Every finding on record at Lincoln Knolls Health & Rehab LLC

Based on interview and record review, the facility failed to ensure newly hired staff received orientation and training on abuse prohibition upon hire. This had the potential to affect all 39 residents residing in the facility. Findings include: Review of the personnel files for Certified Nursing Assistant (CNA) #509 (date of hire 06/25/26), CNA #506 (date of hire 05/13/26), Certified Medication Assistant (CMA) #507 (date of hire 06/11/26), Housekeeper #512 (date of hire 07/06/26) and [NAME] #511 (date of hire 05/21/26) revealed no evidence of orientation and training on abuse upon hire. An interview with [NAME] #511 on 07/09/26 at 11:13 A.M. revealed they had received no training on abuse since hire. An interview with Human Resources (HR) #510 on 07/09/26 at 9:58 A.M. confirmed there was no abuse training on the forms in the personnel files to account for abuse training for new hires. HR #510 stated the Administrator checks new hires against the abuse registry and abuse training was done during the yearly in-service. An interview with the Administrator, Director of Nursing and HR #510 on 07/09/26 at 11:22 AM confirmed employee files for [NAME] #511, Housekeeper #512, CMA #507 and CNA #506 and #509 did not have abuse training records and confirmed they did not know if it was done since there was no record of it in the files. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 2021, revealed under the section of Employee Training that all new employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. This deficiency represents non-compliance investigated under Complaint Number 3069121.

Based on interview, record review and review of facility policy, the facility failed to ensure a thorough investigation was completed for an allegation of abuse. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 39. Findings include: Review of the medical record for Resident #9 revealed an admission date of 12/08/25 with diagnoses including malignant neoplasm of ovary, heart failure, bipolar disorder, and anxiety disorder. Resident #9 was her own responsible party. Review of the care plan for Resident #9 dated 03/11/26 revealed a behavior problem related to false beliefs and false statements regarding dietary, staff, other residents, herself and her belongings. Interventions included to give medications as ordered, caregivers to provide opportunities for positive interactions, discuss behaviors, and intervene as necessary. The care plan also revealed the resident was sexually active. Interventions included reduce opportunities that may increase risk of falls/fall related injuries and use best method of communication with resident to meet or anticipate needs. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/08/26, revealed the resident had intact cognition, was independent for bed mobility, transfers, and ambulation. Review of the facility document titled Grievance Complaint Report, dated 07/02/26 and received by the Administrator, revealed Resident #9 reported that she broke up with her boyfriend and did not want him coming to her room anymore. The Director of Nursing (DON), the Administrator and Social Service met with the boyfriend and he said ok. Both parties agreed to break off the relationship and the complaint was resolved on 07/02/26 and signed by Resident #9. The document also revealed on 07/03/26 an entry stating follow up with resident who stated it was a mistake, and they are back together.An interview with Certified Nursing Assistant (CNA) #500 on 07/08/26 at approximately 11:00 A.M. revealed she went into Resident #9's room in the morning on 07/01/26 to lay eyes on her and Resident #9 stated Resident #25 raped her. CNA #500 stated she immediately took Resident #9 to Registered Nurse (RN) #503 to inform the nurse and have Resident #9 checked. CNA #500 stated they were not asked to write a witness statement at any time.An interview with CNA #506 on 07/08/26 at 12:55 P.M. revealed on the morning of 07/01/26 she came out of a resident's room on the 400 hall and saw Resident #9 coming from Resident #25's room around 6:30 A.M. Resident #9 stated Resident #25 raped her by having oral sex, but Resident #9 seemed all over the place with her thoughts. CNA #506 stated the nurse it was reported to was RN #505 who took it very seriously. CNA #506 stated she was never asked to give a witness statement, and no one questioned her about it.An interview with Director of Nursing (DON) on 07/08/26 at 1:02 P.M. revealed when he spoke to Resident #9 she denied being raped. The DON stated Resident #9 stated she did not want to date Resident #25 anymore then changed her mind and wanted to continue the relationship. The DON confirmed allegations of abuse should be thoroughly investigated. The DON stated no abuse involving Resident #9 had been reported to him. An interview with the Administrator on 07/08/26 at 1:17 P.M. revealed she went to Resident #9 first thing in the morning on 07/02/26 and Resident #9 stated they didn't want to be in a relationship anymore and didn't want to be bothered by Resident #25 anymore. The Administrator stated it was reported to her by a nurse the day before that Resident #25 was bothering Resident #9 and no abuse was reported. The Administrator stated social services followed up with Resident #9 to address her concerns about the relationship. The Administrator confirmed no witness statements were obtained from staff who initially reported the concern to nursing on 07/01/26. An interview with RN #503 on 07/08/26 at approximately 1:30 P.M. revealed she got report from RN #505 about a rumor going around about Resident #9 and had passed it on to the DON so did not take it any further. RN #503 stated she was not asked to do a witness statement.A follow-up interview with the Administrator and Social Service Designee on 07/08/26 at 2:40 P.M. revealed after speaking to Resident #9 on 07/02/26, they determined abuse did not occur, so they filed a resident grievance concern to address it. An interview with Certified Medication Assistant (CMA) #507 on 07/08/26 at 3:48 PM revealed when she came back to work on 07/02/26 Resident #25 and Resident #9 were both on 15-minute checks. CMA #507 stated she was told it was because Resident #9 made a statement that Resident #25 had raped her. CMA #507 stated she was never interviewed about anything. An interview with RN #505 on 07/09/26 at approximately 9:00 A.M. revealed a CNA overheard Resident #9 talking to another resident about Resident #25 bothering Resident #9. RN #505 stated the CNA reported it to her so RN #505 called the Administrator to let them know Resident #25 was bothering Resident #9 and the Administrator stated to RN #505 they would look into it. An interview on 07/09/26 at 10:00 A.M. with Resident #9 revealed she had a bad dream because of her medication and thought she was being touched by her boyfriend (Resident #25) without her consent and told staff. Resident #9 stated she usually did not have bad dreams and chose to stay away from him after that for a couple of days. Resident #9 confirmed she filed a grievance on 07/02/26 then changed her mind because she wanted to see and be around Resident #25 and wished for him to come to her room again. An interview on 07/09/26 at 10:15 A.M. with Resident #25 revealed he was on good terms with Resident #9, but was told to stay away from Resident #9 on 07/02/26 which was after Resident #9 came to his room around 7:30 A.M. in the morning yelling at him but then later talked it out and everything was fine. Record review of policy titled Abuse, Neglect and Exploitation revealed an immediate investigation is warranted when there is suspicion of abuse or reports of abuse. All involved persons should be identified and interviewed including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. Complete and thorough documentation of the investigation should be provided. This deficiency represents non-compliance investigated under Complaint Number 3069121.

Based on record review, observation, interviews and facility policy review, the facility failed to ensure a safe, clean, comfortable, homelike environment for one Resident (#115) of 34 residents investigated for physical environment. This had the potential to affect all residents in the facility. The facility census was 34.Findings include:A review of Resident #115's medical record revealed an admission date of 06/15/20 and diagnoses including chronic obstructive pulmonary disease (COPD) diabetes mellitus type II, morbid obesity, major depressive disorder, cirrhosis of the liver, anxiety disorder, attention deficit hyperactivity disorder (ADHD), chronic pain syndrome, muscle wasting, venous insufficiency, acquired absence of left foot, and alcohol abuse.A review of Resident #115's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Resident #115 required set-up and clean-up for eating and oral hygiene and required moderate assistance with bed mobility. The MDS also indicated Resident #115 often refused showers and shower transfers and preferred to be in bed most of the time.An observation of Resident #115's room on 04/21/26 at 12:30 P.M. revealed the following:- Multiple dark-colored stains on the wall opposite the bed under the television- Multiple yellow streaks on the wall next to the bed- A large pile resembling drywall dust on the floor behind the head of bed- A clear plastic pitcher on the floor under the bed- A clear empty pill cup on the floor near the head of the bed- A balled-up baseball-sized piece of used clear plastic wrap under the bed- Multiple spots resembling dried food debris on the bed frame and oxygen concentratorAn interview on 04/21/26 at 12:35 P.M. with Licensed Practical Nurse (LPN) #547 confirmed the above findings.An interview on 04/21/26 at 12:36 P.M. with Resident #115 revealed he was unaware of the last time his room was cleaned and stated he shouldn't have to live this way.An interview on 04/21/26 at 2:20 P.M. with the Administrator revealed housekeeping was expected to thoroughly clean each resident's room daily.Review of the facility's policy titled Routine Cleaning and Disinfection dated 2023 revealed routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas and cleaning of walls, blinds and window curtains will be conducted when visibly soiled.Review of the facility's policy titled Safe and Homelike Environment dated 2025 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.This deficiency represents noncompliance investigated under Master Complaint Number 2969318 and represents continued noncompliance from the annual survey completed on 02/23/26.

