Every finding on record at Lakes of Sylvania, The

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure pressure relieving interventions were implemented. This affected one (#11) of three residents reviewed for pressure ulcers. The facility census was 59. Findings include:Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of epilepsy, morbid obesity, lymphedema, and anxiety.Review of the significant change comprehensive Minimum Data Set (MDS) assessment, dated 01/15/26, revealed Resident #11 had impaired cognition and was dependent on staff for bed mobility, transfers, and transitioning from lying to sitting. Further review revealed Resident #11 had a stage three pressure ulcer and did not reject care. Review of Resident #11's care plan, initiated 01/26/18, revealed the resident was at risk for skin breakdown related to impaired mobility, incontinence of bowel and bladder, history of pressure ulcers and obesity. Interventions included encourage and assist to turn and reposition for comfort as needed, keep resident as clean and dry as possible, and minimize skin exposure to moisture. Review of the physician orders revealed Resident #11 had an order dated 09/23/24 to encourage to turn and reposition while in bed twice daily and encourage the resident to float heels while in bed as tolerated Review of the Wound Management Detail Report (WMDR) revealed the facility identified an abrasion to Resident #11's right buttock on 11/04/25. Further review of the weekly wound assessment dated [DATE] revealed the abrasion to right buttock progressed to a stage three pressure ulcer to the coccyx. Continued review of weekly wound assessments through 02/10/26 revealed the wound was improving.Review of wound care orders for Resident #11 revealed orders entered on 11/05/25 for Triad Wound Dressing, apply a thin layer topically to the sacrum and buttock twice daily and nystatin powder 100,000 unit/gram (u/g), apply a small amount to the buttocks and sacrum twice daily. On 12/30/26, a new order was initiated to cleanse the buttock with soap and water, pat dry, apply collagen to open area to crease of buttock, thin layer of Triad to buttock, sprinkle nystatin powder, and cover with super absorbent pad daily. Continued review revealed on 01/17/26, a new order was initiated to cleanse the wound with wound cleanser, lightly pack with collagen alginate, cover the wound with a two by (x) two bordered gauze, and apply antifungal cream to the peri-wound once daily. Review of Treatment Administration Record (TAR) from 12/01/25 through 02/10/26 revealed wound care was completed as ordered. Observation on 02/10/26 at 1:59 P.M. revealed Resident #11 was lying in bed on her back with no pillows or other pressure relieving devices observed under her hips to offload the pressure from the coccyx wound. Interview on 02/10/26 at 2:15 P.M. with Certified Nursing Assistant (CNA) #254 revealed he was familiar with Resident #11 and stated the resident allowed staff to reposition her every two hours. Observation on 02/11/26 at 7:12 A.M. revealed Resident #11 was in bed, lying flat on her back with no pillows observed under her hips to relieve pressure from the coccyx wound.Observation on 02/11/26 at 8:30 A.M. revealed Resident #11 was lying on her back, with the head of the bed elevated to eat breakfast. No pillows were observed under her hips, buttocks, thighs, or shoulders. Interview on 02/11/26 at 8:30 A.M. with the Director of Nursing (DON) confirmed Resident #11's heels were not offloaded as ordered. Observation on 2/11/26 at 9:12 A.M. revealed Resident #11 was positioned in bed with pillows under her knees to elevate her heels. No pillows were observed under her hips, buttocks, thighs or shoulders.Observation on 02/11/26 at approximately 10:19 A.M. revealed Resident #11 was sitting up in bed with a pillow placed under her knees. No other pillows were observed to relieve pressure from the coccyx wound.Interview on 02/11/26 at 10:21 A.M. with with CNA #240 revealed she repositioned Resident #11 earlier in her shift by placing pillows under the resident's knees and lying the head of the bed down. CNA #240 stated she repositioned Resident #11 by raising and/or lowering the head of bed or the foot of the bed. CNA #240 stated she had not placed pillows under Resident #11's hips or behind her back to offload the pressure on the coccyx wound since the start of her shift at 6:00 A.M. CNA #240 also stated there were no pillows to offload the pressure under Resident #11's hips when her shift started. CNA #240 stated she was aware Resident #11 had a wound to her coccyx. Observation on 02/11/26 at 11:24 A.M. of Resident #11 revealed once wound care was completed by the wound nurse, the resident was placed on her back in bed with no pillows to offload pressure to the coccyx wound and the resident's heels were not elevated off of the bed as ordered. Interview on 02/11/26 at 2:12 P.M. with CNA #240 revealed Resident #11 did not refuse care and was agreeable to repositioning.Interview on 02/12/26 at 8:48 A.M. with Registered Nurse (RN) #212 revealed expectations for offloading pressure on wounds was to get the resident off of the wound, which included turning the resident on their side, getting the resident up or floating the wound (removing all pressure to promote healing and prevent further tissue breakdown). RN #212 stated Resident #11 was discussed this morning with the CNAs and RN #212 recommended that pillows be placed under the resident's bilateral hips due to the resident not liking to be on her side.Review of the facility policy titled, Guidelines for General Wound and Skin Care, dated 05/10/17, revealed staff were to turn/reposition residents who were immobile according to their care plan requirements. Further review revealed staff were to use pillows or wedges for positioning to avoid skin on skin contact.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered per physician orders. This affected one (#29) of one resident reviewed for oxygen therapy. The facility identified eight residents (#1, #9, #11, #19, #29, #42, #47, and #84) who received oxygen therapy. The facility census was 59. Findings include:Review of the medical record for Resident #29 revealed an admission date of 12/10/20 with the diagnosis of acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD).Review of current physician orders revealed Resident #29 was ordered oxygen to be administered at two liters/minute (l/m).Review of the care plan, revised 02/26/25, revealed Resident #29 had shortness of breath with interventions to administer oxygen per physician orders.Observation on 02/09/26 at 9:54 P.M. revealed Resident #29 had oxygen running via nasal cannula at 2.5 l/m.Observation on 02/10/26 at 8:31 A.M. revealed Resident #29 had oxygen running via nasal cannula at three l/m.Interview on 02/10/26 at 8:35 A.M. with Licensed Practical Nurse (LPN) #204 verified Resident #29's oxygen was running at three l/m and further confirmed the physician order was for oxygen at two l/m. Review of the facility policy titled, Administration of Oxygen, reviewed 12/13/24, revealed to verify the physician's order for the procedure.

