Every finding on record at Laurels of Worthington, The

Based on observations, staff interviews, and policy review, the facility failed to ensure all stored medications were not expired. This had the potential to affect 42 (#1, #3, #4, #5, #6, #9, #12, #27, #28, #19, #21, #37, #41, #42, #44, #47, #48, #49, #53, #55, #58, #60, #64, #68, #72, #73, #75, #78, #79, #80, #81, #84, #86, #92, #93, #94, #96, #97, #98, #99, #100, and #101) residents with medications stored in the north and east medication cart. The facility census was 91.Findings include: Observation and staff interview on [DATE] at 6:59 A.M. of the north medication cart revealed the following: one opened bottle of Zinc tablets with a best by date of 2026/01, one opened bottle of sodium chloride tablets with a best by date of 05/26, and one unopened bottle of calcium tablets with a best by date of 07/2025. Interview with Registered Nurse (RN) #268 at the time of the observation confirmed the three bottles of expired medication were present on the medication cart. Observation and staff interview on [DATE] at 7:05 A.M. of the east medication cart with RN #299 revealed one opened bottle of oyster shell calcium tablets with a best by date of 05/2026. Interview with RN #299 at the time of the observation confirmed the expired medication was present on the medication cart. Interview on [DATE] at 9:23 A.M. with the Director of Nursing (DON) revealed the expectation is that all nurses are checking the expiration dates of the medications on their carts before administration. The facility confirmed there are 42 (#1, #3, #4, #5, #6, #9, #12, #27, #28, #19, #21, #37, #41, #42, #44, #47, #48, #49, #53, #55, #58, #60, #64, #68, #72, #73, #75, #78, #79, #80, #81, #84, #86, #92, #93, #94, #96, #97, #98, #99, #100, and #101) residents with medications stored in the north and east medication cart. Review of facility policy titled medication storage with an effective date of [DATE] stated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy if replacements are needed.

Based on observations and resident and staff interviews, the facility failed to ensure a comfortable, home-like environment through the use of overhead paging and alarms. This affected two (#3 and #44) of five residents reviewed for environmental concerns. The facility census was 91.Findings include:Observations on 06/08/26 at 8:00 A.M. and throughout the survey revealed overhead alarm paging when alarmed doors are opened. The announcements were broadcasted throughout the facility. Interview on 06/09/26 at 9:50 A.M. with Resident #3 confirmed the alarm goes off throughout the day and night and wakes her up. Resident #3 stated she is the president of resident council and brought the concern up in the meeting in May 2026. Resident #3 stated she was told that the alarms cannot be turned down or turned off. Interview on 06/09/26 at 9:50 A.M. with Resident #44 confirmed the alarm was bothersome and interrupted her sleep. Observations on 06/09/26 from 9:50 A.M. to 10:00 A.M. during the interview with Residents #3 and #44 revealed the overhead alarms went off four times. Interview on 06/11/26 at 9:03 A.M. with Director of Maintenance (DM) #252 confirmed the door alarms alert facility-wide via an overhead paging system to notify staff members that an external door had been opened so they can respond quickly. DM #252 confirmed he was not aware of any complaints from residents regarding the noise levels or the announcements of the alarm. Review of the policy titled, Federal Resident Rights and Facility Responsibilities, not dated, stated the facility must maintain comfortable sound levels.

Based on record review, observation, interview, and policy review the facility failed to provided Activities of Daily Assistance (ADL) assistance to dependent residents. This affected one (#59) of one residents reviewed for ADL care. The facility census was 91. Finding include: Record review of Resident #59 medical records revealed an admission date of 06/09/23 and medical diagnosis of senile degermation of the brain, dementia, hypertension, hyperlipidemia, asthma, hypothyroidism, insomnia, muscle weakness, contracture, and gastro-esophageal reflux disease. Review of Resident #59 Minimum Data Set last updated 03/31/26 revealed the resident had a Brief Interview of Mental Status score of zero and had severe cognitive impairment, the resident required maximum assistance for personal care and required supervision with eating. Review of Resident #59 Care Plan last revised 06/10/26 revealed the resident had a function ability deficit and required assistance with self-care and mobility related to dementia and non-ambulator status. Interventions include to cue the resident at meals and assist as needed due to poor intakes. Observation on 06/09/26 at 8:50 A.M. revealed Resident #59 in their room eating breakfast with their right hand. The residents' right hand was covered in a dark brown substance that was both under the residents nails and clumped on top of residents nails. Interview on 06/09/26 at 8:51 a.m. with Licensed Practical Nurse (LPN) #260 confirmed Resident #59 had a dark brown substance on and under their fingernails that would not have come from their breakfast. Resident #59's hands were cleaned by LPN #260 and the resident continued eating their breakfast. Interview on 06/11/26 with the Director of Nursing (DON) confirmed that the facilities expectation is that staff assist all dependent residents with the proper ADL care prior to eating. Review of the undated facility policy, Resident Rights and Facility responsibilities revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on record review, observations and staff interviews, the facility failed to ensure provider orders were accurately implemented/followed. This affected two (#1 and #69) of 21 residents reviewed for implementation of physician orders. The facility census was 91. Findings include:1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to end stage renal disease, vascular dementia, and hypertensive chronic kidney disease with stage five chronic kidney disease or end stage renal disease. Review of the most recent minimum data set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 05. Review of the care plan for Resident #1 revealed the resident is at risk for complications related to hemodialysis related to end stage renal disease. Interventions include do not draw blood or take blood pressures in arm with graft and do not use shunted arm for blood pressure, Veni-puncture, IV, etc Review of the current provider orders for Resident #1 revealed an order for no blood pressures in the left arm due to fistula every shift for blood pressure. Review of vitals for Resident #1 revealed multiple blood pressures documented that were obtained on the left arm. Interview with the Director of Nursing (DON) on 06/10/26 at 2:24 P.M. revealed that there is an order for no blood pressures to be obtained on Resident #1's arm and that blood pressure has been obtained on the left arm on multiple occasions. 2. Review of Resident #69's record revealed the resident was admitted [DATE] and had diagnoses that included vascular dementia, unspecified protein-calorie malnutrition, vitamin D deficiency, and other iron deficiency anemia. The resident's Brief Interview for Mental Status (BIMS) score was 00. Review of Minimum data set 3.0 dated 04/30/26 revealed Resident #69 did not exhibit the behavior of rejecting evaluation or care. Review of care plan revised on 06/03/26 revealed Resident #69 is at risk for impaired skin integrity/pressure injury related to frequent bowel/bladder (B/B) incontinence, poor meal intakes recent, and malnutrition. Further review revealed interventions of Geri sleeves to bilateral upper extremities (BUE) to prevent skin tears and place bilateral elbow protectors on as tolerated. Review of progress notes revealed the following nurse's note on 05/24/26 at 6:41 P.M. skin tear/abrasion noted to the right forearm. Guest was further assessed, vital signs within normal limits. On-call provider was notified, skin tear cleaned with normal saline and dry dressing applied over. Guest's Power of Attorney (POA) and facility on-call nurse both notified. Review of Skin Tear Incident Report dated 05/24/26 revealed the Certified Nursing Assistant (CNA) noted bleeding to the right outer forearm. This nurse assessed guest and a skin tear/abrasion noted but cannot measure due to resident cooperation and shape of wound. Guest stated was scratching on to the right forearm. IDT performed root cause analysis: resident scratching and prefers nails to be longer. Immediate intervention: moisturize skin twice daily (BID) with appropriate moisturizer. Review of Treatment Administration Records (TAR) dated April 2026, May 2026 and June 2026 revealed geri sleeves were documented as administered every day starting on 04/03/26 except for 04/19/26 and 05/24/26, both night shift. Further review revealed elbow protectors were documented as administered everyday starting on 04/29/26 except for 05/24/26 night shift. No refusals were documented on the TARs. Review of physician's orders revealed the following active orders: place bilateral elbow proctors as tolerated with a start date of 04/29/26 and use Bilateral Upper extremity geri sleeves to protect the skin from tearing, every shift for protection with a start date of 04/03/26. Observation on 06/11/26 at 10:39 A.M. revealed Resident #69 sitting in dining room chair at dining room table. Resident #69 was observed wearing a pink short sleeve shirt with a sleeve length ending above the elbow. No geri sleeves or elbow protectors were observed on Resident #69's arms. Observation on 06/11/26 at 11:40 A.M. revealed Resident #69 sitting in dining room chair at dining room table. Resident #69 was observed wearing a pink short sleeve shirt with a sleeve length ending above the elbow. No geri sleeves or elbow protectors were observed on Resident #69's arms. Interview with Licensed Practical Nurse (LPN) #259 on 06/11/26 at 11:40 A.M. confirmed the physician's orders for elbow protectors and geri sleeves for Resident #69. LPN #259 confirmed Resident #69 was not wearing geri sleeves or elbow protectors. LPN #259 stated that the resident refuses to wear them. Interview with LPN #244 on 06/11/26 at 11:40 A.M. confirmed Resident #69 was not wearing geri sleeves or elbow protectors. LPN #244 stated it is an ongoing issue that Resident #69 refuses to wear her geri sleeves. LPN #244 stated that when they try to put the geri sleeves on the resident she will take them off within a couple hours.