Based on record review and interview, the facility failed to have a surety bond to cover the total amount of resident funds managed by the facility. This affected all 27 residents (#2, #3, #4, #8, #9, #11, #12, #16, #17, #18, #22, #23, #24, #25, #26, #27, #28, #29, #31, #33, #34, #35, #36, #37, #38, #39, and #40) who had funds managed by the facility. The facility census was 39. Findings include:Review of the facility's surety bond, signed 07/17/25, revealed they had coverage for up to $35,000. Review of the facility's resident accounts listing, dated 02/18/26, revealed the facility managed funds for Residents #2, #3, #4, #8, #9, #11, #12, #16, #17, #18, #22, #23, #24, #25, #26, #27, #28, #29, #31, #33, #34, #35, #36, #37, #38, #39, and #40. The total balance of residents' accounts was equal to $83,396.36, which was $48,396.36 over the amount covered by their surety bond. Review of the surety bond limit increase notification, signed 02/18/26, revealed the facility had requested the surety bond coverage to be increased to $100,000 on 02/18/26. On 02/18/26 at 4:45 P.M., an interview with Corporate Director of Operations #767 verified the facility realized on 02/18/26 when running a report of resident accounts that their current surety bond was not enough to cover the amount of funds they had. Corporate Director of Operations #767 confirmed a surety bond limit increase from $35,000 to $100,000 was completed on 02/18/26.

Based on interview, observation, and facility policy review the facility failed to ensure all medications were stored appropriately. This had the potential to affect all residents in the facility. The facility census was 38. Findings include:Observation on 02/11/26 at 10:30 A.M. of the Medication Storage room with Registered Nurse (RN) #757 present revealed a frozen dinner in the med storage freezer, a full bottle of liquid Levothyroxine 37.5 milligram/milliliter (mg/ml) with a use by date of 12/25/25, a full bottle of liquid Vancomycin 50 mg.ml with a use by date of 11/07/25, 5 bags of Micafungin 100mg/100ml ordered on 09/26/25 with use by date of 10/23/25, and 1 bag of Cefepime 2 Grams (gm)/100 ml ordered December 2025 use by date 01/13/26. Additionally, the Biohazard fridge, temperature log not filled out since January 2025 with only eight out of 31 days filled in and the Freezer needed defrosted. All observations were verified at this time by RN #757. Observation on 02/11/26 at 11:00 A.M. of the 300 hall med cart with Licensed Practical Nurse (LPN) #752 present revealed loose medications in the drawers including one white oblong pill, one white round pill, and one round yellow pill. Three boxes of expired glucometer control solutions expiration date of 10/10/25, and one box of expired COVID-19 tests expiration date 06/10/25. All observations were verified at this time by LPN #752. Observation on 02/11/26 at 11:21 A.M. of the 400 hall med cart with LPN #752 present revealed one bottle of expired Folic Acid 400 mg tabs, expiration date 01/2026, one box of Nicotine Patches 21 mg expired 12/2025, and one loose peach oblong pill. Additionally the 400 hall med cart sharps container was full 100 hall med cart sharps container was full. This observation was confirmed by LPN #752 at 11:30 A.M. Interview on 02/11/26 at 11:36 A.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the expired medications, the loose pills found, and confirmed the temperature log on the bio hazard refrigerator located in the medication room had not been filled out since January 2025.

Based on observation and interview, the facility failed to store foods in a safe an sanitary manner. This had the potential to affect all 39 residents in the facility. Findings include: On 02/10/26 at 8:00 A.M., an observation of the kitchen revealed the following: On the cereal shelf in the main kitchen area, there was one plastic container of dry cereal with no label and no open date. Interview at the time of observation with Dietary Manager #746 verified there was no label or date on the container, verbally identified the cereal as corn flakes, and was unable to state when the corn flakes were placed into that container. In the walk-in cooler, there was one unsealed plastic bag containing sliced white cheese with no label and no open date. Interview at the time of observation with Dietary Manager #746 verified there was no label or date on the cheese and she was unable to state when the cheese had been placed in that bag. In addition, there was a large cardboard box containing multiple nutritional supplement products including health shakes and ice cream products sitting on the shelf in the walk-in cooler with no indication as to how long they had been out of the freezer. Dietary Manager #746 verified this observation and stated there should have been a date on the box indicating when those items were removed from the freezer. Dietary Manager #746 was unable to state when those nutritional supplements were removed from the freezer and placed into the cooler.