Based on observation, medical record review, and staff interview, the facility failed to ensure accurate documentation for a pressure relieving device. This affected one (#28) of three residents reviewed for pressure ulcers. The facility census was 59.Findings include:Review of the medical record for Resident #28 revealed an admission date of 11/01/23 with diagnoses of spinal stenosis, intervertebral disc degeneration, paraplegia, and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/16/26, revealed Resident #28 had intact cognition, had upper and lower extremity bilateral impairment, and used a wheelchair for mobility. Further review revealed Resident #28 was at risk for developing pressure injuries and had a pressure reducing device for her bed. Review of a physician order, initiated 10/15/25, revealed Resident #28 should have an air mattress in place. Further review of the order revealed staff should check for proper inflation. The order was discontinued on 02/10/26. Review of the Medication Administration History (MAH) for December 2025, January 2026 and February 2026 revealed staff documented Resident #28's air mattress was in place and properly inflated.Interview on 02/10/26 at 4:41 P.M. with Registered Nurse Clinical Support (RNCS) #325, and concurrent observation of Resident #28's bed, confirmed the resident did not have an inflatable air mattress. Interview on 02/11/26 at 4:45 P.M. with RNCS #327, and concurrent review of the MAH for December 2025, January 2026, and February 2026, confirmed staff documented Resident #28 had an air mattress that was properly inflated in place. RNCS #327 stated the documentation was completed in error as Resident #28 did not have an inflatable air mattress.

Based on medical record review and staff interview, the facility failed to ensure comprehensive assessments were completed within required timeframes. This affected one (#73) of one resident reviewed for comprehensive assessments. The facility census was 59.Findings include:Review of the medical record for Resident #73 revealed an admission date of 01/26/26.Review of the admission Minimum Data Set (MDS) revealed the assessment was initiated on 02/02/26 and was incomplete. Interview on 02/11/2026 at 3:06 P.M. with Registered Nurse (RN) #211 verified she had not completed the admission comprehensive assessment (MDS) within the required 14 days. RN #211 further confirmed today was day 16 and the assessment was not completed. Interview on 02/11/2026 at 4:19 P.M. with RN Clinical Support RN (RNCS) #327 revealed the facility did not have a policy for the completion of MDS assessments.

Based on observation, record review and staff interview, the facility failed to ensure nail care was provided to dependent residents. This affected one (#11) resident reviewed for activities of daily living (ADLs). The facility census was 59.Findings include:Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of epilepsy, morbid obesity, lymphedema, and anxiety. Review of the significant change comprehensive Minimum Data Set (MDS) assessment, dated 01/15/26, revealed Resident #11 had impaired cognition and was dependent on staff for bed mobility and transfers. Further review revealed Resident #11 required substantial/maximal assistance for personal hygiene, and was dependent on staff for bathing.Review of the care plan, initiated 01/26/18, revealed Resident #11 required staff assistance to complete ADL tasks completely and safely. Further review revealed no indication of the level of care required by Resident #11 to perform personal hygiene.Observation on 02/09/26 at 8:16 P.M. revealed Resident #11 sitting up in bed and alert. Further observation revealed a dark substance underneath Resident #11's fingernails.Observation on 02/10/26 at 1:59 P.M. revealed Resident #11 alert and lying in bed. Further observation revealed a dark substance underneath Resident #11's fingernails.Interview on 02/11/26 at 8:30 A.M. with the Director of Nursing (DON) and concurrent observation of Resident #11's fingernails confirmed a dark substance was under her fingernails. Interview on 02/11/26 at 10:58 A.M. with Certified Nursing Assistant (CNA) #240, who stated she was familiar with Resident #11, revealed Resident #11's fingernails were often dirty.Follow-up interview on 02/12/26 at 1:50 P.M. with the DON confirmed residents' fingernails should be cleaned as needed.

Based on observation, resident interview, staff interview and record review, the facility failed to ensure a resident received dental services in a timely manner. This affected one (Resident #33) of one reviewed for dental services. The facility census was 50. Findings include Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included kidney disease, emphysema, bipolar disorder and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact with a BIMS of 15 and required limited assistance of one staff member and for mobility and transfers. Review of the baseline care plan dated 01/15/23 revealed Resident #33 was noted to have broken teeth with intervention to ensure lighting in resident room was appropriate. Review of the progress notes dated 02/22/23 revealed Resident #33 was seen by the 360 care dentist and was found to need all top teeth (quantity of eight) extracted. The dental group recommended resident to be seen by an oral surgeon. The resident and family was provided the information to review. Review of the progress note dated 03/01/23 revealed social services spoke with the resident and daughter regarding dental follow up and the resident and family were interested in her getting scheduled for the oral surgeon to have teeth extracted with the possibility of getting dentures. Social Services informed family of process in getting dentures with Medicaid insurance and timeline of taking potentially several months for authorization. Social Services agreed to call around for a local oral surgeon who would accept the resident's insurance and be able to provide her services and confirmed family and the resident were unable to pay privately for dental extractions. Review of the progress note dated 03/07/23 revealed multiple dental offices were contacted and did not accept the resident's insurance. 360 dental service was contacted requesting a list of oral surgeons that accept Medicaid. Review of the progress note dated 03/14/23 revealed 360 dental provider sent list of possible providers further outside of [NAME] and resident and family were agreeable to offices being contacted for possible services. Review of the progress note dated 03/16/23 revealed social services contacted the four locations provided by 360 dental and they did not accept the resident's insurance. Social Services contacted the county health department (about an hour from facility) and learned they did accept the insurance but were booked out through June and not taking any new patients at that time. Offices in further away were contacted and stated they would not accept resident from so far away. The resident and daughter were updated. No additional documentation was done from 03/17/23 to 11/22/23 related to finding a follow-up related to the dental services and resident was not seen for services since this. Observation and interview on 11/20/23 at 2:32 P.M. with Resident #33 revealed the dentist informed her she needed to have teeth pulled several months ago but had not heard follow up related to having an appointment or a provider able to perform the service. She revealed staff had looked at options but was unsure if they were still trying to find assistance for her. Interview on 11/22/23 at 9:30 A.M. with Social Services #569 revealed she checked into the resources that she knew about and was unable to find any providers that would accept Medicaid for dental services/surgery. She revealed she found online a resource with a county health department but they were unable to accept the resident until after June. Social Services revealed she did not document any follow up since 03/2023 and revealed she did not contact the local counties to see what services they offered. She revealed she did not reach out to the hospitals to see if they had any services or knowledge of services. Interview on 11/22/23 at 9:45 A.M. with staff at Dental Clinic #700 revealed they accepted Medicaid and had an oral surgeon come weekly. Staff revealed they were currently not scheduling appointments for new patients but could see Resident #33 same-day for any urgent or acute needs such as pain. Staff revealed they were hoping to re-open appointments for new patients in January. Staff revealed they had an open enrollment system throughout the year and the facility would need to keep checking in to check the status, but revealed they have had openings off and on this past year. Interview on 11/22/23 at 9:55 A.M. with the Director of Nursing (DON) revealed the facility was completing no follow up or monitoring related Resident #33's dental concerns and needing teeth extracted.