Based on record review, observations, staff interview, and policy review, the facility failed to ensure medications were administered as ordered, resulting in two medication errors out of 26 opportunities or a 7.69 percent (%) medication error rate. This affected two (#41 and #79) out of five residents observed for medication administration. The facility census was 91.Findings include: 1. Review of Resident #41's record revealed the resident was admitted [DATE] and had diagnoses that included type 2 diabetes mellitus with hyperglycemia. The resident's Brief Interview for Mental Status (BIMS) score was 15. Observation on 06/10/26 at 8:45 A.M. revealed Registered Nurse (RN) #239 dial HumaLog Injection Pen to 14 units. Further observation revealed RN #239 administer HumaLog Injection Pen to Resident #41. The HumaLog Injection Pen was never observed to be primed prior to administration of insulin. Interview with RN #239 on 06/10/26 at 8:50 A.M. confirmed they did not prime the insulin injection pen prior to administration of insulin to Resident #41. RN #239 confirmed that the nurses are given education on priming insulin pens prior to insulin administration. Interview with the Director of Nursing (DON) on 06/10/26 at 9:23 A.M. revealed all nurses are educated on using insulin injection pens and priming the insulin injection pens prior to administration. DON also stated that she did not have a copy of the manufacturer's instructions for the insulin inject pen, as the copy that came with the pen had been thrown away. Review of facility policy titled insulin administration (effective date 06/21/2017) stated if staff are unsure how to operate an insulin device, they must seek additional advice and support: follow manufacturer's instructions, notify charge nurse, other clinical resource or director of nursing for additional training or reference material, contact the manufacturer for assistance. Further review of the policy revealed many pens require priming or an air-shot prior to administration. Review of Instructions for Use HUMALOG Kwik Pen (insulin lispro) injection, for subcutaneous use 3mL single-patient-use pen 100 units per mL stated prime before each injection. Further review revealed, if you do not prime before each injection, you may get too much or too little insulin. 2. Review of Resident #79's record revealed the resident was admitted [DATE] and had diagnoses that included Non-ST elevation myocardial infarction and essential hypertension. The resident's BIMS score was 09. Observation on 06/10/26 at 8:30 A.M. revealed RN #239 add resident's isosorbide mononitrate ER Tablet Extended Release 24 HR 30 mg tablet to a pill cup with several other oral medications. RN #239 then crushed all pills in the pill cup to a fine powder using a pill crusher. RN #239 then added the crushed medication powder to a small cup of applesauce. RN #239 administered all crushed medications, including isosorbide mononitrate extended-release tablet, to Resident #79 with applesauce. Interview on 06/10/26 at 8:35 A.M. with RN #239 confirmed the nurse crushed and then administered an extended-release medication. RN #239 confirmed that the nurses are not supposed to crush the extended-release medications. Review of the facility's document titled Medications Not to Be Crushed (Rev 10/24) revealed isosorbide mononitrate (extended release) tablet was on the list of medications not to be crushed. Review of the facility's policy titled Medication Administration (last revised 10/17/23) stated check the do not crush list before crushing medications. Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected two (#41 and #79) out of five residents observed for medication administration. The facility census was 91.Findings include: 1. Review of Resident #41's record revealed the resident was admitted [DATE] and had diagnoses that included type 2 diabetes mellitus with hyperglycemia. The resident's Brief Interview for Mental Status (BIMS) score was 15. Observation on 06/10/26 at 8:45 A.M. revealed Registered Nurse (RN) #239 dial HumaLog Injection Pen to 14 units. Further observation revealed RN #239 administer HumaLog Injection Pen to Resident #41. The HumaLog Injection Pen was never observed to be primed prior to administration of insulin. Interview with RN #239 on 06/10/26 at 8:50 A.M. confirmed they did not prime the insulin injection pen prior to administration of insulin to Resident #41. RN #239 confirmed that the nurses are given education on priming insulin pens prior to insulin administration. Interview with the Director of Nursing (DON) on 06/10/26 at 9:23 A.M. revealed all nurses are educated on using insulin injection pens and priming the insulin injection pens prior to administration. DON also stated that she did not have a copy of the manufacturer's instructions for the insulin inject pen, as the copy that came with the pen had been thrown away. Review of facility policy titled insulin administration (effective date 06/21/2017) stated if staff are unsure how to operate an insulin device, they must seek additional advice and support: follow manufacturer's instructions, notify charge nurse, other clinical resource or director of nursing for additional training or reference material, contact the manufacturer for assistance. Further review of the policy revealed many pens require priming or an air-shot prior to administration. Review of Instructions for Use HUMALOG Kwik Pen (insulin lispro) injection, for subcutaneous use 3mL single-patient-use pen 100 units per mL stated prime before each injection. Further review revealed, if you do not prime before each injection, you may get too much or too little insulin. 2. Review of Resident #79's record revealed the resident was admitted [DATE] and had diagnoses that included Non-ST elevation myocardial infarction and essential hypertension. The resident's BIMS score was 09. Observation on 06/10/26 at 8:30 A.M. revealed RN #239 add resident's isosorbide mononitrate ER Tablet Extended Release 24 HR 30 mg tablet to a pill cup with several other oral medications. RN #239 then crushed all pills in the pill cup to a fine powder using a pill crusher. RN #239 then added the crushed medication powder to a small cup of applesauce. RN #239 administered all crushed medications, including isosorbide mononitrate extended-release tablet, to Resident #79 with applesauce. Interview on 06/10/26 at 8:35 A.M. with RN #239 confirmed the nurse crushed and then administered an extended-release medication. RN #239 confirmed that the nurses are not supposed to crush the extended-release medications. Review of the facility's document titled Medications Not to Be Crushed (Rev 10/24) revealed isosorbide mononitrate (extended release) tablet was on the list of medications not to be crushed. Review of the facility's policy titled Medication Administration (last revised 10/17/23) stated check the do not crush list before crushing medications. Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on record review, observations, resident and staff interviews and facility policy review, the facility failed to implement their safe smoking policies and procedures. This affected one (#100) out of one residents reviewed for smoking. The facility census was 91. Findings include:Medical record review of Resident #100 admitted [DATE] with diagnoses of pneumonia, chronic obstructive pulmonary disease and acute sinusitis. Minimum data set (MDS) assessment dated [DATE] revealed resident #100 has a Brief Interview for Mental Status (BIMS) of 15 resident is cognitively intact. Review of resident care plan revealed Resident #100 is a supervised smoker. Interview and observation on 06/09/26 at 9:15 A.M. with Resident #100 revealed resident is a smoker and keeps her smoking materials on herself. Interview on 06/11/26 at 9:19 A.M. with Licensed Practical Nurse (LPN) #294 revealed residents can keep smoking materials on themselves if they do not reside on the memory care unit. Interview on 06/11/26 at 10:14 A.M. with the Administrator confirmed Smoking Policy, dated 06/17/25, is the most up to date policy. Administrator confirmed smoking materials are to be stored in locked cabinet. The Administrator confirmed Resident #100 should not keep smoking material on herself. Review of the facility policy titled Smoking Policy, dated 06/17/25 revealed staff members should maintain all smoking paraphernalia for all unsafe and safe smokers; e.g., cigarettes, e-cigarettes, vaping devices, cigars, pipes, lighters, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members distribute smoking materials to residents that are unsafe to smoke at the designated smoking times, and to residents that are deemed safe to smoke and may smoke independently, at their request. Smoking paraphernalia will be retrieved by staff when smoking activity is concluded.

Based on record review, observation, interview and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when caring for residents with Covid 19 infection. This affected five (Residents #13. #24, #40, #42 and #16) residents. The census was 90. Findings include:1. During an observation on 07/17/25 at 9:20 AM, Resident #13's room had two signs on the door, one for Enhance Barrier Precautions and one for Contact Isolation Precautions. There were four occupants in the room, Residents #13, #34, #40 and #42 . Residents #34, #40 and #42 were exposed to Resident #13, who was positive for Covid #19. Certified Nursing Assistant (CNA) #104 was taking care of Resident #40 and was wearing only a surgical mask, no other PPE. During an interview on 07/17/25 at 9:50 A.M., CNA #104 confirmed Resident #13 was the only resident with Covid 19 in his room. She should have been wearing a gown, face mask, N-95 and gloves due to the positive resident and the others were exposed to Covid 19. During an interview on 07/17/25 at 9:56 A.M., Infection Control Preventionist # 110 confirmed the droplet isolation sign should be the only sign on Resident #13's door and staff were to wear contact droplet isolation PPE when in Resident #13 room. 2. During an observation on 07/17/25 at 10:00 A.M., Licensed Practical Nurses (LPN) #106 and #202 donned a surgical mask, gloves and gown. They walked into Resident #16 room and closed the door. Th Infection Control Preventionist # 110 confirmed the nurses should have been wearing an N-95 mask, goggles or a face shield when giving care to Resident #16. Resident #6 tested positive for Covid 19 on 07/09/25. Review of facility policy titled Coronavirus (COVID 19), dated 02/28/25 , revealed appropriate measures will be utilized for the prevention and control of the Coronavirus (COVID 19) . All recommended COVID-19 PPE should be worn during care of residents under observation or Transmission Based Precautions , which include use of NIOSH approved N-95 mask or a higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face) gloves and gown . This deficiency represents non-compliance investigated under Complaint Number 2563541

Based on staff interview and record review, the facility failed to ensure there was verification of receipt for spenddown notifications and a plan to spenddown the accounts for four residents who received Medicaid Benefits. This affected four residents (#25, #43, #48, and #58) of five residents reviewed for personal funds. The facility census was 91. Findings include: 1. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including Alzheimer's disease and dementia. Review of Resident #48's payer information revealed her primary payor source was Medicaid. Review of Resident #48's resident trust fund authorization revealed the responsible party was to receive statements. Review of Resident #48's quarterly statement dated 03/31/24 revealed her closing balance was $3,423.92. Review of a letter dated 04/19/24 revealed it was notification that Resident #48's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #48's quarterly statement dated 06/30/24 revealed her closing balance was $3,265.46 Review of the letters dated 06/29/24 and 07/29/24 revealed the letters were notifications that Resident #48's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #48's quarterly statement dated 09/30/24 revealed her closing balance was $3,270.18. Review of a letter dated 10/15/24 revealed it was notification that Resident #48's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of the current account balance as of 10/28/24 revealed Resident #48 had $3,146.55 in her account. Interview on 10/31/24 at 11:34 A.M. and 11:39 A.M. with Business Office Manager (BOM) #205 verified they had no evidence that spenddown notification was sent or received by the responsible party. BOM #205 reported he had issues getting ahold of Resident #48's family and had no plan to spend her account down. 2. Review of Resident #58's medical record revealed an admitted [DATE] with diagnoses including dementia. Review of Resident #58's payor information revealed her primary payor source was Medicaid. Review of Resident #58's resident trust fund authorization revealed the responsible party was to receive statements. Review of Resident #58's quarterly statement dated 03/31/24 revealed her closing balance was $2,951.67. Review of a letter dated 04/19/24 revealed it was notification that Resident #58's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #58's quarterly statement dated 06/30/24 revealed her closing balance was $3,050.95. Review of a letter dated 06/29/24 and 07/29/24 revealed it was notification that Resident #58's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #58's quarterly statement dated 09/30/24 revealed her closing balance was $4,159.46. Review of a letter dated 10/15/24 revealed it was notification that Resident #58's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of the current account balance as of 10/28/24 revealed Resident #58 had $4,074.82 in her account. Interview on 10/31/24 at 11:34 A.M. and 11:39 A.M. with Business Office Manager (BOM) #205 verified they had no evidence that spenddown notification was sent or received by the responsible party. BOM #205 reported he knew he had discussed spending down the money with Resident #58's family in the past but he was not sure when. 3. Review of Resident #43's medical record revealed an admitted [DATE] with diagnoses including dementia. Review of Resident #43's payor information revealed her primary payor source was Medicaid. Review of Resident #43's resident trust fund authorization dated 09/29/20 revealed the responsible party was to receive statements. Review of Resident #43's quarterly statement dated 03/31/24 revealed a closing balance of $2,189.11 Review of a letter dated 04/19/24 revealed it was notification that Resident #43's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #43's quarterly statement dated 06/30/24 revealed her closing balance was $2,264.10. Review of a letter dated 06/29/24 and 07/29/24 revealed it was notification that Resident #43's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of Resident #43's quarterly statement dated 09/30/24 revealed a closing balance of $2,441.68. Review of a letter dated 10/15/24 revealed it was notification that Resident #43's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of the current account balance as of 10/28/24 revealed Resident #43 had $2,500.00 in her account. Interview on 10/31/24 at 11:34 A.M. and 11:39 A.M. with Business Office Manager (BOM) #205 verified they had no evidence that spenddown notification was sent or received by the responsible party. BOM #205 reported usually Resident #43's family called him and told him how to spend it down. 4. Review of Resident #25's medical record revealed an admitted [DATE] with diagnoses including neurocognitive disorder with lewy bodies. Review of Resident #25's payor information revealed their primary payor source was Medicaid. Review of Resident #25's trust fund authorization dated 02/13/17 revealed statements were to be sent to her responsible party. Review of Resident #25's quarterly statement dated 06/30/24 revealed her closing balance was less $200 below the Medicaid limit. Review of Resident #25's quarterly statement dated 09/30/24 revealed a closing balance of $2,148,46. Review of a letter dated 10/15/24 revealed it was notification that Resident #25's account exceeded the Medicaid limit. There was no evidence this was sent to or acknowledged by the responsible party. Review of the current account balance as of 10/28/24 revealed Resident #43 had $2,225.34 in her account. Interview on 10/31/24 at 11:34 A.M. and 11:39 A.M. with Business Office Manager (BOM) #205 verified they had no evidence that spenddown notification was sent or received by the responsible party. BOM #205 reported usually Resident #25's family called him and told him how to spend it down.

