.M. revealed Dining Assistant #300 was serving peach cobbler to the residents in the dining room from the dessert cart. After serving over half of the resident's in the dining room, Dining Assistant #300 verified all of the peach cobbler servings were the same size. When asked if any of the resident in the dining room were on a carbohydrate controlled diet, she stated she did not know and she would have to check her sheet which she did not have with her. She verified at that time she had served over half of the residents in the dining room peach cobbler. After the interview, she served the other residents in the dining room peach cobbler.