Based on observation, staff interview, review of facility schedules, and record review, the facility failed to ensure adequate staff was available to timely administer medications and timely turn and reposition dependent residents. This affected two (#11 and #13) of five residents reviewed for timely care and treatment. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition and required extensive assistance of two people for bed mobility. Review of the current care plan for Resident #11 revealed she required staff assistance to complete activities of daily life (ADL) tasks completely. Interventions included turning and repositioning very two hours. Observation on 03/29/23 at 5:24 A.M. revealed Licensed Practical Nurse (LPN) #202 in the room with Resident #11 waiting for State tested Nurse Aide (STNA) #101. Interview on 03/29/23 at 5:24 A.M. with STNA #101 revealed she was the only aide in the facility, along with two LPNs. STNA #101 stated she was responsible for two halls for a total of approximately 44 residents. STNA #101 revealed Resident #11 required two staff to assist with repositioning and incontinence care. Observation at that time revealed LPN #202 in the room with Resident #11 waiting for STNA #101. STNA #101 revealed she previously provided care for Resident #11 at approximately 1:00 A.M. Interview on 03/29/23 at 5:36 A.M., LPN #202 stated two STNAs called off for third shift. Interview on 03/29/23 at 11:55 A.M. with Scheduler #301 confirmed two aides called off the previous night for third shift. Review of the staff schedule for third shift on 03/28/23 revealed one STNA called off for the shift, and another staff left the shift at 2:00 A.M. on 03/29/23. Further review revealed two nurses and one STNA were the only staff during third shift between 2:00 A.M. and 6:00 A.M. Review of the Point of Care (POC) History on 03/29/23 at 1:02 P.M. for Resident #11 revealed was turned and repositioned on 03/29/23 at 12:44 A.M. No additional entries for care were entered in the POC at the time of review. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of Parkinson's disease and dementia. Review of the comprehensive MDS assessment, dated 01/13/23, revealed Resident #13 had intact cognition. Review of a physician order dated 08/17/21 revealed Resident #13 was to receive the medication for Parkinson's disease carbidopa-levodopa 25-100 milligrams (mg) 2.5 tablets three times daily with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of an additional physician order dated 08/17/21 revealed Resident #13 received carbidopa-levodopa 25-100 mg, one tablet three times daily, with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of the Medication Administration Record (MAR) for 03/02/23 revealed Resident #13 received both doses of carbidopa-levodopa scheduled for 10:00 A.M. at 11:58 A.M. The documented reason for the late dose was Resident care. Review of the MAR for 03/23/23 revealed Resident #13 received both doses of carbidopa-levodopa scheduled for 10:00 A.M., at 11:47 A.M. The documented reason for the late dose was Patient care. Observation on 03/29/23 at 10:07 A.M. revealed Medication Technician (MT) #102 was still passing morning medications after 10:00 A.M. Interview at the time of the observation MT #102 revealed all morning medications should be passed by 10:00 A.M. MT #102 stated she was still passing morning medications after 10:00 A.M. because she had helped the STNA provide care to residents on the hall, including mechanical lifts requiring two staff to operate. Interview on 03/29/23 at 10:08 A.M. with Registered Nurse (RN) #203 revealed she was still passing morning medications. RN #203 confirmed the doses were late because she assisted the STNAs with resident care and assisted in passing meal trays, which included repositioning residents so they could eat breakfast. Observation on 03/29/23 at 10:29 A.M. revealed LPN #205 passing medications to residents. Interview at that time with LPN #205 revealed she was late passing morning medications because she was assigned to assist staff on another hall. She assisted residents with breakfast and assisted the STNA with mechanical lifts. This represents non-compliance investigated under Master Complaint Number OH00141638 and Complaint Number OH00141225.

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure dependent residents were turned and repositioned every two hours per plan of care. This affected one (Resident #11) of four residents reviewed for turning and repositioning. The facility census was 57. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition and required extensive assistance of two people for bed mobility. Review of the care plan initiated 04/03/20 for Resident #11 revealed she required staff assistance to complete activities of daily life (ADL) tasks completely. Interventions included turning and repositioning every two hours. Observation on 03/29/23 at 5:24 A.M. revealed Licensed Practical Nurse (LPN) #202 in the room with Resident #11 waiting for State tested Nurse Aide (STNA) #101. Interview on 03/29/23 at 5:24 A.M. with STNA #101 revealed she was the only aide in the facility, along with two LPNs. STNA #101 revealed Resident #11 required two staff to assist with repositioning and incontinence care. STNA #101 stated she previously provided care for Resident #11 at approximately 1:00 A.M. Review of the Point of Care (POC) History on 03/29/23 at 1:02 P.M. for Resident #11 revealed the resident was turned and repositioned on 03/29/23 at 12:44 A.M. No additional entries for care were entered in the POC at the time of review. Observation 04/03/23 at 5:20 A.M. revealed LPN #201 and LPN #207 conducting checks and repositioning rounds for Resident #11. A concurrent interview with LPN #201 revealed Resident #11 was last checked and repositioned at 1:00 A.M. LPN #207 revealed residents were checked and changed twice during the eight-hour shift, usually every three to four hours. Interview on 04/03/23 at 1:00 P.M. with the Director of Nursing confirmed the care plan for Resident #11 revealed she should be turned and repositioned every two hours. Review of the facility policy titled Turning and Repositioning, reviewed 12/31/22, revealed residents requiring assistance to reposition while in bed should be assisted with turning and repositioning as needed to maintain skin integrity, decrease pain and maintain proper body alignment. Further review revealed turning and reposition was a standard of practice that will be performed in accordance with the resident's care plan. This represents non-compliance investigated under Master Complaint Number OH00141638 and Complaint Number OH00141225.