Based on record review, observation, interview, and review of facility policy, the facility failed to implement appropriate infection control protocols during medication administration, wound care, and for residents with ordered isolation precautions. This affected four residents (#8, #23, #26 and #28) and had the potential to affect all 39 residents in the facility. Findings include:1. Review of Resident #8's medical record revealed and admission date of 10/21/13. Diagnosis included spondylosis with myelopathy of the cervical region, quadriplegia, spinal stenosis and an in-house acquired stage IV pressure ulcer to the right and left buttock. Review of Resident #8's right buttock wound care orders dated February 2026 revealed orders to cleanse with normal saline solution (NSS) then apply dakins moistened gauze and cover with a hydrocolloid dressing daily and as needed every night shift, and orders for the left buttock were to cleanse with NSS then apply dakins moistened gauze and cover with a hydrocolloid dressing daily and as needed every night shift. Observation on 02/18/26 at 12:15 P.M. of the Assistant Director of Nursing (ADON) with assistance provided by Certified Nursing Assistant (CNA) #748 revealed CNA #748 assisted with positioning Resident #8 on their left side so ADON could perform wound care to right buttock. ADON placed barrier on dirty tray table and began to open sterile items on top of barrier. The tray table had a sticky substance spilled on it and multiple personal items such as remotes, water pitchers, note books, and other miscellaneous items. ADON cleansed her hands and applied gloves, she provided privacy, did not change gloves, she then proceeded to cleanse the wound with normal saline, touched the trash can with gloved hand, then proceeded with dressing the wound per physician orders without removing gloves and completed hand hygiene prior to applying the new wound care supplies. ADON and CNA #748 positioned the resident on his right side so the ADON could perform wound care to left buttock. The ADON did not change their gloves, cleansed wound with normal saline and again did not change gloves and applied new dressing per physician orders. Interview on 02/18/26 at 12:20 P.M. with the ADON confirmed she did not follow proper infection control procedure during wound care. 2. Review of the medical record for Resident #23 revealed an admission date of 04/06/21. Diagnosis included anemia, coronary artery disease (CAD), diabetes, congestive heart failure (CHF), and hypertension. Resident #23 was cognitively aware and required assistance by staff for ADLs and medication administration including monitoring of blood sugars. Observation on 02/09/2026 at 8:25 PM of Registered Nurse (RN) #719 perform blood glucose testing on Resident #23 revealed RN #719 placed the glucometer on resident #23's tray table with no barrier underneath, did not perform hand hygiene prior to gloving for blood glucose check, did not clean the glucometer after blood glucose check, and RN #719 did not clean insulin pen prior to administration and there was no hand hygiene performed after insulin administration. Interview on 02/09/26 at 8:15 P.M. with RN #719 confirmed she should of put a barrier like a tissue down before setting the glucometer on the tray table, and she should of performed hand hygiene prior to gloving for blood glucose check. When questioned why she did not clean the glucometer prior to putting it back in the cart she stated what am I supposed to clean it with, I did not know I was supposed to clean it. RN #719 also confirmed at this time she was supposed to clean the insulin pen with an alcohol wipe prior to inserting the needle for administration and again she should of done hand hygiene and gloved at the time of insulin administration. 3. Review of the medical record for Resident #26 revealed an admission date of 09/27/24. Diagnosis included Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia, epilepsy, vascular dementia, viral hepatitis C, and prostate cancer. Resident #26 is cognitively impaired and requires assistance by staff for Activities of Daily Living (ADLs) and medication administration. Observation on 02/09/26 at 8:05 P.M. of RN #719 revealed she was prepping to give Resident #26 his medication. RN #719 was observed removing two medications (Tamsulosin and Gabapentin) from the medication cup, with her bare hands, and placed them on top of the medication cart and proceeded to crush the remaining meds. RN #719 then proceeded to pick up the two medications off of the medication cart with her bare hands and opened each capsule and placed the contents into the medication cup. At no point did RN #719 wear gloved or preform any hand hygiene. Interview on 02/09/26 at 8:15 P.M. with RN #719 confirmed she should of been wearing gloves when touching any medications and should not of placed them on top of the medication cart. RN #719 stated she should of performed hand hygiene before and after touching the medications. 4. Review of the medical record for Resident #28 revealed an admission date of 05/22/22 with diagnoses of chronic obstructive pulmonary disease, heart failure, type II diabetes mellitus, interstitial pulmonary disease, other abnormalities of gait and mobility, and other specified respiratory disorders. Resident #28 was sent to the hospital on [DATE] due to respiratory symptoms and returned to the facility on [DATE] with orders for droplet isolation precaution due to Human Metapneumovirus (a contagious respiratory infection). Observation on 02/10/26 at 11:45 A.M. revealed CNA #765 and Resident #28 returning to his room from the shower room. CNA# 765 was not wearing personal protective equipment (PPE) and Resident #28 was not wearing a mask. CNA #765 was pushing Resident #28 in his wheelchair past the nurse's desk and through the 100 hallway with other residents and staff also in the vicinity. Observation at this time revealed PPE supplies to the right of the resident's room along with sign posted at eye height with notice of droplet precautions. Observation on 02/10/26 at 11:50 A.M. revealed Resident #28 was being pushed in his wheelchair by CNA #765 from the resident's room to the dining room and the resident was not wearing a mask. CNA #765 assisted Resident #28 to his table in the dining room and left him there. Interview on 02/10/26 at 11:55 A.M. with ADON #720 confirmed Resident #28 was sitting at his table in the dining room without a mask on. ADON #720 also confirmed Resident #28 was to have a mask on when out of his room due to droplet precautions. ADON #720 immediately removed Resident #28 from the dining room and returned him to his room. At this time, CNA #765 was observed to be walking with ADON #720 and Resident #28. CNA #765 stated she did not know Resident #28 was on droplet precautions. Interview on 02/10/26 at 1:20 P.M. with ADON #720 revealed Resident #28 was diagnosed with Human Metapneumovirus. Resident #28 was under droplet precaution and needed to wear a mask when out of his room. Droplet precautions would remain in effect until Resident #28 was no longer symptomatic. Interview on 02/10/26 at 1:45 P.M. with CNA #765 who confirmed she did not have PPE on when assisting Resident #28 earlier today, specifically when assisting Resident #28 with showering and when pushing the resident in his wheelchair in hallway and placing the resident in the dining room. CNA #765 also confirmed Resident #28 did not have a mask on during the same timeframe. CNA #765 stated she was not aware of the droplet precautions and would have worn PPE to protect herself. The PPE supply cart and droplet precaution were still outside of the residents room where the interview took place. CNA #765 stated she did not know if precaution notice and PPE supplies applied to Resident #28. CNA #765 stated she did not inquire with nurse or other staff prior to entering resident's room earlier today. Review of Transmission-Based (Isolation) Precautions policy dated 2023 revealed healthcare personnel will wear a facemask for close contact with an infectious resident. Gloves and gown as well as goggles should be worn if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions. Residents on Droplet Precautions who must be transported outside of the room should wear a facemask if tolerated.

Based on observation and interview, the facility failed to maintain a safe, sanitary, homelike environment, maintain resident showers in proper working order, and ensure cigarettes were disposed by residents properly. This had the potential to affect all 39 residents in the facility.Findings include:1. Observation on 02/10/26 at 8:47 A.M. of Resident #22's room revealed the resident's room was dirty, stains on the curtain between beds, the wall was dirty, appeared to have a tan liquid spilled on it, no sheets were on the bed, pillowcase had boost, a dietary supplement spilled on it. Resident was observed to be laying in the bed at this time. Observation on 02/10/26 at 9:05 A.M. of general environment revealed in the occupied Resident Rooms 103, 107,108,109,302 and the unoccupied resident room [ROOM NUMBER] revealed there were dryer sheets tucked in the top vents in the Packaged Terminal Air Conditioner (P-Tac) units, a ductless commercial cooling and heating unit, which was on and blowing out heat. Interview and observation on 02/10/26 at 9:15 A.M, with the Director of Nursing (DON) revealed she verified the dryer sheets in the P-Tac units and stated this was a fire hazard and immediately removed the dryer sheets. The DON verified all observations in Resident #22's room as well at this time. Interview on on 02/10/26 at 9:35 A.M. with the Maintenance Director revealed staff should not be putting dryer sheets in the vents of the P-Tac units as this is a fire hazard. 2. On 02/10/26 at 11:26 A.M., an interview with Resident #12 stated there was no cold water in the shower in his room. Resident #12 stated the valve on the shower broke off and needed replaced. An observation at the time of interview confirmed this statement. On 02/10/26 at 11:37 A.M., an interview with Maintenance Director #730 verified the showers in the building were not working properly. Maintenance Director #730 stated the former Maintenance Director had broken all the shut off valves and there was only one working shower in the building when he took over this role. Maintenance Director #730 stated there were currently three working showers in the facility, however, there were still multiple valves and pipes that needed replaced and repaired. 3. On 02/12/26 at 9:58 A.M., an observation of the facility's courtyard, which was the designated smoking area for residents, revealed more than 100 cigarettes were littered on the ground throughout the courtyard and there were several used cigarettes discarded in a trashcan that had a plastic liner bag inside. On 02/12/26 at 10:03 A.M., an interview with Registered Nurse (RN) #757 verified there were cigarettes littered throughout the courtyard and in the plastic liner bag in the trash can. On 02/12/26 at 10:07 A.M., an interview with the Administrator confirmed the courtyard needed to be cleaned up.