Based on observation and interview, the facility failed to ensure a homelike environment for 27 residents (#7, #14, #17, #25, #28, #29, #30, #33, #35, #40, #43, #45, #46, #48, #51, #53, #57, #67, #70, #71, #72, #75, #78, #83, #241, #242, and #291) on the memory care unit when they served meals on trays in the dining room. This affected 27 residents of 49 residents on the memory care unit. The facility census was 91. Findings include: Observation on 10/28/24 at 12:15 P.M. of the lunch meal revealed all residents in the dining room had been served their meals on trays. Interview on 10/28/24 at 12:17 P.M. with Licensed Practical Nurse (LPN) #152 verified the residents were served meals on trays in the dining room. She reported it helped residents recognize what food was theirs. Interview on 10/31/24 at 12:50 P.M. with the Director of Nursing (DON) verified keeping food on trays did not keep residents from taking food of each other's trays. The facility had no relevant policy.

Based on observations, family and staff interview, review of facility policy, and record review, the facility failed to ensure the residents who required assistance from staff with activities of daily living were provided adequate and timely assistance with nail care and eating. This affected four residents (#11, #30, #55, and #61) of seven residents reviewed for activities of daily living. The facility census was 91. Findings include: 1. Review of Resident #30's medical record revealed an admitted [DATE] with diagnoses including dementia, peripheral vascular disease, and muscle weakness. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and vision. Resident #30 required set up or clean up assistance from staff for personal hygiene and eating. Review of Resident #30's plan of care dated 09/19/24 revealed he had a functional ability deficit and required assistance with self-care related to impaired cognition, unsteady gait, poor trunk control, poor vision, and incontinence. Interventions included setup or clean up assistance with personal hygiene, and partial or moderate assistance with showering bathing, and dressing. Observation on 10/28/24 at 10:16 A.M. revealed Resident #30 had long dirty nails that were curled at the top. Subsequent observation on 10/29/24 at 2:53 P.M. revealed Resident #30's fingernails remained dirty and long, curled at the top. Interview on 10/29/24 at 2:53 P.M. with Assistant Director of Nursing (ADON) #132 verified Resident #30's nails needed cleaned and cut. Interview on 10/29/24 at 3:49 P.M. with State tested Nursing Assistant (STNA) #128 revealed Resident #30 required maximal assistance with personal hygiene. Interview on 10/30/24 at 2:41 P.M. with Unit Manager #210 verified Resident #30's plan of care did not accurately reflect his assistance needs. 2. Review of Resident #55's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease. Review of Resident #55's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. She was dependent on staff for eating. Review of Resident #55's plan of care dated 07/23/24 revealed she had a functional ability deficit and required assistance with self-care and mobility related to diagnoses, poor trunk control, and weakness. Interventions included providing a consistent routine, diet as ordered, encouraging the resident to participate in self-care, and the resident was dependent on staff for eating. Observation on 10/28/24 at 12:00 P.M. revealed lunch carts were brought to the memory care unit. Observations from 12:15 P.M. to 12:49 P.M. revealed Resident #55 had a tray in her room and had not been fed yet. State tested Nursing Assistants (STNA) #170 and STNA #202 were observed assisting other residents and then cleaning up in the dining room. Interview on 10/28/24 at 12:49 P.M. with STNA #202 verified Resident #55 still needed fed her lunch meal. Observation and interview on 10/28/24 at 12:55 P.M. revealed STNA #170 entering the room to feed Resident #55. STNA #170 verified she was just feeding Resident #55 her lunch meal. 3. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including severe dementia with psychotic disturbance, type two diabetes mellitus, protein-calorie malnutrition, and dysphagia. Review of Resident #11's comprehensive Minimum Data Set (MDS) 3.0 assessment revealed she was rarely or never understood. She required substantial to maximal assistance from staff with eating. Review of Resident #11's plan of care dated 08/11/24 revealed the resident had a functional ability deficit and required assistance with self-care and mobility related to severely impaired cognition, impaired mobility, and frequent bowel and bladder incontinence. Interventions included allowing adequate time for completion of task, attempting to use consistent routines as much as possible, break task into smaller subtasks, and substantial or maximal assistance with eating. Observation on 10/28/24 at 12:00 P.M. revealed lunch carts were brought to the memory care unit. Observations from 12:00 P.M. to 12:49 P.M. revealed Resident #11 was in her room and had not been fed yet. STNA #170 and STNA #202 were observed assisting other residents and then cleaning up in the dining room. Interview on 10/28/24 at 12:49 P.M. with STNA #202 verified Resident #11 still needed fed she just was not sure where the resident's tray was. Observation on 10/28/24 at 12:52 P.M. revealed STNA #202 began feeding Resident #11. 4. Review of Resident #61's medical record revealed an admitted [DATE] with diagnoses including dementia, osteoarthritis, and muscle weakness. Review of Resident #61's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. He needed setup or clean-up assistance from staff with meals. Review of Resident #61's plan of care dated 10/16/24 revealed he had a functional ability deficit and required assistance with self/care related to diagnoses. Interventions included observing and reporting to the nurse any changes in functional ability, supervision or touching assistance with eating, and partial or moderate assistance with personal hygiene. Review of Resident #61's plan of care revealed it was absent for refusals. Review of Resident #62's activity of daily living documentation from 10/01/24 to 10/29/24 revealed no indication he had refused meal assistance or assistance with personal hygiene. Interview on 10/28/24 at 1:55 P.M. with Resident #61's family revealed the resident needed assistance at meals, but he did not think the facility provided it. Observation on 10/29/24 at 1:45 P.M. revealed Resident #61's fingernails were long and dirty. Observation on 10/30/24 at 12:37 P.M. revealed Resident #61 with his meal tray, staff were not providing assistance. From 12:42 P.M. to 12:49 P.M., Resident #61 was observed chewing a bite of food, he then spit it out on to his plate. Resident #61 was observed attempting to drink water from a cup that was still covered. Interview on 10/30/24 at 12:49 P.M. with Unit Manager #210 verified Resident #61 was unsupervised and required assistance at meals. She additionally verified the cover had not been removed from his drink. She reported he refused assistance at times. Unit Manager #210 reported he had a behavior of chewing and spitting out his food. Observation on 10/30/24 at 12:50 P.M. revealed Unit Manager #210 cueing the resident to swallow his food and she assisted him to take bites, his intake improved. Interview on 10/30/24 at 1:03 P.M. with Unit Manager #210 verified Resident #61 had eaten better with prompting and cueing. She reported he had been at the 'feed' table in the past and did not like it. She additionally verified Resident #61's nails were long and dirty; she reported he often refused nail care. Review of the facility policy 'Standards of CNA[Certified Nursing Assistance]/STNA Practice' revealed STNAs were to assist the resident in activities of daily living such as feeding and nail care.