Based on observation, record review, staff interview, review of prescribing information website, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (#11 and #13) of three residents reviewed for medication administration. The facility census was 57. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition. Review of a physician order dated 12/30/22 revealed Resident #11 received levothyroxine tablet 50 micrograms (mcg) one tablet daily by mouth for hypothyroidism. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #11 received levothyroxine after breakfast on 03/02/23 at 11:17 A.M., on 03/03/23 at 11:19 A.M., on 03/04/23 at 11:02 A.M., on 03/05/23 at 10:00 A.M., on 03/16/23 at 11:00 A.M., and on 03/19/23 at 10:32 A.M. Review of the meal intake for Resident #11 revealed she consumed breakfast on 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/16/23, and 03/19/23. Review of the prescribing guidelines at https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021402s024s028lbl.pdf for levothyroxine (generic for Synthroid) reveal it should be administered once daily, preferably on an empty stomach, one-half to one hour before breakfast. Interview on 03/29/23 at 8:42 A.M. with State tested Nurse Aide (STNA) #105 revealed breakfast was served between 7:00 A.M. and 9:00 A.M. Interview on 03/29/23 at approximately 1:00 P.M. with the Administrator confirmed the documentation in the MAR for Resident #11 revealed levothyroxine was provided after the scheduled breakfast time on 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/16/23, and 03/19/23. Interviews on 03/29/23 at 2:25 P.M. with STNA #106, Medication Technician (MT) #102, and Registered Nurse (RN) #203 confirmed Resident #11 ate breakfast daily. Continued interview with RN #203 confirmed late levothyroxine medication administration was a concern as it should be given before breakfast. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of Parkinson's disease and dementia. Review of the comprehensive MDS assessment, dated 01/13/23, revealed Resident #13 had intact cognition. Review of a physician order dated 08/17/21 revealed Resident #13 was to receive the medication for Parkinson's disease carbidopa-levodopa 25-100 milligrams (mg) 2.5 tablets three times daily with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of an additional physician order dated 08/17/21 revealed Resident #13 received carbidopa-levodopa 25-100 mg, one tablet three times daily, with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of the MAR for 03/01/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 5:00 A.M., at 6:35 A.M. Review of the MAR for 03/02/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 10:00 A.M., at 11:58 A.M. Review of the MAR for 03/23/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 10:00 A.M., at 11:47 A.M. Interview on 03/29/23 at approximately 1:00 P.M. with the Administrator confirmed the documentation in the MAR for Resident #13 revealed the carbidopa-levodopa was not given as ordered on 03/01/23, 03/02/23, and 03/23/23. Review of the policy titled Medication Administration, dated November 2018, revealed medications are to be administered in accordance with written orders, and are to be administered within 60 minutes of the scheduled time, except before with or after meal orders which are administered based on mealtimes. This is an incidental citation of non-compliance discovered during the complaint investigation.