Based on record review, interview, and review of guidance from the Ohio Department of Medicaid, the facility failed to notify Medicaid recipients when their total resources were within $200 of the maximum limit for maintaining Medicaid eligibility. This affected 15 residents (#8, #9, #11, #12, #16, #17, #18, #22, #23, #29, #31, #33, #34, #36, and #37) out of 27 residents whose funds were managed by the facility. The facility census was 39. Findings include:Review of the most recent spend down notices issued by the facility on 02/07/25 revealed Residents #11, #16, #33, #37, and #39 were all issued spend down notices on that date. No other spend down notices were provided by the facility after 02/07/25 to any resident. Review of the facility's payer source information for residents revealed 38 out of 39 residents were currently Medicaid recipients and one resident (#11) was previously a Medicaid recipient until 01/31/26 when his benefits lapsed. Review of the resident account balances, current as of 02/18/26, revealed the following: Resident #8 had a total account balance of $3,871.64, which was $1,871.64 over the allowable Medicaid limit of $2,000. Resident #9 had a total account balance of $3,398.75, which was $1,398.75 over the allowable Medicaid limit of $2,000. Resident #11 had a total account balance of $7,876.25, which was $5,876.25 over the allowable Medicaid limit of $2,000. Resident #12 had a total account balance of $3,752.85, which was $1,752.85 over the allowable Medicaid limit of $2,000. Resident #16 had a total account balance of $6,529.44, which was $4,529.44 over the allowable Medicaid limit of $2,000. Resident #17 had a total account balance of $4,050.37, which was $2,050.37 over the allowable Medicaid limit of $2,000. Resident #18 had a total account balance of $1,812.44, which was within $200 of the allowable Medicaid limit of $2,000. Resident #22 had a total account balance of $2,500.41, which was $500.41 over the allowable Medicaid limit of $2,000. Resident #23 had a total account balance of $2,614.93, which was $614.93 over the allowable Medicaid limit of $2,000. Resident #29 had a total account balance of $2,722.09, which was $722.09 over the allowable Medicaid limit of $2,000. Resident #31 had a total account balance of $2,141.68, which was $141.68 over the allowable Medicaid limit of $2,000. Resident #33 had a total account balance of $7,419.90, which was $5,419.90 over the allowable Medicaid limit of $2,000. Resident #34 had a total account balance of $2,825.58, which was $825.58 over the allowable Medicaid limit of $2,000. Resident #36 had a total account balance of $2,174.23, which was $174.23 over the allowable Medicaid limit of $2,000. Resident #37 had a total account balance of $4,031.75, which was $2,031.75 over the allowable Medicaid limit of $2,000. On 02/12/26 at 9:26 A.M., an interview with the Administrator verified Resident #11 should have had Medicaid benefits as well, however, the former Business Office Manager (BOM) failed to complete the renewal paperwork timely resulting in Resident #11 losing his Medicaid benefits on 01/31/26. On 02/23/26 at 11:05 A.M., an email from the Administrator verified no spend down notices had been provided to any residents after February 2025. Review of the Ohio Department of Medicaid's Medicaid Standards Help Sheet, dated 01/01/26, revealed the Medicaid resource limit for single persons was $2,000.00 and the resource limit for couples was $3,000.

Based on interview, observation, and record review the facility failed to accommodate Resident #1's request for new motorized wheelchair. This affected one resident (#1) out of one residents reviewed for therapy services. The facility census was 38. Findings include:Record review for Resident #1 revealed admission date 06/15/20 of with diagnosis including acute respiratory failure with hypoxia, unspecified abnormalities of gait and mobility, hereditary and idiopathic neuropathy, major depression, muscle weakness, and localized edema. Review annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 15 (no cognitive impairment), functional limitations: upper extremity as no impairment, lower extremity as impairment of both sides, roll in bed as partial/moderate assistance, lying to sitting on side of bed not attempted due to medical condition or safety concerns.Review of annual therapy screen completed on 01/08/26 revealed Resident #1 stated he would like to start getting out of bed. Interview on 02/10/26 at 1:08 P.M. with Resident #1 revealed in December 2025, Resident #1 discussed with Director of Rehab (DOR) #701 wanting to get out of bed into wheelchair. Resident #1 requested a new motorized wheelchair at this time due to current motorized wheelchair being too small. Approval by insurance for new motorized wheelchair was relayed to resident by DOR in December 2025. DOR informed Resident #1 he would be on wait list for therapy until March 2026 to start therapy services and request for new motorized wheelchair at that time.Interview on 02/11/26 at 10:11 A.M. with DOR confirmed Resident#1 was told he will not start therapy for another two weeks due to no therapy staff available. DOR also confirmed in December Resident #1 and Viacast caseworker discussed with DOR that the resident wanted to start to get out of bed more and into his wheelchair. Resident's #1's current motorized wheelchair was too small, DOR submitted the request for a new wheelchair to insurance in December 2025 and was notified Resident #1 qualified for a motorized wheelchair at that time. DOR also revealed she was told by facility management not to order power wheelchairs for residents due to the amount of issues the facility has with residents leaving facility in their power chairs and riding on the street.

Based on record review, observation, and interview, the facility failed to maintain a clean, safe, sanitary environment in good repair. These finding affected two residents (Resident #26 and Resident #36) of 13 residents reviewed for environmental concerns. Findings included: 1. Observation on 02/11/26 at 9:20 A.M. of Resident # 26's room revealed a large brown water stain on the ceiling measuring approximately six feet by one and a half feet directly above the resident bed. Interview on 02/11/26 at 9:25 A.M., Resident #26 complained the brown stain was directly above his bed and might drip on him and he was worried it may collapse. Asked Resident if he wanted to move rooms or move beds in the room, since the other bed in the room was unoccupied, he said no, the staff had already asked him, and he did not want to move all his stuff but would if the stain or wetness became any worse. Resident #26 stated the brown stain had been there over a week, since the weather had been warming up a little. Interview with the Administrator on 02/11/26 at 10:20 A.M. verified the large water stain and stated it could not be painted over at this time because it was still partially wet. The Administrator stated she asked Resident @26 to move to the bed on the other side of the room, but he refused. Interview on 02/11/26 at 10;55 A.M. with the Maintenance Director (MD) stated the roof was leaking from the extreme cold and freezing from the recent frigid sub-zero winter temperatures, and the resulting ice damming on several sections of the roof. The MD stated he would be able to make a temporary repair to the residents ceiling as soon as it dried out, but the problem is likely to return because the facility needed five roof heater/deicers units to prevent ice buildup and the corresponding leaks in the roof due to the ice damming and continual freeze/thaw cycle that creates the gaps in the roof. Review of Safe and Homelike Environment policy dated 2025 revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 2. Observation on 02/09/26 at 9:43 P.M. revealed large brown water stains on Resident #36 ceiling immediately to the left of resident's bed along outside wall of facility and a blue bucket actively collecting leaking water under the discolored ceiling. Interview at the time of observation with Resident #36 revealed Resident #36 was pointing to the ceiling directly to the left of the bed and a bucket on floor with approximately two to three inches of water. Resident had a speech impairment but was able to relay the ceiling had been an issue for about one week. Resident indicated she was bedbound and saw the stains all day and did not want to look at it any longer. Interview on 02/10/26 at 9:52 A.M. with CNA #700 confirmed brown water stains on Resident's ceiling and have been visible for about one week. CNA #700 indicated maintenance department was aware of leak as they placed blue bucket under brown spots on ceiling. Interview on 02/11/26 at 10;55 A.M. with the Maintenance Director (MD) stated the roof was leaking from the extreme cold and freezing from the recent frigid sub-zero winter temperatures, and the resulting ice damming on several sections of the roof. The MD stated he would be able to make a temporary repair to the residents ceiling as soon as it dried out, but the problem is likely to return because the facility needed five roof heater/deicers units to prevent ice buildup and the corresponding leaks in the roof due to the ice damming and continual freeze/thaw cycle that creates the gaps in the roof. Review of Safe and Homelike Environment policy dated 2025 revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on record review, observation, and interview, the facility failed to ensure wound care treatments were timely completed per physician orders. This affected one resident (Resident #8) of three residents reviewed for skin impairment. The facility census was 38.Findings include:Review of Resident #8's medical record revealed and admission date of 10/21/13. Diagnosis included spondylosis with myelopathy of the cervical region, quadriplegia, spinal stenosis and an in-house acquired stage IV pressure ulcer (the most severe form of pressure injury, involving full-thickness tissue loss with exposed fascia, muscle, tendon, or bone) to the right and left buttock.Review of Resident #8's physician wound treatment orders and Treatment Administration Records (TAR) from March 2024 through January 2026 revealed missing documentation of completion of wound care to Resident #8's right and left buttock Stage IV pressure ulcer multiple days each month until August 2025.Observation on 02/18/26 at 12:15 P.M. of the Assistant Director of Nursing (ADON) with assistance from Certified Nursing Assistant (CNA) #748 revealed Resident #8 had a wound to his left and right buttock. Interview on 02/19/2026 at 11:33 AM with Director of Nursing and ADON confirmed the missing documentation on Resident #8's TARs from March 2024 through August 2025, indicating if the treatment was not signed they were not done. The ADON revealed she began to do daily reviews of all resident TARs in September 2025 to ensure the TAR was completed, but did not verify if the treatment was actually done. There were no other corrective measures taken to ensure treatments were completed as ordered.