Based on observations, staff interview, and record review, the facility failed to ensure activities were offered and provided for Residents #11, #30, #55, and #72. This affected four residents (#11, #30, #55, and #72) of six residents reviewed for activities. The facility census as 91. Findings include: 1. Review of Resident #30's medical record revealed an admitted [DATE] with diagnoses including dementia, adult failure to thrive, chronic kidney disease, peripheral vascular disease, depression, and muscle weakness. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and vision. Review of Resident #30's plan of care dated 11/14/23 revealed he enjoyed playing spades, biz wiz, conversing about the news, listening to music therapy, listening to daily chronicles, audiobooks, and going outdoor when the weather was nice. Interventions included offering outdoor activities when the weather was appropriate, providing an activities calendar and inviting and encouraging resident to attend scheduled activities of interest, providing materials for individual activities as desired, resident needs assistance to attend activities, he prefers independent activities but may show interest in the following types of group activity such as price is right, cards, TV time, music therapy, reading daily chronicles or other stories. Review of Resident #30's activity evaluation dated 05/09/24 revealed it was somewhat important for the resident to listen to music he liked and keep up with the news. He had interest in games, crafts, sports, music, reading, baking, religious activities, spending time outdoors, listening to radio, talking, volunteer work, parties, and news. The resident received check ins twice a week and one on ones if needed, he helped fold clothes, did certain busy hand puzzles and participated in clubs like cooking and men's group occasionally. Review of Resident #30's activities for from 10/01/24 to 10/29/24 revealed he was not documented as having participated in activities. He was offered and refused arts and crafts on 10/02/24, 10/04/24, and 10/13/24, conversing with others on 10/06/24, exercise on 10/20/24, games on 10/13/24, gardening on 10/06/2, and pet visits on 10/20/24. There was no evidence he was offered additional activities. Observation on 10/28/24 at 10:01 A.M., 11:17 A.M. and 1:45 P.M. revealed Resident #30 at a table in the common area there were no activities or entertainment available. The television was on at the far end of the room but could not be heard from Resident #30's location. Observation on 10/29/24 at 10:49 A.M., 1:52 P.M., 2:33 P.M., and 3:38 P.M. revealed Resident #30 at a table in the common area there were no activities or entertainment available. Observation on 10/30/24 at 10:03 A.M., 10:53 A.M., 11:55 A.M., 1:56 P.M., and 2:33 P.M. revealed Resident #30 at a table in the common area there were no activities or entertainment available. At 2:33 P.M., Recreation Services Assistant #157 was observed asking five to six residents if they wanted to attend activities. Resident #30 was not asked. Interview on 10/30/24 at 2:10 P.M. with State tested Nursing Aide (STNA) #128 verified residents were sitting in the common area with no entertainment. She reported the residents spent a lot of quiet time in the dining room. She said activities came in the afternoon and did an activity with them. Interview on 10/30/24 at 2:12 P.M. with Licensed Practical Nurse (LPN) #120 stated she was unable to identify activities for residents who could not do independent activities or would not think to request independent activities. She reported activities did popcorn parties at times. Interview on 10/30/24 at 4:22 P.M. with Director of Recreation Service #190 and the Administrator stated they were trying to find staff to work, at this time they did not have sufficient staff to place activities personnel in the memory care unit throughout the day. They reported activities was usually in memory care in the morning, then they did the skilled side, and then they did an activity that involved residents from both sides. They stated all residents should be offered activities every time they were scheduled and nursing staff should be assisting in bringing people down to activities. Director of Recreation Service #190 stated there was an [NAME] (smart home device) on the memory care unit so staff could play music for residents, and there were also activities that could be given to the residents to do throughout the day. Resident #30 was supposed to be receiving more sensory activities and he enjoyed listening to music. The Director of Recreation Service #190 verified Resident #30's activity record did not reflect that he was offered every activity or participating. 2. Review of Resident #55's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, paranoid personality disorder, and adult failure to thrive. Review of Resident #55's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #55's plan of care revised 04/23/24 revealed the resident may benefit from sensory stimulation and variety of settings that groups or one to one programs provide. She enjoyed family visits, rhythm and blues and jazz music, being out of room around group of people, socializing to the best of her ability, passively observing group or small group activities, one on ones when she does not want to participate in group activity. Interventions included assisting resident to programs that may offer comfort and sensory stimulation, one-on-one staff contact during programs, use touch, call the resident by name to bring program content or program equipment closer to resident. Review of Resident #55's activity evaluation dated 10/09/24 revealed the resident passively watched group activities and expressed some interest and enjoyment. She watched television and movies and liked to listen to music. They were to trial one-on one activities to see if it would boost her participation or moods. Review of Resident #55's activities from 10/01/24 to 10/29/24 revealed she was not documented as having participated in activities. She was offered and refused arts and crafts on 10/02/24, 10/04/24, and 10/13/24, conversing with others on 10/06/24, games on 10/13/24, gardening on 10/06/24, and pet visits on 10/20/24. She was not available for arts and crafts on 10/20/24, exercise on 10/19/24, and religious services on 10/20/24. There was no evidence she was offered one-on-ones or additional activities. Observation on 10/28/24 at 10:15 A.M., 11:17 A.M., and 1:40 P.M. revealed Resident #55 in bed watching television. Observation on 10/30/24 at 10:04 A.M. and 1:01 P.M. revealed Resident #55 in bed and awake, her television was not on and there was no entertainment. Interview on 10/30/24 at 1:03 P.M. with Unit Manager #210 verified Resident #55 was sitting in silence, she reported the resident did not like the television. Observations on 10/30/24 at 10:03 A.M., 10:53 A.M., 11:55 A.M., 1:56 P.M., and 2:33 P.M. revealed Resident #30 at a table in the common area there were no activities or entertainment available. At 2:33 P.M. Recreation Services Assistant #157 was observed asking five to six residents if they wanted to attend activities. Resident #55 was not asked. Interview on 10/30/24 at 2:10 P.M. with State tested Nursing Aide (STNA) #128 verified residents were sitting in the common area with no entertainment. She reported the residents spent a lot of quiet time in the dining room. She said activities came in the afternoon and did an activity with them. Interview on 10/30/24 at 2:12 P.M. with Licensed Practical Nurse (LPN) #120 stated she was unable to identify activities for residents who could not do independent activities or would not think to request independent activities. She reported activities did popcorn parties at times. Interview on 10/30/24 at 4:22 P.M. with Director of Recreation Service #190 and the Administrator revealed they were trying to find staff to work, at this time they did not have sufficient staff to place activities personnel in the memory care unit throughout the day. They reported activities was usually in memory care in the morning, then they did the skilled side, and then they did an activity that involved residents from both sides. They stated all residents should be offered activities every time they were scheduled and nursing staff should be assisting in bringing people down to activities. Director of Recreation Service #190 revealed there was an [NAME] (smart home device) on the memory care unit so staff could play music for residents, there was also activities that could be given to the residents to do throughout the day. Resident #55 was supposed to receive one-on-ones, and she verified the documentation did not show her receiving activities. 3. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including severe dementia with psychotic disturbance, delusional disorders, adult failure to thrive, and anxiety disorder. Review of Resident #11's comprehensive Minimum Data Set (MDS) 3.0 assessment revealed she was rarely or never understood. Review of Resident #11's plan of care dated 04/19/24 revealed the resident showed little awareness of programing surrounding. She would benefit from small group awareness or sensory stimulation. The focus was to provide independent materials for busy hands during downtime, but to also include her and continuing to attempt having active participation in music and motion, live entertainment, games, and picture books. Resident #11 would be a good candidate for one on ones. Interventions included escorting to socials and special events, providing sensory activities to promote response, resident enjoyed picture books, instrumental music, conversing and guardian, and using name and tactile stimulation to keep the resident engaged in the activity. Review of Resident #11's activity assessment dated [DATE] revealed the resident was confused and trying to be more mobile. She was not able to answer questions well due to loss in focus. The resident would stay with staff and usually sort and shuffle through items and she enjoyed music and motion as well. Review of Resident #11's activities for from 10/01/24 to 10/29/24 revealed she was offered and refused arts and crafts on 10/02/24, 10/13/24, and 10/20/24, conversing with others on 10/13/24, exercise on 10/19/24, games on 10/13/24 and 10/19/24, pet visit on 10/20/24, and religious services on 10/20/24. She was listed as not available for conversing with others and gardening on 10/06/24. Observation on 10/28/24 at 10:18 A.M., 11:19 A.M., and 1:46 P.M. revealed Resident #11 curled up in a ball in her bed. Observation on 10/29/24 at 10:51 A.M. revealed Resident #11 curled up in bed. Observation at 1:52 P.M., 2:33 P.M., and 3:38 P.M. revealed her in the common area with no activities or form of entertainment. The resident went from leaning her head on the table to leaning up against another resident. Observation on 10/30/24 at 10:03 A.M., 10:53 A.M., 11:55 A.M., 1:56 P.M., and 2:33 P.M. revealed Resident #30 at a table in the common area there were no activities or entertainment available. At 2:33 P.M. Recreation Services Assistant #157 was observed asking five to six residents if they wanted to attend activities. Resident #11 was not asked. Interview on 10/30/24 at 2:10 P.M. with State tested Nursing Aide (STNA) #128 verified residents were sitting in the common area with no entertainment. She reported the residents spent a lot of quiet time in the dining room. She said activities came in the afternoon and did an activity with them. Interview on 10/30/24 at 2:12 P.M. with Licensed Practical Nurse (LPN) #120 stated she was unable to identify activities for residents who could not do independent activities or would not think to request independent activities. She reported activities did popcorn parties at times. Interview on 10/30/24 at 4:22 P.M. with Director of Recreation Service #190 and the Administrator revealed they were trying to find staff to work, at this time they did not have sufficient staff to place activities personnel in the memory care unit throughout the day. They reported activities was usually in memory care in the morning, then they did the skilled side, and then they did an activity that involved residents from both sides. They stated all residents should be offered activities every time they were scheduled and nursing staff should be assisting in bringing people down to activities. Director of Recreation Service #190 stated there was an [NAME] (smart home device) on the memory care unit so staff could play music for residents, there was also activities that could be given to the residents to do throughout the day. Director of Recreation Service #190 verified Resident #11's activity record did not reflect that he was offered every activity or participating in activities. Review of the policy 'activities/recreation program documentation' dated 08/01/24 revealed a resident's daily pattern of activity involvement was to be monitored including documenting attendance or refusal. 44080 4. Review of medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was severely cognitively impaired. Observations on 10/28/24 at 9:50 A.M. through 12:30 P.M. revealed Resident #72 was sitting at a table in the dining room after breakfast and no activities were offered or provided. A television was present on the other end of the dining room, but it was out of site for Resident #72. Observations on 10/29/24 from 1:40 P.M. through 3:00 P.M. revealed Resident #72 was in his Broda chair and was sleeping on and off. No activities were were offered or provided. Observation on 10/30/24 at 10:10 A.M. with Recreation Service Assistant (RSA) #157 revealed RSA #157 offered an activity to Resident #48, but did not offer the activity to Resident #72 who was sitting next to Resident #48 at the same table. At 10:25 A.M., Resident #72 was sitting in their Broda chair with no activities offered or provided. Interview on 10/30/24 at 3:30 P.M. with Director of Recreation Services (DRS) #190 verified Resident #72 did not have any record that he had received activities for days 10/28/24, 10/29/24, and 10/30/24.