Based on medical record review, staff interviews, review of the facility investigation, review of the facility policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPN), and review of personnel files, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) for one resident (Resident #01) found unresponsive, with no pulse oximeter registering, and who was identified as a Full Code status. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #01 did not receive CPR after he was discovered with absent readings on the pulse oximetry and EMS was not contacted for assistance. This affected one (#01) of three residents (#01, #02, and #03) who expired unexpectedly at the facility. The facility census was 52. On [DATE] at 3:52 P.M., the Interim Executive Director, Administrator in Training (AIT) #600, Clinical Support Nurse #800, Regional Minimum Data Set (MDS) Nurse #810, and the Director of Health Services (DHS) were notified Immediate Jeopardy began on [DATE] at approximately 3:05 A.M. when Resident #01, who was a Full Code resuscitation status, was found unresponsive by LPN #200. LPN #200 entered the resident's room and noticed him to be unresponsive after calling out his name. The nurse turned on the light and found his pulse oximeter to be absent of a reading. At 3:15 A.M., LPN #200 contacted the DHS to inform her Resident #01 was unresponsive and direction was given to begin chest compressions immediately and contact the family regarding their wishes. During the investigation on [DATE] it was confirmed by witnesses that LPN #200 responded with the decision to not initiate CPR or call EMS. LPN #200 notified the family of the resident's death at 3:20 A.M. and notified the funeral home, who picked up Resident #01's body on [DATE] at 4:44 A.M. The facility failed to notify the physician of Resident #01's death until 10:00 A.M. on [DATE] when it was completed by the DHS. The Immediate Jeopardy was removed on [DATE] when the facility completed education for all staff on the proper response when finding an unresponsive resident. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] at 4:00 P.M. when the facility completed the following corrective actions: On [DATE] at 3:16 P.M., LPN #200 was suspended pending investigation. On [DATE] at 7:39 P.M., LPN #200 was terminated. On [DATE], Clinical Support Nurse #800 completed an audit on all in house resident's code status. On [DATE], the Executive Director completed Code Education with all staff through a virtual platform. The Code Education defined the proper response when finding an unresponsive individual at the facility. Beginning [DATE], the DHS/designee audited new admissions to compare the resident's advance directives to the physician orders for accuracy. On [DATE], the Quality Assurance and Performance Improvement (QAPI) committee reviewed the plan of correction, including education and audits. On [DATE], the facility-initiated CPR quizzes to be given to all employees twice a week for four weeks, then twice a month for three months, then every month for two months, then as recommended by the QAPI committee. These will be completed by AIT #600. On [DATE], the facility-initiated audits of new admission/readmission charts to verify resident code status five times a week for one month, then three times a week for three months, then weekly for two months, then as recommended by the QAPI committee. This will be completed by the DHS. On [DATE], the DHS completed an audit of all nursing staff for CPR certifications. On [DATE], the medical record for Resident #02 and Resident #03, who expired unexpectedly at the facility, were reviewed, and found staff responded appropriately. Staff interviews on [DATE] at 10:52 A.M. with Certified Resident Care Associate (CRCA) #510, on [DATE] at 8:56 A.M. with CRCA #500, and on [DATE] at 8:25 A.M. with Registered Nurse (RN) #500 verified they had been educated by the facility on the proper response when finding an unresponsive individual at the facility. On [DATE] a review of the audits of new admission/readmission charts, audits of residents' records for residents who expired at the facility, and review of the facility-initiated CPR quizzes to be given to all employees verified the auditing and monitoring had been completed for four weeks with no identified concerns. Findings include: Review of Resident #01's medical record revealed an admitted [DATE]. Diagnoses included atrial fibrillation, congestive heart failure, atrioventricular block, left bundle branch black, and pacemaker placement. Review of a physician order dated [DATE] revealed Resident #01 had a Full Code resuscitation status. Review of a progress note dated [DATE] at 3:05 A.M. revealed LPN #200 went into Resident #01's room and called out his name but received no response. The nurse turned on the light and found him to be pale in color, but his skin remained warm. The pulse oximetry machine had no reading. Chest compressions were initiated. At 3:20 A.M., LPN #200 reached out to Resident #01's daughter-in-law and explained his change in condition. The daughter-in-law instructed for staff to stop compressions, that her father-in-law was a Do Not Resuscitate (DNR), and she would be coming to the facility. At 4:05 A.M., Resident #01's daughter-in-law arrived and stated she planned to bring in paperwork regarding his code status in the morning. The daughter-in-law then requested LPN #200 contact a local funeral home to pick up the body. The funeral home picked up Resident #01 at 4:44 A.M. There was no documentation of the physician being notified of the resident's death. Review of the facility investigation related to Resident #01's death, initiated on [DATE], revealed the AIT #600 obtained statements via an interview from staff working the night Resident #01 expired. The statement from LPN #200 revealed on [DATE] she was notified that Resident #01 had vomited on his gown and was complaining of shortness of breath. Oxygen was applied and suction was obtained from a RN at bedside. Continuous pulse oximetry was applied to his finger while LPN #200 contacted the physician for additional orders. Orders were received for a chest x-ray, aerosol treatments, and a decongestant. The aerosol treatment was administered. RN #300 contacted Resident #01's family to assess his code status. The family stated they believed he was a DNR and they would bring the paperwork to the facility in the morning. On [DATE] at 12:05 A.M., a respiratory treatment was administered, and his pulse oximeter read in the low 90's and no distress was noted. LPN #200 went in to check on the resident at 3:05 A.M. and when she called him by name no response was noted and no pulse oximeter reading could be obtained. Chest compressions were started. The residents' daughter was called to verify wishes and the daughter ordered to stop chest compressions because Resident #01 was a DNR. When the daughter arrived at the facility, she requested a local funeral home be contacted. The funeral home picked up Resident #01's body at 4:44 A.M. Review of the documented interview statement from LPN #210, dated [DATE], revealed at 3:00 A.M. LPN #210 was asked by LPN #200 to look at Resident #01 because he was noted to be unresponsive. LPN #210 asked if they needed to start CPR and LPN #200 stated she was uncertain and wanted to clarify the code status. LPN #210 then left the resident's room. Review of the documented interview statement from CRCA #500, dated [DATE], revealed the CRCA was at a nearby nurses' station when LPN #200 asked for assistance with Resident #01. LPN #210 and CRCA #500 followed LPN #200 to Resident #01's room where he had expired. CRCA #500 and CRCA #510 proceeded to clean up the resident. CRCA #500 revealed she was unaware if anyone performed CPR. Review of the documented interview statement from RN #500, dated [DATE], revealed LPNs #200 and #210 asked the RN for assistance with Resident #01 as he had passed away and they were not sure what to do at that time. The RN informed them to call the DON or 911. LPN #200 proceeded to make a phone call, but the RN was unsure of who she was speaking with or the conversation. LPN #200 instructed RN #500 to go into Resident #01's room and tell CRCA #500 and CRCA #510 to stop. RN #500 assumed it meant to stop chest compressions, but when he entered the resident's room the aides were cleaning Resident #01 and were not performing chest compressions. Review of the documented interview statement from CRCA #510, dated [DATE], revealed LPN #200 came to a neighboring nurse's station where the aide was and asked LPN #210 what to do as Resident #01 was unresponsive. The LPNs went to the resident's room. LPN #210 returned to the nurse's station after approximately 10 minutes and asked CRCA #510 to assist in changing Resident #01's brief and to get him cleaned up and repositioned. RN #500 came into the room, and they all walked out at the same time. Review of the documented interview statement from the DHS, dated [DATE], revealed she received a phone call from LPN #200 at approximately 3:10 A.M. on [DATE]. The LPN informed her Resident #01 was found without vital signs. The DHS instructed LPN #200 to start CPR and call the family to confirm their wishes. Review of a second documented interview statement from the DHS, dated [DATE], revealed she was called on [DATE] at approximately 3:30 A.M. by LPN #200 and informed Resident #01 was found to be without vital signs. The DHS stated she told someone to contact the family to verify code status and to initiate CPR. The DHS revealed when she followed up with LPN #200, the LPN stated the family said to stop CPR and they would be into the facility. The DHS denied knowledge of CPR not being initiated and stated she told LPN #200 to start compressions at the time of the first phone call. The DHS reported the physician was not notified until [DATE] later in the day of Resident #01's death. Interview with CRCA #510 on [DATE] at 10:52 A.M. revealed she was not caring for Resident #01 on the night of [DATE] but was asked to assist in postmortem care. She denied seeing a crash cart in his room and as far as she knew, CPR failed to be initiated. Interview with the Executive Director on [DATE] at 11:02 A.M. revealed after investigation it was found that Resident #01 had a Full Code status and was found unresponsive on [DATE]. Further interview revealed LPN #200 no longer worked at the facility. The Executive Director revealed LPN #200's employment was terminated for multiple reasons, and ultimately for failure to follow physician orders. It was also found that LPN #200 falsified records by documenting CPR was initiated when during the investigation it was found that chest compressions were never performed. Telephone interview on [DATE] at 8:56 A.M. with CRCA #500 revealed on [DATE] she was at the nurse's station with LPN #210 when LPN #200 approached and stated Resident #01 was unresponsive, and she did not know what to do. CRCA #500 revealed she followed the nurses to Resident #01's room and no one was observed performing CPR, nor were emergency medical services contacted. She and CRCA #510 prepped the body for the funeral home to pick up. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed if the resident is a Full Code and is found to be in cardiopulmonary arrest campus staff will: a. Assess for viable signs of life, measure blood pressure, skin temperature, skin color/cyanosis, pulse (absence, rhythm, and quality), respirations (absence, rhythm, quality, level of consciousness). b. Initiate CPR. c. Call 911 to have emergency medics transport the resident to the nearest hospital. d. Notify the attending physician or medical director for instructions. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. This deficiency demonstrates non-compliance with Complaint Number OH00138669.

Based on review of the medical record, staff interview, review of documented staff statements, and facility policy, the facility failed to timely notify the physician of the death of one resident (#01) out of three resident reviewed. The facility census was 52. Findings include: Review of Resident #01's medical record revealed an admitted [DATE]. Diagnoses included atrial fibrillation, congestive heart failure, atrioventricular block, left bundle branch black, and pacemaker placement. Review of a progress note dated [DATE] at 3:05 A.M. revealed Licensed Practical Nurse (LPN) #200 went into Resident #01's room and called out his name but received no response. The nurse turned on the light and found him to be pale in color, but his skin remained warm. The pulse oximetry machine had no reading. Chest compressions were initiated. At 3:20 A.M. LPN #200 reached out to Resident #01's daughter-in-law and explained his change in condition. The daughter-in-law instructed for staff to stop compressions, that her father-in-law was a Do Not Resuscitate (DNR), and she would be coming to the facility. At 4:05 A.M. Resident #01's daughter-in-law arrived and stated she planned to bring in paperwork regarding his code status in the morning. The daughter-in-law then requested LPN #200 contact a local funeral home to pick up the body. The funeral home picked up Resident #01 at 4:44 A.M. There was no documentation of the physician being notified of the resident's death. Review of a documented interview statement from the Director of Health Services (DHS), dated [DATE], revealed she was called on [DATE] at approximately 3:30 A.M. by LPN #200 and informed Resident #01 was found to be without vital signs. The DHS reported the physician was not notified until [DATE] later in the day of Resident #01's death. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed if the resident is a Full Code and is found to be in cardiopulmonary arrest campus staff will notify the attending physician or medical director for instructions. This is an incidental deficiency discovered during the investigation.