Based on observation, record review, interview, and facility policy review, the facility failed to provide appropriate supervision and implement safe smoking interventions for all residents. This affected three residents (#6, #26, and #34) out of four reviewed for smoking. The facility census was 39. Findings include:1. Review of the medical record for Resident #6 revealed an admission date of 05/09/23 with diagnoses including muscle weakness, muscle wasting and atrophy, adjustment disorder with anxiety, and major depressive disorder. Review of the smoking care plan, revised 08/03/23, revealed Resident #6 was a smoker. Interventions included staff to inform resident of smoking policy and designated smoking times (initiated 05/10/23), staff were to keep cigarettes, lighter, and matches in a designated area (initiated 12/11/24), and resident was a supervised smoker (revised 06/30/25). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/23/26, revealed Resident #6 had moderate cognitive impairment. Review of the smoking evaluation dated 01/23/26 revealed Resident #6 must be supervised at all times while smoking. On 02/11/26 at 10:28 A.M., an observation of the facility's courtyard revealed Residents #6 and #26 were smoking in the courtyard and there were no staff present supervising their smoking. An interview at the time of observation with Licensed Practical Nurse (LPN) #752, who was at the nurse's station, verified Residents #6 and #26 were smoking in the courtyard without staff supervision. Review of the facility's list of residents who smoked revealed there were 19 residents on the list, all of whom required supervision. Review of the facility's policy titled Resident Smoking, dated 2025, indicated all residents who smoked would be assessed to determine whether supervision was required for smoking, any resident deemed safe to smoke with or without supervision would be allowed to smoke in accordance with their care plan, and residents who did not abide by the smoking policy could forfeit their smoking privileges. 2. Review of the medical record for Resident #26 revealed an admission date of 09/27/24 with diagnoses including chronic obstructive pulmonary disease, vascular dementia, major depressive disorder, and nicotine dependence. Review of the smoking care plan, dated 09/28/24, revealed Resident #26 was at-risk for injury related to smoking. Interventions included staff to inform resident of smoking policy and designated smoking times (initiated 09/28/24), staff were to keep cigarettes, lighter, and matches in a designated area (initiated 09/28/24), and resident was a supervised smoker (revised 06/30/25). Review of the smoking evaluation dated 11/07/25 revealed Resident #26 must be supervised at all times while smoking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/26, revealed Resident #26 had no cognitive impairment. On 02/11/26 at 10:28 A.M., an observation of the facility's courtyard revealed Residents #6 and #26 were smoking in the courtyard and there were no staff present supervising their smoking. An interview at the time of observation with Licensed Practical Nurse (LPN) #752, who was at the nurse's station, verified Residents #6 and #26 were smoking in the courtyard without staff supervision. Review of the facility's list of residents who smoked revealed there were 19 residents on the list, all of whom required supervision. Review of the facility's policy titled Resident Smoking, dated 2025, indicated all residents who smoked would be assessed to determine whether supervision was required for smoking, any resident deemed safe to smoke with or without supervision would be allowed to smoke in accordance with their care plan, and residents who did not abide by the smoking policy could forfeit their smoking privileges. 3. Review of the medical record for Resident #34 revealed an admission date of 06/08/24 with diagnoses including major depressive disorder, dementia, schizoaffective disorder bipolar type, intermittent explosive disorder, and muscle weakness. Review of the smoking care plan, dated 06/20/24, revealed Resident #34 was at-risk for injury related to smoking. Interventions included staff to inform resident of smoking policy and designated smoking times (initiated 06/20/24), staff were to keep cigarettes, lighter, and matches in a designated area (initiated 06/20/24), resident was a supervised smoker (initiated 06/20/24), and resident required a smoking apron (revised 12/08/25). Review of the smoking evaluation dated 11/13/25 revealed Resident #34 must be supervised at all times while smoking and must wear a smoking apron. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/16/26, revealed Resident #34 had no cognitive impairment. On 02/12/26 at 2:02 P.M., an observation of the courtyard revealed Resident #34 was smoking without a smoking apron. At 2:04 P.M., Housekeeper #734, who was supervising the residents smoking, retrieved a smoking apron and instructed another staff member to put it on Resident #34. Interview at the time of observation with Housekeeper #734 verified Resident #34 was not initially wearing the smoking apron while smoking. Review of the facility's list of residents who smoked revealed there were 19 residents on the list, all of whom required supervision. Resident #34 was identified as requiring a smoking apron. Review of the facility's policy titled Resident Smoking, dated 2025, indicated all residents who smoked would be assessed to determine whether supervision was required for smoking, any resident deemed safe to smoke with or without supervision would be allowed to smoke in accordance with their care plan, and residents who did not abide by the smoking policy could forfeit their smoking privileges.