Based on observation, interview, and record review, the facility failed to ensure residents had access to call lights. This affected two (#5 and #58) of two residents reviewed for call lights. The facility census was 91. Findings included: 1. Review of medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included congestive heart failure, congestive heart failure, and Alzheimer's disease. Review of the Minimum Date Set quarterly assessment, dated 08/20/24, revealed Resident #5 had a some cognitive impairment. Resident #5 was setup and clean up for meals; supervision and touching for oral care, toileting, bathing; and independent dressing with lower and upper body, placing shoes on and off, and personal hygiene. Review of plan of care dated 08/20/24 revealed Resident #5 was deaf and hard to hear you. Resident #5 was also incontinent and required every two hours incontinence care. Observation on 10/31/24 at 2:00 P.M., with Resident #5 who was lying in bed, and the call light was not in reach. The call light was observed wrapped around the bed post, and the resident was unable to reach call light. Interview on 10/31/24 at 2:05 P.M., with State tested Nurse Aide (STNA) #123 verified Resident #5 did not have her call light in reach. 2. Review of medical record for Resident #58 revealed an admitted [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, and idiopathic epileptic. Review of Quarterly Minimum Data Set assessment, dated 06/19/24, revealed Resident #58 was severely cognitively impaired. Review of required assistance revealed Resident #58 was independent with meals; setup and clean up assistance for oral care, toileting hygiene; supervision and touching for bathing, personal hygiene, putting on and off shoes, dressing lower body, and dressing upper body. Review of plan of care dated 09/17/24 revealed Resident #58 had functional ability deficit and required assistance with self-care mobility related to having unsteady gait without support, confusion, dementia, chronic pulmonary disease, and periods of shortness of breath. Interventions included allow adequate time for completion of tasks, attempt to use consistent routines as much as possible, break task into smaller subtasks as needed, explain all procedures and tasks before starting, report all refusals, and call light within reach. Observation on 10/31/24 at 2:10 P.M., with Resident #58 who was lying in bed, and the call light was not in reach. The call light was wrapped around the bed post, and the resident was unable to reach call light. Interview on 10/31/24 at 2:10 P.M. ,with STNA #123 verified Resident #58 did not have her call light in reach.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure one resident's (#42) guardian was notified of a change in condition and new medication order. This affected one (Resident #42) of 21 residents reviewed for notification of change. The facility census was 91. Findings include: Review of the medical record for Resident #42 revealed an initial admitted [DATE] with the diagnoses including memory deficit following cerebral infarct. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a moderate cognitive deficit. Review of the Nurse Practitioner (NP) progress note dated 10/10/24 revealed Resident #42 complained of pain with urination for two days. The NP ordered a complete blood count (CBC), urinalysis and culture and sensitivity (UA/C&S) and if leukocytes were positive she would be treated for a urinary tract infection (UTI). Review of the UA/C&S revealed the resident's urine was cloudy, was positive for nitrates and had a large amount of leukocytes. The culture grew 50,000 to 100,000 klebsiella oxytoca. Review of the resident's discontinued physician orders revealed an order dated 10/14/24 for Cipro (a medication used to treat infections) 250 milligrams (mg) by mouth every 12 hours for five days for UTI. There was no documented evidence the resident's guardian was notified of the change in condition and the new medication Cipro 250 mg was ordered. On 10/29/24 at 2:16 P.M., an interview with the Director of Nursing (DON) verified the resident's guardian was not notified of the resident's change in condition or new medication order to treat the UTI. Review of the facility policy titled Notification of Change, last revised on 02/14/24 revealed the facility must inform the resident, consult with the resident's practitioner and notify the resident's representative when there is a change in status. A change in status would include a need to alter treatment significantly and a significant change in the resident's physical, mental or psychosocial status. Changes in the resident's status, including but not limited to those identified above or any unusual occurrence, the licensed nurse will notify the resident attending practitioner. Any new orders or directives will be implemented by the licensed nurse. Changes in the resident status, including but not limited to those identified above or any unusual occurrences the licensed nurse will notify the resident's representative unless otherwise dictated by the resident. The licensed nurse will document in the resident's electronic medical record the notification and the information that was provided including any additional orders from the practitioner.

Based on observation, family and staff interview, and record review, the facility failed to arrange podiatry services for Resident #61. This affected one (#61) of seven residents reviewed for activities of daily living. The facility census was 91. Findings include: Review of Resident #61's medical record revealed an admitted [DATE] with diagnoses including dementia, chronic kidney disease, schizoaffective disorder, osteoarthritis, muscle weakness. Review of Resident #61's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #61's physician order dated 06/26/24 revealed an order for podiatry evaluation and treatment as indicated. Review of Resident #61's medical record revealed it was absent for ancillary consents or evidence of podiatry consult. Interview on 10/28/24 at 2:01 P.M. with Resident #61's family revealed he had wanted Resident #61 to be seen by the podiatrist. He reported his toenails were long enough that it was rubbing on the sheets. He reported the resident also had corns to his feet that he wanted taken care of. Observation on 10/29/24 at 1:45 P.M. of Resident #61 revealed he had long, dry, and crumbly nails. Interview on 10/30/24 at 10:51 A.M. with the Director of Social Services (DSS) #106 reported usually residents were offered ancillary services upon admission. The son had not previously signed a consent for ancillary services. However, she verified there was no documentation to indicate Resident #61's son had been offered ancillary services. DSS #106 confirmed Resident #61 had not seen the podiatrist.

Based on observation, medical record review and staff interview, the facility failed to ensure residents with contractures were provided splints and/or palm protectors to prevent worsening of contractures. This affected two (#1 and #55) of two residents reviewed for range of motion. The facility census was 91. Findings include: 1. Review of the medical record for Resident #1 revealed an initial admitted [DATE] with the latest readmission of 10/28/23. Diagnoses included cerebrovascular accident (CVA) with right sided hemiplegia, dysarthria, aphasia, vascular dementia, chronic kidney disease, adult failure to thrive, atopic and schizoaffective disorder. Review of the plan of care dated 10/26/23 revealed Resident #1 had a functional ability deficit and required assistance with self care/mobility related to effects of CVA, dementia, non-ambulatory, right sided weakness, right sided neglect, poor trunk control confusion, bowel and bladder incontinence and can get agitated during care giving. Interventions included attempt to use consistent routines as much as possible, break task into smaller subtasks, encourage resident to use call light to call for assistance, encourage to participate in self-care as much as able, provide positive reinforcement for all activities attempted, praise resident for all efforts and accomplishments, explain all procedures/tasks before starting, keep finger nails trimmed and clean, palm protector to right hand when splint not worn, check skin before and after apply/removing, therapy treatment when ordered, refer to therapy plan of care for additional information as needed, right resting elbow splint to be donned when right resident hand splint is not donned (one to two hours for each splint) check skin before and after applying/removing, provide assistance devices wheelchair and bilateral half side rails for mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a severe cognitive deficit. Resident #1 displayed verbal behaviors directed towards others. Resident #1 had impaired functional limitation in range of motion (ROM) on one side of the upper extremity. Review of the resident's monthly physician orders for October 2024 identified orders dated 08/02/23 for a splint to right hand and right elbow daily for two hours as tolerated every shift, skin check before and after applying splints daily and palm protector to right hand when splint not on. Observation on 10/28/24 at 9:59 A.M., revealed Resident #1's right hand was contracted with no splint or palm protector to prevent further contracture. Interview on 10/29/24 at 1:24 P.M., with Registered Nurse (RN) #125 revealed the resident refuses to wear the palm protector at times and will yell out when it is in place. RN #125 verified the medical record contained no documented evidence the resident refused the palm protector at the time of the interview. Observation on 10/29/24 at 1:28 P.M., of Resident#1's room revealed the splint was in the resident's second drawer of the night stand and the resident had no palm protector available in her room. Interview on 10/29/24 at 1:38 P.M., with State tested Nursing Assistant (STNA) #128 and #209 revealed they were assigned to provide the resident's care. STNA #128 and #209 revealed they were unsure if the resident had a splint or palm protector and would have to look in her room. Further interview with STNA #128 and #209 revealed therapy applies and removes all splints in the facility. Interview on 10/29/24 at 1:48 P.M., with Occupational Therapist (TO) #220 revealed once the resident was discharged from therapy services, the nursing staff were educated on the application and removal of splints. TO #220 verified Resident #1 was discharged from therapy with an order for the placement of the splint and palm protector when the splint is not in place. Interview on 10/29/24 with the Director of Nursing revealed the facility does not have a splint/brace policy. 43064 2. Review of Resident #55's medical record revealed an admitted [DATE], with diagnoses: including Alzheimer's disease, depression, paranoid personality disorder, dysphagia, and adult failure to thrive. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely or never understood. She had an upper and lower extremity impairment on both sides. Review of Resident #55's occupational therapy discharge summary dated 10/26/23 revealed the resident had a goal of a resting hand splint on left hand or wrist for four hours a day with staff education provided for carry over to decrease risk of joint issues. She met this goal on 10/23/23. The discharge recommendation included a splint and brace program of a resting hand splint to the left upper extremity for three hours. Review of Resident #55's orders and progress notes from 10/26/23 to 05/14/24 revealed no mention of a resting hand splint. Review of Resident #55's occupational therapy discharge summary dated 05/14/24 revealed the resident had a goal of tolerating left hand and elbow splint two hours per day to decrease risk of further joint stiffness. She met this goal on 05/09/24 wearing them on her left upper extremity. The discharge recommendation revealed staff was educated on elbow and hand splints for two-hour wear schedule for each. Review of Resident #55's orders and progress notes from 05/14/24 to 10/28/24 revealed no mention of a hand or elbow splint. Review of Resident #55's physician's orders from October 2023 to October 2024 revealed no evidence of orders of a splint or hand brace to the left upper extremity. Review of Resident #55's plan of care on 10/28/24 revealed it did not address contracture's or limited range of motion in her left upper extremity. It did not address the need for splints or braces for her upper extremities. Observation on 10/28/24 at 11:18 A.M. and 1:40 P.M. and on 10/29/24 at 10:50 A.M. and 12:26 P.M., revealed Resident #55's left hand was contracted in a tight fist. She did not have a hand or elbow splint on. Interview and observation on 10/29/24 at 1:46 P.M., with Unit Manager #210 verified Resident #55's left hand was contracted. Resident #55's left hand was bent forward at the wrist and her fingers were clenched tight against her hand. Resident #55 pulled back her hand when Unit Manager #210 asked to open it. Unit Manager #210 reported the resident had a history of being noncompliant with splints but was unsure if therapy was currently implementing splints. Interview on 10/29/24 at 3:14 P.M., with Unit Manager #210 verified Resident #55's contracture was not mentioned in the medical record nor any documentation that the splint had ever been tried. Interview on 10/29/24 at 3:22 P.M., with Therapy Director #226 verified a splint had been recommended for Resident #55 on 05/14/24. She reported the aides had received training for the splints but were uncomfortable using it because of the resident's inability to give feedback. She reported they had agreed to discontinue the splint but verified it was not documented anywhere. When asked what they were doing to prevent the hand contracture from getting worse she reported they were protecting the skin and screening with therapy. Interview on 10/30/24 at 3:34 P.M., with Occupational Therapist (TO) #220, Therapy Director #226, Unit Manager #210, and the Director of Nursing (DON) and observation of Resident #55 revealed with time, stretching, rubbing muscles, TO #220 was able to stretch Resident #55's arm out, extend her elbow, and flex her wrist. She did not extend Resident #55's middle three fingers which she called 'swan-necked'. Resident #55 had been reevaluated by TO #220 on that day and she was going to implement another splint. Staff verified there had never been any documentation nursing followed up on TO #220's recommendations to implement a splint.

Based on observation, staff interview, medical record,review and policy review, the faciliy failed to have fall interventions in place for a resident who was at risk for falls. This affected one (63) of one resident reviewed for fall interventions. The facility census was 91. Findings include: Review of medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included cerebral aneurysm, dementia, schizoaffective disorder, and epilepsy. Review of Quarterly Minimum Data Set date 07/22/24 revealed Resident #63 revealed the resident was severely cognitively impaired. Resident #63 required substantial maximal assistance oral care, toileting hygiene, personal hygiene, dressing upper and lower body, oral care, and bathing. Review of plan of care dated 10/22/24 revealed Resident #63 was at risk for risk for falls related to confusion, dementia, with poor safety awareness, non-ambulatory, antidepressant medication, restlessness, servers' impulsiveness, and lowers to herself to the floor on purpose. Interventions included administer meds, anticipate all needs, dose reduction will be attempted as appropriate, encourage resident to wear non-skid footwear when out of bed, and as needed. Keep the resident's environment free of clutter and safe, lock wheels on Geri chair, mattress with bolsters to bed to help define bed boundaries, may have one side of bed against the wall, provide clean eyeglasses daily. Observation on 10/29/24 at 2:39 P.M. with State tested Nurse Aide (STNA) #128, revealed Resident #63 was in her chair and did not have non-skid socks on. Interview with STNA #128 at the time of the observation, verified Resident #63 did not have non-skid socks on. Interview at the time of the observation, with Unit Manager #210 verfiied Resident #63 did not have her non skid socks on and and stated she was a fall risk. Observation on 10/30/24 at 12:11 P.M. with Resident #63 who was sitting at the dining room table in her Broda chair. Resident #63 had regular socks on only. Interview on 10/30/24 at 12:25 P.M., with STNA #198 verified Resident #63 only had regular socks on her feet. STNA #198 verified Resident #63 did not have her non-skid socks on her feet. Review of the policy titled Fall Management, dated 09/22/23, revealed the facility was to provide each resident in assisted in attaining and maintain his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and or functional programs as appropriate to minimize the risk for falls.