Based on record review, facility policy review, and staff interview, the facility failed to ensure nursing staff did not falsify documentation in the medical record regarding the initiation of cardiopulmonary resuscitation for one (#01) of three residents reviewed. The facility had 26 residents designated with a Full Code resuscitation status. The facility census was 52. Findings include Review of Resident (#01's medical record revealed an admitted [DATE]. Diagnoses included atrial fibrillation, congestive heart failure, atrioventricular block, left bundle branch black, and pacemaker placement. Review of a physician order dated [DATE] revealed Resident #01 had a Full Code resuscitation status. Review of a progress note dated [DATE] at 3:05 A.M. revealed LPN #200 went into Resident #01's room and called out his name but received no response. The nurse turned on the light and found him to be pale in color, but his skin remained warm. The pulse oximetry machine had no reading. Chest compressions were initiated. At 3:20 A.M. LPN #200 reached out to Resident #01's daughter-in-law and explained his change in condition. The daughter-in-law instructed for staff to stop compressions, that her father-in-law was a Do Not Resuscitate (DNR), and she would be coming to the facility. At 4:05 A.M. Resident #01's daughter-in-law arrived and stated she planned to bring in paperwork regarding his code status in the morning. The daughter-in-law then requested LPN #200 contact a local funeral home to pick up the body. The funeral home picked up Resident #01 at 4:44 A.M. Review of the facility investigation related to Resident #01's death, initiated on [DATE], revealed the Administrator in Training (AIT) obtained statements via an interview from staff working the night Resident #01 expired. The statement from LPN #200 revealed on [DATE] at 3:05 A.M. LPN #200 went in to check on the resident and when she called him by name no response was noted and no pulse oximeter reading could be obtained. Chest compressions were started. The resident's daughter was called to verify wishes and the daughter ordered to stop chest compressions because Resident #01 was a DNR. Review of the documented interview statement from LPN #210, dated [DATE], revealed at 3:00 A.M. LPN #210 was asked by LPN #200 to look at Resident #01 because he was noted to be unresponsive. LPN #210 asked if they needed to start CPR and LPN #200 stated she was uncertain and wanted to clarify the code status. LPN #210 then left the resident's room. Review of the documented interview statement from Certified Resident Care Associate (CRCA) #500, dated [DATE], revealed the CRCA was at the a nearby nurses' station when LPN #200 asked for assistance with Resident #01. LPN #210 and CRCA #510 followed LPN #200 to Resident #01's room where he had expired. The CRCAs proceeded to clean up the resident. CRCA #500 revealed she was unaware if anyone performed CPR. Review of the documented interview statement from RN #500, dated [DATE], revealed LPNs #200 and #210 asked the RN for assistance with Resident #01 as he had passed away and they were not sure what to do at that time. The RN informed them to call the Director of Health Services (DHS) or 911. LPN #200 proceeded to make a phone call, but the RN was unsure of who she was speaking with or the conversation. LPN #200 instructed RN #500 to go into Resident #01's room and tell the CRCAs to stop. RN #500 assumed it meant to stop chest compressions, but when he entered the resident's room the aides were cleaning Resident #01 and were not performing chest compressions. Review of the documented interview statement from CRCA #510, dated [DATE], revealed LPN #200 came to a neighboring nurse's station where the aide was and asked LPN #210 what to do as Resident #01 was unresponsive. The LPNs went to the resident's room. LPN #210 returned to the nurse's station after approximately 10 minutes and asked CRCA #510 to assist in changing Resident #01's brief and get him cleaned up and repositioned. Interview with CRCA #510 on [DATE] at 10:52 A.M. revealed she was not caring for Resident #01 on the night of [DATE] but was asked to assist in postmortem care. She denied seeing a crash cart in his room and as far as she knew CPR failed to be initiated. Interview with the Executive Director on [DATE] at 11:02 A.M. revealed after investigation it was found that Resident #01, who had a Full Code status and was found unresponsive on [DATE], was failed to be administered CPR. It was also found that LPN #200 falsified records by documenting CPR was initiated when during the investigation it was found that chest compressions were never performed. Telephone interview on [DATE] at 8:56 A.M. with CRCA #500 revealed on [DATE] she was at the nurse's station with LPN #210 when LPN #200 approached and stated Resident #01 was unresponsive, and she did not know what to do. CRCA #500 revealed she followed the nurses to Resident #01's room and no one was viewed performing CPR nor were emergency medical services contacted. She and another CRCA prepped the body for the funeral home to pick up. Interview with the DHS on [DATE] at 2:23 P.M. verified LPN #200 falsified medical documentation regarding performing CPR for Resident #01 on [DATE]. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed the attending nurse shall document using the CPR event in the health electronic record or nursing progress note: Resident condition and assessment results before CPR was initiated. Assessment results after completion of CPR, if applicable. Resident condition and assessment results if CPR was not initiated and reason why it was not initiated. This is an incidental violation citation discovered during the complaint investigation.