Based on record review, interview, and review of facility policy, the facility failed to ensure residents requiring dialysis treatments had reliable transportation to and from dialysis, maintain adequate communication with the dialysis providers, and complete pre and post dialysis assessments. This affected all three residents (#3, #11, and #20) identified by the facility as receiving dialysis treatments. The facility census was 39. Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 08/16/24 with diagnoses including end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the dialysis care plan dated 08/18/24 revealed Resident #3 needed dialysis related to end stage renal disease. Interventions included no blood pressures to be taken on arm with fistula (revised 02/10/25), complete pre and post dialysis assessments per facility policy (revised 06/30/25), check bruit and thrill of left arm fistula every shift (revised 06/30/25), and dialysis treatments every Monday, Wednesday, and Friday with pickup at 4:00 A.M. via facility transport (revised 12/05/25). Review of the physician's orders for Resident #3 identified orders for dialysis three times weekly on Monday, Wednesday, and Friday (ordered 03/18/25). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/30/26, revealed Resident #3 had no cognitive impairment and required dialysis treatments. Review of Resident #3's dialysis assessments completed by the facility revealed the following: there was no post-dialysis assessment completed on 01/02/26, there was no pre-dialysis assessment completed on 01/07/26, there were no pre- or post-dialysis assessments completed on 01/09/26, there was no pre-dialysis assessment completed on 01/12/26, there were no pre- or post-dialysis assessments completed on 01/26/26, the pre-dialysis assessment dated [DATE] indicated the most recent vitals obtained were from 01/23/26, there was no pre-dialysis assessment completed on 02/02/26, there were no pre- or post-dialysis assessments completed on 02/04/26, there were no pre- or post-dialysis assessments completed on 02/09/26, the pre-dialysis assessment dated [DATE] indicated the most recent vitals obtained were from 02/11/26, and there was no post-dialysis assessment completed on 02/16/26. On 02/19/26 at 2:40 P.M., an interview with the Director of Nursing (DON) verified dialysis assessments were not completed as they should have been for Resident #3. Review of the facility's policy titled Hemodialysis, dated 2023, revealed the facility would assure that arrangements were made for safe transportation to and from the dialysis facility, assessment of the resident's condition and monitoring for complications would be completed before and after dialysis treatments, and there would be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. 2. Review of the medical record for Resident #11 revealed an admission date of 10/29/19 with diagnoses including end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the dialysis care plan dated 11/11/19 revealed Resident #11 received dialysis three times weekly with transportation arranged. Interventions included nursing to check for new orders upon return from dialysis (revised 06/30/25), complete pre and post dialysis assessments per facility policy (revised 06/30/25), and dialysis treatments three times weekly on Monday, Wednesday, and Friday with a transportation pickup time of 9:30 A.M. (revised 12/03/25). Review of the physician's orders for Resident #11 identified orders for dialysis three times weekly on Monday, Wednesday, and Friday (ordered 04/02/25). Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/25, revealed Resident #11 had no cognitive impairment and required dialysis treatments. Review of the dialysis communication folder for Resident #11 revealed there were no dialysis communication sheets for 12/03/25, 12/08/25, 12/17/25, 12/19/25, 12/21/25, 12/26/25, 12/28/25, 12/30/25, 01/02/26, 01/05/26, 01/07/26, 01/09/26, 01/14/26, 01/16/26, 01/19/26, 01/21/26, 01/23/26, 01/27/26, 01/28/26, and 01/30/26. Review of Resident #11's dialysis assessments completed by the facility revealed there were no pre- or post-dialysis assessments completed on 12/10/25 and 12/28/25. Review of the progress note dated 01/12/26 at 10:18 A.M. revealed Resident #11's transportation to dialysis was cancelled and dialysis treatment was missed as a result. Review of the progress note dated 02/06/26 at 9:27 A.M. revealed Resident #11 was being sent to the emergency room due to missing dialysis on 02/06/26. The note indicated Resident #11 would receive dialysis treatment at the hospital. Review of the progress note dated 02/09/26 at 11:49 A.M. revealed Resident #11 was being sent to the hospital due to missing dialysis on 02/09/26. The note indicated Resident #11 would receive dialysis treatment at the hospital. On 02/10/26 at 10:25 A.M., an interview with Licensed Practical Nurse (LPN) #752 verified Resident #11 had missed dialysis appointments due to transportation being cancelled. LPN #752 confirmed Resident #11 had to go to the hospital to receive dialysis treatments on 02/06/26 and 02/09/26 due to missing his dialysis appointments. On 02/10/26 at 4:21 P.M., an interview with the Long Term Care Ombudsman said the dialysis center had contacted their office regarding concerns with Resident #11 missing dialysis appointments and a lack of communication from the facility. The Ombudsman stated the facility confirmed that Resident #11 had missed dialysis appointments because the transportation had been cancelled. On 02/10/26 at 4:58 P.M., an interview with the Administrator confirmed Resident #11's transportation to the dialysis center had been cancelled, the facility was not able to arrange alternate transportation to the dialysis center, and Resident #11 had to be sent to the hospital to receive dialysis treatments as a result. On 02/11/26 at 10:53 A.M., an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said Resident #11's transportation issue was due to his insurance lapsing. The DON stated Resident #11 also missed dialysis on 02/04/26 due to a refusal and confirmed that information was not documented anywhere in his medical record. On 02/11/26 at 11:01 A.M., an interview with the DON verified the missing dialysis communication sheets and incomplete documentation regarding dialysis for Resident #11. On 02/12/26 at 8:54 A.M., an interview with the Dialysis Social Worker at Resident #11's dialysis center verified Resident #11 had missed dialysis appointments on 01/12/26, 02/04/26, 02/06/26, and 02/09/26. Dialysis Social Worker stated Resident #11 never refused dialysis treatments and missed appointments were due to transportation issues. Dialysis Social Worker stated Resident #11 did not arrive for treatment as scheduled on 02/04/26 and when she contacted the facility about the missed appointment, she was told transportation never arrived to pick up Resident #11. Dialysis Social Worker further stated the facility decided on their own to just send Resident #11 to the hospital for dialysis rather than arranging alternate transportation. On 02/12/26 at 11:32 A.M., an interview with Resident #11 stated he never refused to go to dialysis and the only times he missed dialysis was when he could not get transportation. Resident #11 further stated he had been getting dialysis treatments for 13 years. Review of the facility's policy titled Hemodialysis, dated 2023, revealed the facility would assure that arrangements were made for safe transportation to and from the dialysis facility, assessment of the resident's condition and monitoring for complications would be completed before and after dialysis treatments, and there would be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. 3. Review of the medical record for Resident #20 revealed an admission date of 03/29/22 with diagnoses including end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the dialysis care plan dated 03/29/22 revealed Resident #20 needed dialysis related to end stage renal disease. Interventions included complete pre and post dialysis assessments per facility policy (revised 06/30/25), monitor dialysis port for signs of bleeding (revised 03/18/25), and dialysis treatments every Monday, Wednesday, and Friday with pickup at 4:00 A.M. via facility transport (revised 12/23/25). Review of the physician's orders for Resident #20 identified orders for dialysis three times weekly on Monday, Wednesday, and Friday (ordered 03/19/25). Review of the annual Minimum Data Set (MDS) assessment, dated 01/23/26, revealed Resident #20 had moderate cognitive impairment and required dialysis treatments. Review of Resident #20's dialysis assessments completed by the facility revealed the following: there was no pre-dialysis assessment completed on 01/02/26, there were no pre- or post-dialysis assessments completed on 01/05/26, there was no pre-dialysis assessment completed on 01/09/26, there were no pre- or post-dialysis assessments completed on 01/12/26, the vitals recorded on the pre-dialysis assessment on 01/14/26 were timestamped as obtained after returning from dialysis that day and were identical to the vitals recorded on the post-dialysis assessment on 01/14/26, there was no pre-dialysis assessment on 01/16/26, there was no post-dialysis assessment on 01/23/26, there was no post-dialysis assessment completed on 02/06/26, and there was no pre-dialysis assessment completed on 02/11/26. On 02/19/26 at 2:40 P.M., an interview with the Director of Nursing (DON) verified dialysis assessments were not completed as they should have been for Resident #20. Review of the facility's policy titled Hemodialysis, dated 2023, revealed the facility would assure that arrangements were made for safe transportation to and from the dialysis facility, assessment of the resident's condition and monitoring for complications would be completed before and after dialysis treatments, and there would be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on interview, observation and record review the facility failed to provide therapy services in a timely manner. This affected one resident (Resident #1) of one resident reviewed for therapy services. The census was 39.Findings include:Record review for Resident #1 revealed admission date 06/15/20 of with diagnosis including acute respiratory failure with hypoxia, unspecified abnormalities of gait and mobility, hereditary and idiopathic neuropathy, major depression, muscle weakness, and localized edema. Review annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 15 (no cognitive impairment), functional limitations: upper extremity as no impairment, lower extremity as impairment of both sides, roll in bed as partial/moderate assistance, lying to sitting on side of bed not attempted due to medical condition or safety concerns.Review of annual therapy screen completed on 01/08/26 revealed Resident #1 stated he would like to start getting out of bed and therapy will be determined after consultation with durable medical equipment provider. The screening also indicated the resident had a power wheelchair. Occupational therapy noted occupational therapy was recommended to address positioning, upper body strength, core strength and simple hygiene and grooming. Interview on 02/10/26 at 1:08 P.M. with Resident #1 revealed in December 2025, Resident #1 discussed with Director of Rehab (DOR) #701 wanting to get out of bed into wheelchair. Resident #1 requested a new motorized wheelchair at this time due to his current motorized wheelchair being too small. Approval by insurance for new motorized wheelchair was relayed to resident by DOR in December 2025. DOR informed Resident #1 he would be on wait list for therapy until March 2026 to start therapy services and request for new motorized wheelchair at that time.Interview on 02/11/26 at 10:11 A.M. with DOR confirmed Resident #1 was told he will not start therapy for another two weeks due to no therapy staff available. DOR also confirmed in December 2025 Resident #1 and his mental health provider caseworker discussed with DOR that the resident wanted to start to get out of bed more and into his wheelchair. Resident's #1's current motorized wheelchair was too small, DOR submitted the request for a new wheelchair to insurance in December 2025 and was notified Resident #1 qualified for a motorized wheelchair at that time. DOR also revealed she was told by facility management not to order power wheelchairs for residents due to the amount of issues the facility has with residents leaving facility in their power chairs and riding on the street. DOR reported rehab staff included one full time physical therapy aide, two as needed (PRN) occupational therapists, three PRN certified occupational therapy assistants, three PRN physical therapists, one PRN physical therapy assistants and four PRN speech therapists. Interview on 02/12/2026 at 7:45 A.M. with Director of Rehab (DOR) #701 confirmed Resident #1 has not been assessed for physical and occupational therapy. DOR has not requested additional therapy staffing due to no other residents currently waiting to start therapy services. DOR also revealed the facility is low on residents in therapy. DOR now reported Resident #1 was not on wait list for therapy due to staffing, and the wait was because the resident will only be authorized for a limited number of sessions and wanted to ensure the power wheelchair arrival with start of therapy sessions. DOR revealed Resident #1 had not been assessed with his current wheelchair to determine if his current wheelchair was an appropriate fit. Interview on 02/18/26 at 8:19 AM with Administrator and Assistant Director of Nursing (ADON) #720 revealed facility does not have a policy regarding process for when a resident requests therapy. Administrator or DOR receives the request for therapy, a therapy screen would be completed, then resident would be scheduled for therapy services if the screen indicates a need. There was no set timeline for how long the process should be completed. Reviewed list of residents with start of service date for physical and or occupational therapy since December 2025 revealed 27 residents started either physical or occupational therapy since December 2025, and Resident #1 was not on list.