Based on observation, staff interview, record review, and review of policies, the facility failed to provide timely incontinence care for a resident dependent on staff for care. This affected one (#72) of one resident reviewed for incontinence care. The facility census was 91. Findings include: Review of medical record revealed Resident #72 was admitted [DATE]. Diagnoses included Alzheimer's disease, overactive bladder, and major depressive disorder. Review of Minimum Data Set, dated dated dated [DATE] revealed Resident #72 indicated th resident was severely cognitively impaired. Resident #72 required dependent during meals, oral care, toileting hygiene, bathing, putting on and off shoes, and personal hygiene. Review of plan of care dated 10/16/24 revealed Resident #72 was at risk for impaired skin integrity/pressure injury related to non-ambulatory, frequent bowel and bladder incontinence, confusion to skin needs, poor bed mobility, performance, and weight loss. Interventions included conduct weekly head to toe skin assessments, dietary consult, nutritional supplement per orders, observe skin with showers, and provide diet as ordered. Observation randomly on 10/30/24 from 9:05 A.M. through 1:34 P.M., revealed Resident #72 was not provided any personal care, including incontinence care. At 1:35 P.M., State tested Nurse Aides (STNA) #168 and STNA #123 were observed to provide incontinent care for Resident #72. Interview on 10/3024 at 1:40 P.M., with STNA #123 verified Resident #72 was moderate saturated of urine in his incontinent brief. STNA #123 stated Resident #72 was not checked and changed timely, since she had provided care before 9:00 A.M. this morning. Review of the policy titled Routine Resident Care, dated 03/07/23, revealed residents receive the necessary distance to maintain good grooming and personal/oral hygiene. Incontinence care was provided timely in according to each resident's needs. Review of the policy titled Standards of Certified Nurse Aide/State tested Nurse Aide Practice, dated 08/15/23, revealed the Certified Nurse Aide/State tested Nurse Aide makes routine rounds to check each resident assigned resident's condition and ensure their needs are met.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a resident had colostomy supplies available for self care. This affected one (#147) of one resident reviewed for colostomy care. The faciliy census was 91. Findings include: Review of Resident #147's medical record revealed an admitted [DATE], with diagnoses including: surgical aftercare following surgery on the digestive system, acute gastric ulcer with hemorrhage, iron deficiency anemia secondary to blood loss (chronic), chronic diastolic (congestive) heart failure, hypertension (HTN), primary pulmonary hypertension, paroxysmal atrial fibrillation (AFIB), atherosclerotic heart disease of native coronary artery without angina pectoris without angina, ischemic cardiomyopathy, chronic kidney disease stage 3, primary general osteoarthritis, osteoporosis, disorders of bone density and structure multiple sites, attention to colostomy, personal history of malignant neoplasm, and rectal prolapse. Review of the care plan for Resident #172 revealed At risk for potential complications related to new colostomy: altered elimination pattern, altered body image, fluid imbalance, skin breakdown and pain. Date initiate: 10/17/24. Resident #172 will have adequate bowel function via ostomy through the review date. Interventions included: Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. Allow resident to verbalize feelings regarding change in body image. Refer for counseling if needed. Change colostomy bag as needed. Check for proper fit of colostomy bag to stoma. Educate resident/family/care giver regarding ostomy function and care. Educate resident/family/caregiver on how to change colostomy bag as needed and observe return demonstration. Empty colostomy bag every shift and as needed. Observe for air in the colostomy bag frequently and release as needed. Date these interventions initiated: 10/18/24. Observation on 10/28/24 at 3:42 P.M., revealed Resident #147 seated on the bedside attempting to empty her colostomy bag of air and stool. A strong odor of feces was noted in the hallway. Resident #147 was not wearing gloves during the task, and was observed to have feces on her fingers, lap, and shirt. Interview on 10/28/24 at 3:50 P.M., with Resident #147 confirmed she was attempting to perform self-care with her colostomy, staff keep supplies in the drawers of her bedside table, because she preferred to perform colostomy care at the bedside. Resident #147 opened the drawers to reveal no colostomy care supplies were available. Interview on 10/28/24 at 3:56 P.M., with Registered Nurse (RN) #172 confirmed Resident #147 had been educated on how to care for her colostomy, and is caring for her colostomy on her own as much as possible. RN #172 confirmed there were no colostomy care supplies available for Resident #172 at the bedside.