Based on record review, staff interview, and review of the shower schedule, the facility failed to ensure a resident received bed baths as scheduled. This affected one (#30) of three residents reviewed for bathing. The facility census was 54. Findings include: Review of Resident #30's medical record revealed an admitted [DATE], and discharge date on 09/25/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The assessment identified the resident as requiring extensive assistance with hygiene and bathing was marked as activity did not occur. Review of Resident #30's most recent care plan revealed the resident required staff assistance to complete activities of daily living (ADL) completely and safely. Interventions included to provide adequate rest periods between activities. Review of the facility's shower schedule reviewed Resident #30 was scheduled to have shower/bath on Tuesdays and Fridays. Review of Resident #30's ADL record revealed the resident did not receive a bath from 08/26/21 through 09/11/21. Interview on 10/01/21 at 2:50 P.M. with the Director of Nursing (DON) verified according to the documentation, Resident #30 did not receive a bath from 08/26/21 through 09/11/21. This deficiency substantiates Complaint Number OH 173.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a resident received a follow up visit from an oral surgeon. This affected one (#30) of three residents reviewed for dental services. The facility census was 54. Findings include: Review of Resident #30's medical record revealed an admitted [DATE], and discharge date on 09/25/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The assessment identified the resident as having mouth or facial pain and discomfort or difficulty swallowing. Review of Resident #30's care plan dated 06/11/21 revealed the resident had mouth/gum pain. Interventions included dental evaluation and intervention as needed. Review of Resident #30's nurse's note dated 05/24/21, revealed the resident had reported having at gumline on the bottom left side of the mouth. The physician's office was notified and would like the resident to see a dentist. Review of Resident #30's social services notes from 05/24/21 through 06/14/21, revealed the social worker did contact the dentist office. Review of Resident #30's nurse's note dated 06/23/21, revealed the resident had returned from the hospital after a visit for an elevated temperature. The resident had a Computed Tomography (CT) scan of his face for mouth pain. The CT scan showed calculus in the submandular gland and the resident needed to see an oral surgeon to have the tooth pulled. Review of Resident #30's nurse's note dated 06/25/21, the facility dentist recommended the resident follow up with an oral surgeon. Review of Resident #30's dentist visit dated 06/25/21, revealed the resident was seen by a dentist for an evaluation and X-rays were taken. Review of Resident #30's nurse's note dated 06/29/21, revealed the oral surgeon's office was contacted regarding the need to schedule an appointment. The surgeon's office requested insurance information to schedule an appointment. The resident's mother was called to get the information and was awaiting a call back. Further review of Resident #30's nurse's notes between 06/29/21 and 09/25/21, revealed there was no documentation regarding the resident's oral surgeon appointment. Interview on 10/01/21 at 3:25 P.M. with the Administrator, verified there had been no follow up regarding Resident #30's appointment with the oral surgeon. Review of the facility policy titled, Dental Services Including Repair, Replacement, dated 11/08/17, revealed the facility will assist residents in obtaining routine and emergency dental care per the resident request. The facility will assist by making appointments and/or by arranging for transportation to and from the dental service location. This deficiency substantiates Complaint Number OH 173.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of one resident's elevated blood sugar levels. This affected one (#20) of three residents reviewed for blood glucose monitoring. The facility census was 54. Findings include: Review of Resident #20's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately intact cognition. The resident was identified as receiving insulin injections. Review of Resident #20's most recent care plan revealed the resident was at risk for [CONDITION(S)]/[CONDITION(S)] related to diabetes mellitus. Interventions included to monitor blood sugars per physician orders. Review of Resident #20's physician order dated 08/08/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #20's nurse's notes dated 08/08/21 through 09/08/21, revealed the notes were absent of any documentation the physician was notified of the resident's elevated blood sugars. Interview on 09/30/21 at 2:15 P.M. with the Director of Nursing (DON) stated usually the physician was not notified unless the resident's blood sugar was 400. Review of the undated facility policy titled, Notification of Change in Condition, revealed, the facility will notify the physician of a critical laboratory value which required an immediate intervention. This deficiency substantiates Complaint Number OH 934.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's wound was assessed, documented and monitored. This affected one (#20) of three residents reviewed for wounds. The facility census was 54. Findings Include: Review of Resident #20's medical record revealed an admitted [DATE], and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately intact cognition. The resident was identified as being at risk for pressure ulcers. Review of Resident #20's care plan revealed on 08/20/21, the resident had a lesion on her left second toe. Interventions included to observe lesion for signs and symptoms of infection. Review of Resident #20's physician order dated 08/08/21, and discontinued on 08/10/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 500 mg orally four times a day for infection second toe was ordered on 08/25/21, and discontinued on 08/31/21. The resident had a physician order dated 08/18/21, to cleanse left second toe, apply [MEDICATION(S)] and dry dressing daily. Review of Resident #20's interdisciplinary (IDT) note dated 08/18/21, revealed the resident was noted to have a bruise/blister to the toe. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/30/21 at 2:15 P.M. with the Director of Nursing (DON) stated Resident #20 had a blister on her toe and the blister opened up. The DON verified there was no documentation of the toe wound. Review of the facility policy titled, Guidelines for General Wound and Skin Care, dated 05/23/18, revealed documentation of wounds were completed weekly using the wound/skin treatment flow sheet. This deficiency substantiates Complaint Number OH 934.

Based on observation, review of the COVID-19 screening log, staff interview, and review of the facility policy, the facility failed to ensure proper screening procedures were in place for to assess visitors entering the facility for signs and symptoms of COVID-19. This had the potential to affect all 56 residents residing in the facility. Additionally, the facility failed to properly clean, sanitize and, store bed pans in resident bathrooms. This affected two (#33 and #41) residents, who reside in the same resident room. The facility census was 56. Findings include: 1. Observation on 08/12/21 at 8:15 A.M. revealed the front entrance door was unlocked, allowing outside persons entrance to the building. Once inside, a posted sign indicated visitors are to be screened for signs and symptoms of COVID-19. No staff were available to provide visitor screening for signs and symptoms of COVID-19, allowing visitors to enter building unscreened. Review of the COVID-19 screening log revealed four visitor entries without initials, indicating screening was completed by staff. Interview on 08/12/21 at 8:50 A.M., with Director of Nursing (DON) revealed the business office staff screen visitors for signs and symptoms of COVID-19 upon entrance. Review of facility policy titled Guidelines for COVID-19, dated 03/11/20, revealed precautionary measures taken in all campuses included complete infection control education and screening questionnaires for all employees, visitors, outpatients, and contractors who attempt to enter the campus. The screening will include temperature monitoring. The facility should have designated campus employee at main entrance providing education and screening. 2. Observation on 08/09/21 at 11:00 A.M., of Resident #33 and #41's bathroom revealed two soiled bed pans filled with fluid stacked on top of each other on the bathroom floor. This was verified at the time of the observation with State tested Nursing Assistant (STNA) #410. STNA #410 revealed bed pans were to be sanitized and placed in a plastic bag.

Based on observation and staff interview, the facility failed to change contaminated gloves before touching food items when serving resident meals. This had the potential to affect all residents who received food from the kitchen. Resident #7 was identified by the facility as receiving nothing by mouth. The facility census was 56. Findings include: Observations on 08/09/21 from 11:40 A.M. to 11:55 A.M. of lunch service revealed Dietary Aide (DA) #478 plating resident meals. DA #478 gloved her hands, picked up a plate, touched the serving utensils for the chopped steak, mashed potatoes and California blend vegetables. Then without changing the gloves, picked up a dinner roll with a gloved hand and placed the roll on a plate. DA #478 repeated this process ten times without changing her gloves. In addition, observation of DA #464 revealed she donned gloves and proceeded to touch serving tongs, french fries, a metal pan, opened a refrigerated drawer, and then picked up a hot dog and placed it on the grill. DA #464 then removed her gloves and donned a new pair. DA #464 picked up a loaf of bread, reached inside and removed two slices of bread, buttered the bread and placed the bread on the grill on the grill. Without changing her gloves DA #464 opened a refrigerated drawer and removed slices of deli meat with her gloved hand, placed the deli meat on the grill, opened a refrigerator and removed a package of sliced cheese and a bottle of salad dressing. DA #464 then opened the package of cheese and removed a slice. DA #464 then removed her soiled gloves and donned a clean pair. DA #464 placed the cheese slice on the deli meat on the grill, opened a refrigerated drawer, picked up fish fillets and placed them on the grill and then removed her gloves and donned a new pair. Interview, at the time of the observation with Dietary Manager (DM) #461 and Assistant Dietary Manager (ADM) #490 verified DAs #478 and #464 touched food and non-food items using the same gloves.