Based on record review and interview, the facility failed to provide assistance to Resident #11 to maintain the Medicaid benefits for which he was eligible. This affected one resident (#11) out of two reviewed for Medicaid coverage. The facility census was 39. Findings include: Review of the medical record for Resident #11 revealed an admission date of 10/29/19 with diagnoses including end stage renal disease, dependence on renal dialysis, type two diabetes mellitus, cerebral infarction, peripheral vascular disease, dementia, and congestive heart failure. Review of the payer source information for Resident #11 revealed the primary payer was listed as Medicaid. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/25, revealed Resident #11 had no cognitive impairment. Review of the progress note dated 01/12/26 at 10:18 A.M. revealed Resident #11's transportation to dialysis was cancelled and dialysis treatment was missed as a result. Review of the Medicaid Benefits and Assignment Plan for Resident #11 revealed his Medicaid benefits ended on 01/31/26. Review of the progress note dated 02/06/26 at 9:27 A.M. revealed Resident #11 was being sent to the emergency room due to missing dialysis on 02/06/26. Review of the progress note dated 02/09/26 at 11:49 A.M. revealed Resident #11 was being sent to the hospital due to missing dialysis on 02/09/26. On 02/10/26 at 10:25 A.M., an interview with Licensed Practical Nurse (LPN) #752 verified Resident #11 had missed dialysis appointments due to transportation being cancelled. On 02/10/26 at 4:21 P.M., an interview with the Long Term Care Ombudsman said the dialysis center had contacted their office regarding concerns with Resident #11 missing dialysis appointments because the transportation had been cancelled due to insurance coverage. On 02/10/26 at 4:58 P.M., an interview with the Administrator confirmed Resident #11's transportation to the dialysis center had been cancelled by the transportation company. On 02/11/26 at 10:53 A.M., an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed Resident #11's transportation issue was due to his insurance coverage lapsing. On 02/12/26 at 8:54 A.M., an interview with the Dialysis Social Worker at Resident #11's dialysis center verified Resident #11 had missed dialysis appointments on 01/12/26, 02/04/26, 02/06/26, and 02/09/26. Dialysis Social Worker stated Resident #11 never refused dialysis treatments and missed appointments were due to transportation issues. Dialysis Social Worker stated she contacted the transportation company herself to find out why transportation was cancelled and discovered Resident #11's Medicaid coverage had lapsed and the transportation company was no longer a covered provider. On 02/12/26 at 9:10 A.M., an interview with the Administrator stated Resident #11's Medicaid renewal paperwork was just completed that week on 02/09/26. On 02/12/26 at 9:26 A.M., an interview with the Administrator verified it was the Business Office Manager's (BOM) responsibility to complete insurance renewal paperwork and the former BOM had failed to do so for Resident #11.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interviews and facility policy review, the facility failed to ensure a safe transfer via mechanical lift (Hoyer) for Resident #45. This affected one (Resident #45) of three residents reviewed for falls/Hoyer transfers. The facility census was 44.Findings include:Review of the closed medical record for Resident #45 revealed an admission date of 12/07/22 with diagnoses including type two diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), anxiety disorder, failure to thrive, morbid obesity, and chronic kidney disease (CKD). Review of the physician's order dated 01/15/25 revealed an order for a Hoyer lift for transfers. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact, was dependent on others for mobility and required extensive assistance/dependence with activities of daily living (ADL). Review of Resident #45's Fall Risk assessment dated [DATE] revealed the resident was at a moderate risk for falls, was completely incontinent, had a history of falls, was confined to a chair and was unable to independently come to a standing position. Review of the progress note dated 06/12/25 at 6:17 P.M. revealed Resident #45's nurse was notified that while two Certified Nursing Assistants (CNAs) #553 and #557 were getting the resident into bed with the Hoyer lift, the Hoyer tilted over sideways and fell. The resident then fell to the ground landing on her buttocks. Upon walking in the room, the nurse witnessed the resident sitting in the upright position on her buttocks in the Hoyer sling that was tilted over and lying on the ground. The nurse along with both CNAs and a second nurse adjusted the resident to a flat position on the ground to assess her. Upon assessment, Resident #45's vital signs included blood pressure 178/72, pulse 78, respirations 20, oxygen saturation was 94 percent on room air, temperature was 98.6 degrees Fahrenheit (F). The resident stated she had pain in her buttocks. After the assessment, staff got the resident up from the floor using the Hoyer and put her safely into the bed. The doctor was notified, and the Director of Nursing (DON) was notified. The physician ordered STAT (urgent) bilateral hip and pelvis x-rays. Review of the progress note dated 06/12/25 at 11:55 P.M. revealed Resident #45 complained of pain and was medicated with one tablet of Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg) (opioid pain medication). Review of Resident #45's fall investigation revealed a statement on 06/12/25 signed by the DON stated CNA #553 was unable to remember if the legs on the Hoyer were open or closed when it tipped causing Resident #45's fall to the ground. Review of the progress note dated 06/13/25 at 3:57 A.M. revealed Resident #45 denied any pain or discomfort following her fall. Review of the progress note dated 06/13/25 at 1:39 P.M. revealed Resident #45 was sent to the emergency room for possible fracture post hip and pelvis x-ray and admitted to the hospital. Interview with the DON on 08/01/25 at 2:35 P.M. revealed audits and a plan of correction were conducted immediately following Resident #45's fall. An interview with the Administrator on 08/01/25 2:41 P.M. revealed her statement that the Hoyer didn't tip all the way over and only partially tipped. She further stated the legs of the Hoyer were open partially but not all the way. Review of the policy entitled Lifting Machine, Using a Mechanical, dated July 2017, revealed staff were to make sure the lift was stable and locked. The deficient practice was corrected on 06/18/25 when the facility implemented the following corrective actions: On 06/13/25 at 5:20 P.M. when the Hoyer lift used to transfer Resident #45 was immediately removed from service pending maintenance department. On 6/13/25 beginning at 4:17 P.M. the DON assessed all Hoyer lift residents with no ill effects noted. On 6/14/25 at 7:00 A.M. the DON observed the weight capacity on the lift and ensured it was appropriate size for the resident that was transferred. The lift's weight capacity was noted to be appropriate for the resident's weight. The Hoyer lift was inspected on 06/14/25 at 8:30 A.M. by the facility Maintenance Director #547 and found to be in proper working order. On 6/14/25 at 8:30 A.M. the Maintenance Director #547 inspected all mechanical lifts to ensure they were in good repair and functioning appropriately. From 6/13/25 through 6/18/25 the DON completed Hoyer lift competency training and re-education with all licensed nursing staff and CNA staff. The facility planned to monitor its performance to make sure that solutions were sustained by having the DON or designee directly observing the nursing staff performing mechanical lift transfers three times weekly time four weeks, then as determined by the Quality Assurance and Performance Improvement (QAPI) committee. This deficiency represents noncompliance investigated under Complaint Number 1317076 (OH00167577).

Based on observation and interview the facility failed to maintain an outside sidewalk to allow for safe passage of residents. This had the potential to affect all residents residing in the facility. The facility census was 49. Findings include: Interview on 07/08/24 at 8:55 A.M. with Residents #24, #27, and #32 while they were out on the patio smoking confirmed they get their wheelchairs stuck in the large cracks in the sidewalks all the time. They also confirmed that the large divots on the sides of the sidewalk had wheelchair marks from where they rolled off the sidewalk and got stuck. Observation during the interview revealed the sidewalk to the smoking area had four cracks in sidewalks measuring six inches wide and two to three inches deep. There were numerous divots on the grass area next to the sidewalks measuring four to twelve inches deep with wheelchair marks where they got stuck. Interview and observation on 07/08/24 at 2:00 P.M. with the Director of Nursing (DON) confirmed the large cracks in the sidewalk leading to the smoking patio. He also confirmed the areas next to the sidewalks with large divots with wheelchair tire marks in them. He reported thankfully no one has been hurt out here. Interview on 07/08/24 at 2:25 P.M. with Maintenance Supervisor #555 confirmed there are a lot of big cracks in the sidewalk leading to the outside patio. He reported in the past staff have filled in the divots with hay and used quick concrete to fill them in, but it does not last, and residents get stuck in them. Interview on 07/09/24 at 1:40 P.M. with Resident #5, Resident #8, and Resident #34 confirmed they got stuck in the cracks in the sidewalk leading to the patio all the time. They confirmed they have not fallen but they get stuck, and it is hard especially with limited mobility and a bigger size. They reported no other concerns with their care. Interview on 07/09/24 at 1:45 P.M. with State tested Nursing Assistant (STNA) #530 confirmed the cracks in the sidewalk are extremely hard to push resident's wheelchairs over safely. She confirmed no injuries had happened that she is aware of, but it was not safe.