Based on medical record review, staff interview, and policy review, the facility failed to ensure daily weights were obtained and post dialysis communication forms were returned to the facility following dialysis. This affected one (#18) of one resident reviewed for dialysis. The facility census was 91. Findings include: Review of the medical record for Resident #18 revealed an initial admitted [DATE], with the diagnoses including: surgical aftercare following surgery on the skin and subcutaneous tissue, peripheral venous insufficiency, end stage renal failure (ESRD), dependence on renal dialysis, hypertension, diabetes mellitus, hyperlipidemia, anemia, polyneuropathy, hyperparathyroidism, and depressive disorder. Review of the plan of care dated 04/04/24 revealed the resident was at risk for hypovolemia related to dialysis related to ESRD and calls dialysis center and cancels appointments two to three times a month. Inventions included check bruit/thrill per facility policy, notify physician if not detected, check vital signs post dialysis, do not draw blood or take blood pressure in left arm, encourage her to go to hemodialysis as scheduled, instruct her on the negative outcomes if she continues to cancel sessions, encourage resident to avoid salt substitutes high in potassium as needed, obtain daily weights as ordered, notify physician of weight changes per physician ordered parameters, upon return from the dialysis center observe the resident's access site and obtain vital signs, document findings in the medical record and report abnormal findings to the physician, medications as ordered, Nepro supplement per orders, observe dialysis site for signs/symptoms of infection, observe for fatigue and encourage frequent rest periods as needed, observe for signs/symptoms of infection to access site, observe for signs of anemia or uremia and notify physician for treatment as needed, observe for signs of fluid retention, observe for signs/symptoms of bleeding, observe skin for sings of pruritis or being dry or scaly and apply lotion as needed, labs as ordered, provide diet as ordered, receives dialysis Monday, Wednesday and Friday at 11:00 A.M., refer to dietician as needed, takes bag lunch to dialysis and weight per order as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received dialysis. Review of the resident's monthly physician orders for October 2024 identified orders dated 04/05/24, to check vital signs post dialysis on Monday, Wednesday, Friday; daily weight at 6 A.M. for dialysis weight; an order dated 04/09/24, to monitor Left AV fistula for positive bruit and thrill every shift for monitoring; no blood pressure in left arm; an order dated 09/23/24, for hemodialysis every Monday, Wednesday, Friday; check bruit and thrill every shift and observe fistula/graft site for thrombosis, bleeding, stenosis, infection, Steal Syndrome, and aneurysm every shift. Review of the resident's daily weights revealed the facility failed to obtained the physician ordered resident's weight at 6:00 A.M., on the following dates: 04/06/24, 04/10/24, 04/29/24, 05/13/24, 05/14/24, 05/15/24, 05/23/24, 05/29/24, 05/30/24, 07/10/24, 07/16/24, 07/28/24, 07/31/24, 08/07/24, 08/23/24 and 08/28/24. Review of the resident's medical record revealed no post dialysis communication forms for the following dates: 04/05/24, 04/08/24, 04/10/24, 04/12/24, 04/15/24, 04/17/24, 04/19/24, 04/22/24, 04/24/24, 04/26/24, 04/29/24, 05/01/24, 05/03/24, 05/06/24, 05/08/24, 05/10/24, 05/15/24, 05/17/24, 05/20/24, 05/22/24, 05/24/24, 05/27/24, 05/29/24, 05/31/24, 06/03/24, 06/05/24, 06/07/24, 06/10/24, 06/12/24, 06/14/24, 06/17/24, 06/19/24, 06/21/24, 06/24/24, 06/26/24, 06/28/24, 07/01/24, 07/03/24, 07/05/24, 07/08/24, 07/10/24, 07/12/24, 07/15/24, 07/17/24, 07/19/24, 07/22/24, 07/24/24, 07/26/24, 07/29/24, 07/31/24, 08/02/24, 08/05/24, 08/07/24, 08/09/24, 08/12/24, 08/14/24, 08/16/24, 08/19/24, 08/21/24, 08/23/24, 08/26/24, 08/28/24, 09/02/24, 09/04/24, 09/06/24, 09/11/24, 09/13/24, 09/16/24, 09/18/24, 09/20/24, 09/23/24, 09/30/24, 10/04/24, 10/18/24, 10/21/24 and 10/23/24. Interview on 10/31/24 at 12:49 P.M., with the Director of Nursing (DON) verified the daily dialysis physician ordered weights were not obtained on the listed dates and the facility had no documented evidence of the post dialysis communication forms listed. Review of the policy titled, Hemodialysis, last revised on 09/26/23, revealed the facility completes the appropriate section of the hemodialysis communication form prior to the resident receiving each dialysis session and again when the resident returns from hemodialysis.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), data contained on the State of Ohio coronavirus.ohio.gov dashboard, observations, medical record reviews, review of the facility Coronavirus (COVID-19) policy and Bed Management, review of employee files, and staff and local health department staff interviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy when two residents (#92 and #82) were admitted to the facility under quarantine status and placed in rooms with other residents who were not in quarantine status. Additionally, staff were observed not using proper Personal Protective Equipment (PPE) or completing hand hygiene appropriately. The lack of current effective infection control practices in the facility placed all 90 residents at risk for potential harm, complications and/or death related to the facilities failure to prevent a potential COVID-19 outbreak. The facility census was 90 residents. On 08/06/20 at 4:55 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 06/15/20 when two residents (#92 and #82) were admitted to the facility under quarantine status from a hospital and placed with six other residents (#93, #14, #94, #43, #52, and #95) who were not in a quarantine status. Observations at the facility on 08/05/20 revealed seven additional residents (#59, #32, #29, #47, #96, #40, and #13) under a quarantine status that were placed throughout the facility in rooms with residents who were not under quarantine. Additionally, the facility did not implement any interventions, increase monitoring or test any residents, after possible exposure to Licensed Practical Nurse (LPN) #200 who tested positive for COVID-19 on 07/24/20. On 08/05/20 at 12:15 P.M., Activities Assistant (AA) #01, and at 1:35 P.M. AA #04 were observed not using proper PPE prior to entering a quarantine room under droplet precautions and did not perform hand hygiene appropriately after leaving the room. On 08/05/20 at 1:20 P.M., observations revealed State tested Nurse Aide (STNA) #02 was observed donning PPE to go into a room, which had signage indicating the resident was on droplet precautions, without goggles or a face shield. On 08/05/20, several observations were made on the Memory Care Unit of Resident #13, who was under quarantine status, walking throughout the unit and entering other resident rooms without any PPE on. The Immediate Jeopardy was removed on 08/07/20 at 1:30 P.M., when the facility implemented the following corrective actions: · On 08/06/20, all residents in the facility were assessed by the DON or designee for signs and symptoms of COVID-19 as identified by the CDC. None of the residents displayed signs and/or symptoms of COVID-19. · On 08/06/20, Residents #32, #87, #06, #11, #47, #96, #29, # 55, # 59, #56, #71, #14, #54, #27, #72, #67, #73, and #08, began moving to the North Unit and have been placed on fourteen (14) days of droplet and contact isolation precautions, their COVID monitoring increased to three times a day (TID) for 14 days, and their care plans were reviewed and updated accordingly by the DON or designee. All were moved by 08/07/20. · On 08/06/20, Residents #13 and #70 were placed on fourteen (14) day droplet and contact isolation, but are remaining on the memory care unit for their safety due to exit seeking behaviors. The DON has designated a nurse and STNA to care for these residents identified. · On 08/06/20, all residents in the facility were assessed by the DON or designee for signs and symptoms of COVID-19 as identified by the CDC. None of the residents displayed signs and/or symptoms of COVID-19. · On 08/06/20, All residents in the facility have been placed on monitoring three times a day for signs and symptoms of COVID 19, including temperature checks, to increase monitoring of their status due to alleged potential for exposure. These evaluations were completed by the Nurse Managers. · On 08/06/20, all facility staff will frequently monitor residents out of rooms wearing masks throughout the day. Staff will provide redirection when necessary regarding precautions. · On 08/06/20, all high touch areas will have increased cleaning schedules in place by all staff. · On 08/06/20, social distancing benchmarks have been put in place such as chairs and tables six feet apart for residents and staff. Monitoring tools for observation have been developed for management use, to identify any potential issues. · On 08/06/20, the Administrator, DON and Quality Assurance Performance Improvement (QAPI) team members reviewed the facility infection control policy regarding COVID-19 and deemed it appropriate, which included droplet/contact isolation precautions and staff PPE requirements. · On 08/06/20, the Administrator, DON and QAPI team members reviewed the Bed Management Decision Tree policy for new and readmission of residents, isolation precaution requirements, dedicated staff, and deemed it appropriate. The policy addresses the (quarantine) isolation (droplet/contact isolation precautions) of residents on admission and readmission to the facility for fourteen days, and monitoring of the resident for signs and symptoms of COVID-19 as identified by the CDC every day. · On 08/06/20, the DON and nurse managers educated all staff on duty at the time the Immediate Jeopardy was issued on the following: the quarantine/isolation policy for new and readmitted residents; the use of all PPE with a special focus on face shields; the dedicated staff for isolation/quarantine residents; Cohorting procedures for residents on droplet/contact isolation precautions and handwashing. The remaining employees will be educated prior to their next scheduled shift by the DON and/or designee. New employees will receive the same education during new employee orientation. As of 08/07/20 at 1:30 P.M., there are 24 remaining employees that will be educated prior to their next scheduled shift. · On 08/06/20, the Administrator and DON/designee began conducting random audits five times a week for four weeks, then three times weekly for four weeks, then weekly for four weeks, for room placement and droplet/contact isolation precautions of residents, staff use of PPE with a special focus on face shield use, handwashing and use of dedicated staff for guests on droplet/contact isolation precautions. · On 08/06/20, Registered Nurse (RN) #400 informed the Medical Director of the elements of the abatement plan. · On 08/06/20, education and allegation of deficiencies were reviewed in ad hoc QAPI meeting. Although the Immediate Jeopardy was removed on 08/07/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). 1) Review of reporting data for the facility on the coronavirus.ohio.gov website, which reflects current and cumulative cases of COVID-19 among facility staff and residents reported to the Ohio Department of Health revealed as of 07/29/20 the facility had reported no current resident cases, 67 cumulative resident cases, one current staff case and 21 cumulative staff cases. Data updated as of 08/05/20 revealed no current resident cases, 67 cumulative resident cases, 3 current staff cases and 23 cumulative staff cases. Current case counts are defined as residents or staff that had active COVID-19 infection during the prior week (Wednesday through Tuesday). Cumulative counts are defined as residents or staff that had active COVID-19 infection at any point from April 15, 2020 onward. The cumulative totals do not include patients or staff who have recovered, have been hospitalized , or have passed away prior to April 15, 2020. During the survey process, the facility was asked to provide evidence of on-going communication/collaboration with the local health department to ensure any health department recommendations being made were implemented timely. Review of the coronavirus.ohio.gov website on 08/05/20 revealed(NAME)County is at a level 3 public emergency: very high exposure and spread. Limit activities as much as possible. On 08/07/20 at 3:00 P.M., an interview with an employee of the(NAME)Health Department (CHD) #204 revealed she had been recently assigned as the contact person for the facility and her only contact had been a couple of days ago, when the facility called after they had been informed of concerns by the Ohio Department of Health surveyors. CHD #204 verified the facility's current system of placing quarantined residents into the same rooms as non-quarantined residents would not be a recommendation of the health department. CHD #204 stated recommended PPE for staff caring for quarantined residents would include, gown, gloves, N95 mask, and eye protection. CHD #204 stated, the staff should wear the same PPE for quarantined residents as they would for residents in isolation. As of 08/07/20, no additional information had been provided from the facility regarding on-going correspondence with the local health department. 2. On 08/05/20 from 11:07 A.M. to 3:40 P.M., onsite observations and interviews conducted at the facility revealed the following concerns: a. Ten resident rooms were observed with signage on the doors noting droplet precautions with PPE carts outside of the rooms. It was revealed by staff that residents placed in those rooms were new admissions and were under a 14-day quarantine period. However, the rooms were observed to have two or more residents in them. Residents #59, #32, #29, #47, #96, #40, and #13 were identified as being new admissions under a quarantine status and had been placed in rooms with Residents #73, #56, #72, #14, #54, #27, #67, and #70 who were not on a quarantine status. The rooms were intermingled throughout the facility with resident rooms who did not require additional precautions for COVID-19. b. On 08/05/20 at 12:05 P.M., observations revealed Resident #13 (identified as being under droplet precautions) was walking in the hallway on the Memory Care Unit with a surgical mask under her chin. Also, Resident #22 (identified as being under droplet precautions) was observed walking in the same hallway on the same unit without a mask on at all. c. On 08/05/20 at 12:15 P.M., AA #01 was observed donning PPE at the entrance to the room for Residents #11 and #55. She put on a gown, gloves and a surgical mask over her N95 that she was already wearing. She took some shopping bags into the resident and exited the room by removing her PPE except for the N95 mask. She threw them in the trash container in the room and exited the room without performing hand hygiene. Interview with AA #01 at the time, verified she did not perform hand hygiene when exiting the room and stated she used hand sanitizer before going into the room. She was not wearing face shield or goggles while in the room. d. On 08/05/20 at 12:26 P.M., observations revealed Resident #13 (identified as being under droplet precautions) had her surgical mask under her chin and walked into another resident room with two residents (#39 and #58). Residents #39 and 58 were not on any precautions. Resident #13 talked for a couple of minutes and then left the room and continued wandering the hallway with her surgical mask under her chin. e. On 08/05/20 at 12:43 P.M., interview with LPN #205 on the North Hall verified five rooms with nine residents (#73, #59, #56, #32, #06, #72, #29, #55, and #11) on the hall were on droplet precautions due to having a new admission in the room and were under a 14-day quarantine status. All rooms except for one, where Resident #06 resided, had two residents in them. f. On 08/05/20 at 12:51 P.M., interview with LPN #206 on the East Hall verified Resident #47 was under droplet precautions due to the resident being a new admission and under a 14-day quarantine status. Resident #47 had two roommates (#14 and #54) in the room, who were not new admissions or under quarantine status. Resident #96 was a new admission and was under droplet precautions with a 14-day quarantine period. Resident #96 had a roommate (#27) in the room, who was not a new admission or under quarantine status. Also, Resident #13 was a new admission under droplet precautions with a 14-day quarantine period. Resident #13 had a roommate (#70) in the room, who was not a new admission or under quarantine status. g. On 08/05/20 at 1:20 P.M., interview with LPN #207 verified Resident #67 did not require any precautions; however, her roommate (#40), was a new admission, under droplet precautions and under a 14-day quarantine status. LPN #207 stated therefore, both residents in the room were under droplet precautions. h. On 08/05/20 at 1:20 P.M., observations revealed STNA #02 was observed donning PPE to go into Resident #27 and #96's room, which had signage indicating the residents were on droplet precautions. She donned a gown, gloves, surgical mask over her N95 mask, foot covers and hair cover. She did not wear goggles or facial shield. i. On 08/05/20 at 1:22 P.M., observations revealed Resident #13 was walking up and down the halls. She had a face mask in her hand and one on her face but was not wearing it over her nose and mouth. Resident #13 was on droplet precautions but was allowed out of her room to wander the halls. She appeared confused and was telling staff she was looking for her car to go to town. Staff Scheduler #03 attempted to get Resident #13 to go into her room after she was observed wandering all over the unit. Staff Scheduler #03 walked into the resident's room without donning PPE, wearing only her N95 mask. She then came out of the room still not wearing PPE. j. On 08/05/20 at 1:35 P.M., observations revealed AA #04 walked into Resident #70's room with a meal tray and signage on the door indicated droplet isolation precautions were in place. AA #04 had no PPE on except for the N95 mask he was wearing on arrival. He walked back out into the hall, looked around and went back into the room. He did not wash his hand, apply gloves or gown or face shield. He picked up the resident's bread in his bare hand and buttered the bread. He then opened the residents milk carton and wiped his hands on his pants. He then used hand sanitizer before exiting the room and did not change his N95 mask. Interview with AA #04 after he exited the room verified he did not don PPE prior to entering the room stating he didn't notice the sign and stated that was his fault. AA #04 stated he had been told to wear PPE in the isolation rooms. k. On 08/05/20 at 2:06 P.M., interview with the Administrator and the DON verified no quarantine unit had been set up in the facility. The Administrator and DON stated they did not have any private rooms in the facility, the rooms had a(NAME)and(NAME)bathroom, and the facility did not have the bed availability to place like residents together or set up a quarantine unit. l. On 08/05/20 at 2:20 P.M., interview with the Administrator and DON, when informed of the observations of AA #01, the Administrator commented the staff was only [AGE] years old. They both verified staff were not wearing facial shields or goggles unless the resident was COVID positive. The Administrator later stated she misspoke, and that staff were to wear goggles or face shields when in the rooms on droplet precautions. She was unable to answer why only one staff member was observed wearing a face shield during visit on 08/05/20. 3. Review of one employee, LPN #200, who had tested positive for COVID-19 revealed LPN #200's last date worked was on 07/23/20. On 08/05/20 at 11:30 A.M., interview with the Administrator and DON verified LPN #200 tested positive for COVID-19 on 07/24/20. The nurse remained asymptomatic both before testing positive and during the recovery period. The facility identified 17 residents (#73, #56, #12, #61, #11, #26, #20, #38, #66, #76, #44, #08, #64, #02, #72, #35, #88) who had been in contact with LPN #200. The facility increased monitoring of the residents identified but did not place any of the residents under a quarantine status or test any of the residents for COVID-19. The DON stated LPN #200 was wearing PPE when contact occurred. The nurse was retested for COVID-19 on 07/29/20 and the results were negative. LPN #200 returned to work on 08/01/20. Interview on 08/11/20 at 10:18 A.M. with CHD #204 revealed the health department would recommend that any exposed residents to a positive staff person should be quarantined and monitored. If the facility is able to test the resident(s), that would also be recommended with the testing completed 3 days after the last exposure. The recommendation would be the same whether the staff was wearing PPE or not. The roommates of any persons under a quarantine status should also be placed under a quarantine status due to possible exposure but it would not be the recommendation of the health department to put a person under a quarantine status in a room with a person that did not also require quarantine. Review of the facility policy titled, Bed Management Decision Tree, dated 05/29/20, indicated the facility must consider all of the items below before making an admit/readmit decision: the facility has sufficient PAR levels of PPE to place the new resident/resident in contact and droplet isolation for 14 days (masks, gowns, eye protection, gloves), the facility has sufficient staff to provide care and support services, able to isolate the resident/resident appropriately (wanderers), there is an appropriate room for placement, and approval from the Regional Director of Operations/Regional Clinical Coordinator obtained by facility if admission/readmission is denied. Review of the facility policy titled Coronavirus (COVID-19) policy, revised 05/20, revealed the facility will make all attempts to have consistent staff caring for residents/residents on precautions. Room placement: Place a resident/resident with a suspected or verified COVID-19 [DIAGNOSES REDACTED]. When a private room is not available, cohort with similar residents/resident. The policy only addresses suspected or verified positive COVID-19 residents and roommates of residents with COVID-19 and does not address quarantine of new admissions or readmissions. Personal Protective Equipment: use of contact and droplet precautions, including gowns, gloves, masks and protective eyewear. Follow CDC guidelines on PPE that should be used and what measures should be taken if there is a shortage of PPE. Wear gloves, (clean non-sterile gloves are adequate) when entering the room and during all care. Remove gloves before leaving the resident's room and perform hand hygiene. After glove removal and handwashing, ensure the hands do not touch potentially contaminated environmental surfaces. Wear a gown when entering the room and during all care. Remove the gown before leaving the resident's room. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other resident and environments. Always wear a mask and eye protection when entering the room and during resident care. Source control. Healthcare care professionals (HCP) wearing a facemask or cloth masks always while in the facility (per CDC guidelines). Remove and discard all PPE prior to leaving the room. Review of the Centers for Disease Control (CDC) Responding to Coronavirus (COVID-19) in Nursing Homes, Cohorting Residents, dated 04/30/20 revealed the facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Review of the Centers for Disease Control (CDC) core practices dated 06/25/20 revealed facilities should consider a targeted approach where designated wings/units/floor or entire facilities are created for COVID-19 or suspected patients. Facilities should consider designating health care personnel (HCP) who are assigned ONLY to those units to care for known or suspected COVID-19 patients to limit HCP exposure and conserve PPE. These units are ideal for residents returning from the hospital care who still need to complete the isolation period before being released into the general population of nursing facility residents. CDC guidance: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Review of Centers for Disease Control (CDC) guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 07/15/20, revealed as a measure to limit health care personnel (HCP) exposure and conserve personal protective equipment (PPE), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or verified [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. This deficiency substantiates Complaint Number OH 672.