Based on observation, medical record review, resident and staff interview and review of facility policy, the facility failed to ensure medications were not left unattended at resident bedside and failed to maintain a safe environment as care planned for fall prevention. This affected three residents (#11, #13 and #29) who were identified by the facility as being cognitively impaired, independently mobile, and one (#2) of two residents reviewed for fall precautions. The facility census was 56. Findings include: 1. Observation on 08/09/21 at 10:13 A.M. of Resident #9's room revealed a medication cup on the resident's tray table with four pills in the cup. Interview Resident #9 at the time of the observation revealed the pills were prescription medications that were left on her tray table by the nurse. Resident #9 stated the nurse was called away before she was able to take them all. Resident #9 picked up the medications and took them. Interview on 08/09/21 at 10:16 A.M. with Licensed Practical Nurse (LPN) #449 verified she left Resident #9's medications in her room. LPN #449 stated Resident #9 did not like to take all of her medications at one time because they caused her to have an upset stomach. LPN #449 stated she always went back to the resident's room to make sure she took them. The facility identified three residents (#11, #13 and #29) who as being cognitively impaired, independently mobile and resided on the same unit as Resident #9. 2. Review of Resident #2's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included fracture of right femur, spinal stenosis, [CONDITION(S)], [CONDITION(S)], orthostatic [CONDITION(S)]; macular degeneration; and disorientation. Review of the Minimum Data Set (MDS) assessment, dated 07/19/21, revealed Resident #2 was moderately cognitively impaired. The resident required extensive two person assistance with bed mobility, transfers and personal hygiene and extensive one person assistance with dressing and toilet use. There was a history of a fall with injury. Review of the plan of care, initiated 12/29/20, revealed Resident #2 was at risk for falling related to weakness, incontinence, history of falls, [CONDITION(S)] medication use, orthostatic [CONDITION(S)] and recent right femur fracture. Interventions, with the initiated dates, included: 12/29/20 ensure the floor is free of liquids and foreign objects, 03/09/21 room was rearranged for increased mobility, 06/29/21 Resident's recliner was decluttered to allow her to sit in it, and 07/20/21 re-arrange the room. Observation on 08/09/21 at 9:49 A.M. of Resident #2's room revealed a fall mat next to the resident's bed. Next to the fall mat, pushed against the front of the resident's recliner, were three boxes, a pillow and two grocery store bags with items in them. There was approximately a six inch space between the fall mat and the boxes in order to walk through the area. Interview of Resident #2 at the time of the observation revealed she was not able to safely get out of her bed. Resident #2 stated the mat and boxes were ridiculous and the nursing staff were not able to walk through without tripping. Interview on 08/09/21 at 3:38 P.M. with Licensed Practical Nurse (LPN) #449 verified the boxes, pillow and grocery store bags with items in them pushed against Resident #2's recliner. LPN #449 stated Resident #2's family brought the boxes, containing personal items, and dropped them off without organizing the contents. LPN #449 stated she was not sure how long the boxes had been in the room or when they were going to be moved. Interview on 08/10/21 at 11:29 A.M. of the Director of Nursing (DON) revealed Resident #2 had a fall on 07/06/21, resulting in a [CONDITION(S)]. Upon the Resident's return from the hospital on 07/09/21, Resident #2 was moved to a room where staff could provide closer supervision. The DON stated the boxes were items that had been moved from the resident's previous room. The family had been contacted to pick them up, but the resident's son was unresponsive to the request. Interview on 08/10/21 at 11:59 A.M. LPN #404 revealed Resident #2 often attempted to get out of bed unassisted and walk or crawl on the floor in her room. Review of facility policy titled Fall Management Program Guidelines, revised 05/31/17, revealed the purpose was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. In addition, care plan interventions should be implemented that address the resident's risk factors.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to treat residents with dignity by hanging signs in resident rooms indicating care needs. This affected two (#13 and #39) of three residents reviewed for dignity. The facility census was 56. Findings include: 1. Review of Resident #39's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/07/21, revealed Resident #39 was severely cognitively impaired and required extensive two person assistance with bed mobility. Review of the plan of care revealed a resident profile intervention, implemented 08/09/21, to place a sign in the resident room as a reminder to put resident's right hip in straight/neutral alignment when seated in chair and in laying position. Observation on 08/09/21 at 9:58 A.M. of Resident #39's room revealed a sign hanging on the outside of the cabinet door, next to the resident's bed, which read Please put patient in straight neutral alignment when seated in chair and in laying position-Therapy. Interview on 08/09/21 at 2:58 P.M. with Licensed Practical Nurse (LPN) #449 verified the sign hanging on Resident #39's cabinet door. LPN #449 stated therapy placed the sign as a reminder on how to appropriately position Resident #39. 2. Review of Resident #13's medical record revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 05/28/21, revealed Resident #13 was moderately cognitively impaired and required extensive one person assistance with dressing. Review of the plan of care, initiated 05/02/17, revealed Resident #13 was at risk for falling related to muscle weakness, difficulty walking, impaired cognition, polypharmacy and absence of right ear drum. Interventions, initiated 04/28/20, included note in room to remind resident to keep shoes off the floor. Observation on 08/09/21 at 2:44 P.M. of Resident #13's room revealed a sign hanging on the resident's shelves, visible from the hall, which read SHOES Please keep shoes off floor so [resident] can reach. Interview on 08/09/21 at 2:58 P.M. with Licensed Practical Nurse (LPN) #449 verified the sign in Resident #13's room. LPN #449 stated the sign was placed by therapy to remind staff to keep Resident #13's shoes up because the resident would lean over to pick them up and fall. Interview on 08/10/21 at 2:02 P.M. with Clinical Support Resident Assessment (CSRA) #488 revealed signs placed in resident rooms were provided as reminders to residents for various reasons, such as to use their walker. The signs were discussed with residents and representatives and were care planned. CSRA #488 verified the signs in Residents #39 and #13 were written as instructions to staff on care needs of residents and not as reminders to residents. Review of facility policy titled Resident Rights Guidelines, revised 05/11/17, revealed residents have a right to be treated with dignity, respect and privacy.