Based on record review, observation and interview, the facility failed to prevent an avoidable fall and failed to ensure preventative fall interventions were in place for a resident with history of falls with injury. This resulted in actual harm when a resident fell in her room unsupervised and suffered a fracture of the jaw and laceration of the chin. This affected one (Resident #103) of two residents reviewed for accidents. The facility census was 92. Findings include: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident was at risk for falls. Review of the comprehensive assessment dated [DATE] revealed the resident had a fall with major injury while at the facility. Review of significant change comprehensive assessment dated [DATE] revealed the resident's cognition was severely impaired, required extensive assistance with bed mobility and transfers with two physical assistance, and required total dependence for locomotion on the unit. Review of progress notes on 04/18/15 revealed the resident had fallen while in the sun porch room and suffered a left hip fracture requiring hospitalization . Upon return from the hospital, physician orders [REDACTED]. Review of ambulation care plan dated 05/31/15 revealed the resident was unable to walk related to unsteady gait, decreased safety awareness, and impaired cognition. Interventions included to use a gait belt and have one person physical assist. Review of the fall plan of care dated 06/02/15 revealed the resident was at risk for fall with injury related to impaired vision, decreased vision acuity, unsteady gait and decreased coordination and balance, history of falls, has [DIAGNOSES REDACTED]. Goal was to be from injury daily. Interventions included bed and chair alarm at all times, observe for fatigue and/or unsteadiness and encourage rest periods, provide clean eye glasses daily, orient to surroundings as needed, provide assistance devices as needed, keep items of frequent use within reach, administer medications as ordered, complete fall risk per protocol, supervise and assist with transfers, encourage guest to wear non-skid footwear when out of bed, and assist guest as needed. Review of progress notes dated 07/25/15 at 7:45 P.M. revealed the resident was on the floor in her room face down. The nurse noted a laceration to the resident 's chin and the area was bleeding heavily. The nurse applied cold towels and pressure. The resident complained of pain to the chin. Her vital signs were blood pressure 106/72, pulse 74 beats per minute and respirations, 18 breaths per minute. The squad arrived at 7:58 P.M. and transported the resident to the hospital. The resident returned to the facility on [DATE] at 1:57 A.M. with sutures to the chin. The medical record did not reveal if the fall interventions including the safety sensor alarm were in place at the time of the fall. There were no further details as to the circumstances surrounding the fall. Review of emergency room notes dated 07/26/15 revealed the resident was diagnosed with [REDACTED]. There was no documentation new interventions were implemented after this fall or what kind of supervision the resident required. Observation of Resident #103 on 07/28/15 from 12:13 P.M. to 1:40 P.M. revealed the resident was sitting in a chair at the dining room table in the sun porch room without a sensor safety alarm in the chair. The resident had bruising covered her nose and cheeks and sutures were present on the chin. There were no staff present in the initial observation at 12:13 P.M. and intermittently thereafter. At 12:17 P.M. Dietary Manager #5 brought in the meal cart and State tested Nurse Aide (STNA) #1 came in to get ice from the ice cart and both the immediately left the sun porch room. At 12:19 P.M. Licensed Social Worker (LSW) #7 came into talk to another resident and STNA #1 came back into the sun porch room and passed out garment protectors to the residents, including Resident #103. At 12:21 P.M. STNA #8 brought the resident her meal tray and set it up for her. At 12:28 P.M. Resident #103 tried getting up and STNA #9 told her to stay at her seat and would be back later to assist her. From 12:31 P.M. to 12:33 P.M. two STNA's were in the sun porch room, sitting at other tables assisting residents with their meals and were not seated to where they could visually supervise Resident #103. From 1:13 P.M. to 1:21 P.M., there were two STNA's present assisting other residents in the room and again the aides were not seated to where the could visually supervise Resident #103. At 1:40 P.M. Activity Director (AD) #15 asked Resident #103 if she would like to join her to the activity area to listen to music. AD #15 took the resident out of the sun porch room and into the secured unit for the activity. Interview with STNA #9 on 07/28/15 at 1:38 P.M. confirmed the safety sensor alarm to Resident #103 chair was not in place. Interview with UM #3 on 07/28/15 at 2:50 P.M. revealed the intervention after 07/25/15 fall was to put padding on the bedside table, although no objects were found around the resident at the time of the fall. Interview with the Director of Nursing (DON) and Regional Clinical Manager #4 on 07/28/15 at 4:15 P.M. confirmed Resident #103 did not have her safety sensor alarm in place and was unsupervised at various times in the sun porch room during the lunch meal. The DON confirmed the medical record did not state if the fall interventions were in place at the time of the fall that occurred on 07/25/15. The DON stated the staff refer to the plan of care and do not investigate if the plan of care was in place at the time of the fall. The DON stated the resident had moved the sensory safety alarm and it did not sound at the time of the fall on 07/25/15 and the fall intervention was to replace the alarm and change the position. The DON confirmed the medical record did not include the resident's behavior to move her safety alarms nor did it include the new fall interventions and also confirmed the plan of care was not revised to reflect the new fall intervention. Interview with STNA #17 on 07/29/15 at 3:44 P.M. stated he was the one who found the resident in her room on the floor. He said the resident kept getting up and down during the beginning of his shift and said he was unable to provide one to one assistance for the resident because he had ten to twelve other residents to take care of. STNA #17 stated the resident would not know how to turn off an safety alarm nor how to move it due to her cognition status. STNA #17 also said the safety alarm was not sounding when he found the resident on the floor and said he thought it should be in place. Interview with Licensed Practical Nurse (LPN) #19 on 07/29/15 at 4:50 P.M. stated she was Resident #103 nurse the night she fell on [DATE] and during her shift the resident was getting up and down constantly and the alarm kept sounds. LPN #19 stated the resident appeared tired, so she laid her down and later she heard a sound that resembled a fall. She said STNA #17 told her she fell and confirmed the safety alarm was not sounding. LPN #19 stated the resident did not hit the bedside the table as there was nothing surrounding the resident when she found her. She stated the resident was messing around with the safety alarm but stated she felt the resident was unable to turn off the safety alarm due to her cognition. She didn't understand how the alarm did not sound when the resident fell because it was sounding all the other times. She replaced the entire safety alarm with a new one to ensure it properly works the next time.