Based on observation, 2019 Food Code - Chapter 3717-1-03 Reference Guide review, and facility policy review the facility did not ensure food was served at a palatable temperature. This had the potential to affect 44 residents who received food from nutrition services. The facility identified one resident (#35) that received nothing by mouth. The facility census was 45. Findings include: Observation was conducted on 03/20/24 at 11:28 A.M. of the tray line temperatures at meal service. The food temperatures were taken with a calibrated digital thermometer as follows: beef pepper patty 169.4 degrees Fahrenheit (F), mashed potatoes 168 degrees F, roasted zucchini 184 degrees F, milk 39 degrees F. The tray line's start time was11:30 A.M. The system being used to retain hot food temperatures was a plate warmer and thermal dome cover. The test tray was placed on the 100/200 hall cart at 12:05 P.M. where staff would pass on the 100 unit then the 200 unit. At 12:11 P.M. a test tray was passed to Dietary Manager #725 who proceeded to take the food temperature with the same digital thermometer used on the tray line. The test tray temperatures were as follows: the roasted zucchini 145.8 degrees F, beef pepper patty 127.6 degrees F, mashed potatoes 148.3 degrees F, and milk 48.2 degrees F. The surveyor tasted the foods and found the milk to be barely cold and the beef pepper steak to be barley warm. The overall flavor and portions of the food were appropriate for the meal. Review of the 2019 Food Code - Chapter 3717-1-03 Reference Guide revealed cold temperature controlled (TCF) for safety cold food should be 41 degrees F or less and TCF hot food should be 130 degrees F or above. Review of an undated facility policy titled Tray Line Checklist revealed food should be on the steam table no more than one half hour prior to start of service, and hot food should be 135 degrees or hotter. Cold food should be 41 degrees or lower and, in a refrigerator, or ice bath.

Based on observations, interviews, and facility policy review the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 44 residents receiving meals from the kitchen. The facility identified one resident (#35) who received nothing by mouth. The census was 45. Findings include: Observation on 03/18/24 at 6:53 P.M. the kitchen dry storage revealed two open undated Potato Pearls containers with no use by date. These findings were verified by the Dietary Manager (DM) #725 at the time of the observation. Observation on 03/20/24 at 1:00 P.M. revealed the resident's refrigerator on the 200-unit had a white plastic bag with three take out containers. The plastic bag did not have a resident name or date. A paper bag with an employee's name on it with perishable food inside the bag was undated, and a gallon of ice cream in the freezer with no resident name or date. This was verified by DM #725 at the time of the observation. Interview with the Administrator on 03/20/23 at 1:12 P.M. revealed the unit-200 refrigerator should not have any food in it. Interview on 03/20/24 at 1:38 P.M. with Licensed Practical Nurses (LPNs) #721 and #724 revealed the facility staff would place resident food from visitors in the 200-unit refrigerator. Interview on 03/21/24 at 8:35 A.M. with the Administrator revealed the 200-unit refrigerator was moved into the employee breakroom. The facility currently had no place to keep food for residents brought in by visitors. Review of the facility policy titled Food Brought in by Family or Visitors, dated October 2017, revealed food brought in by family and visitors that was left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. Perishable foods must be stored in re-sealable containers with tight fitting lids in a refrigerator.

Based on medical record review, observations, staff interview, review of the facility menus and spreadsheets for mechanical soft diets, review of facility policy for therapeutic diets, consistency modified diets, and tray card policy, the facility failed to ensure 10 residents on mechanically altered diets were provided food in the correct form assessed to meet their individual needs. This resulted in Immediate Jeopardy for Residents #6, #11, #19, #30, #31, #36, #37, #201 and #345 who were served whole, intact bone-in chicken by the dietary staff and nursing assistants. Residents #6, #27, #30 and #36 also were assessed to need their liquids thickened to nectar consistency and were served the wrong consistency liquids. The noncompliance to the mechanically altered diets placed them at risk for serious harm such as choking which could have resulted in death. The facility identified ten Residents (#6, #11, #19, #27, #30, #31, #36, #37, #201 and #345) who received mechanically altered diets. The facility census was 48. On 02/17/22 at 9:13 A.M. the Administrator and Regional Director of Operations (RDO) #549 were notified Immediate Jeopardy began on 02/15/22 at approximately 1:00 P.M. when Residents #6, #11, #19, #27, #30, #31, #37, #201 and #345 who were ordered mechanical soft diets were observed receiving whole, bone-in regular fried chicken legs. In addition, Residents #6, #27, #30 and #36 were served liquids at the wrong consistency contrary to their assessed needs for nectar thick liquids. Interview with Cook #516 and Dietary Manager #508 at 1:10 P.M. revealed Cook #516 did not prepare any mechanical soft meat for the meal. The Immediate Jeopardy was removed on 02/16/22 when the facility implemented the following corrective actions: · On 02/15/22 at approximately 2:20 P.M. the Regional Director of Operations (RDO) #549 educated DM #508 on diet spreadsheets including mechanical soft and pureed consistency, the tray ticket program and liquid consistency including nectar and honey thickened liquids and thin liquids. · On 02/15/22 at approximately 3:30 P.M. the Director of Nursing (DON) and Dietetic Technician Registered (DTR) #546 audited 48 of 48 resident diet orders to ensure the ordered diet texture and liquids consistencies matched the resident's assessed needs. · On 02/15/22 at approximately 3:45 P.M. Dietary Manager (DM) #508 educated two of six dietary staff working in the facility on the importance of dietary tray cards, the consistencies of nectar and honey thickened liquids, the consistencies of mechanical soft and pureed modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. The remaining four dietary staff were educated by DM #508 by 2:00 P.M. on 02/17/22. · On 02/15/22 between 4:30 P.M. and 5:30 P.M. the Administrator and DON rounded the floor during dinner and observed all meal trays being delivered with correct diet consistency including 10 of 10 mechanical soft diets and four of four nectar consistency liquids. · On 02/15/22 from 6:30 P.M. to 7:30 P.M. 10 of 10 residents ordered a mechanically altered diet and nectar thickened liquids had respiratory assessments completed by the DON and RN #537. There were no signs or symptoms of respiratory compromise. · On 02/15/22 between 7:30 P.M. and 8:00 P.M. the DON reviewed 10 of 10 mechanically altered and nectar thickened liquid diet orders with Medical Director (MD) #552 and verified the diet orders being implemented for the residents were accurate compared to the physician orders. · On 2/16/2022 beginning at 6:00 A.M. the DON and Administrator began to educate all available staff on shift on the meal tray preparation, meal tray service, the importance of checking dietary tray cards, proper consistency of thin, nectar and honey consistency thickened liquids, consistency of modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. All staff (42 out of 42 staff including 16 out of 16 STNA's, 4 out of 4 RN's, 3 out of 3 LPN's, 5 out of 5 housekeeping/laundry employees, 1 out of 1 activities aid, 6 out of 6 dietary staff, 7 out of 7 department heads) education was completed on 02/17/22 by 2:00 P.M. when DM #508 completed the education with the remaining four of six dietary department employees. · On 02/16/22 beginning at approximately 8:30 A.M. RDO #549 again reviewed for competency with DM #508 the importance of dietary tray cards, consistency of thickened liquids, consistency of modified diets, therapeutic diet policy and examples of mechanical soft items. RDO #549 monitored breakfast and lunch meal service to ensure compliance. · On 02/16/22 at 12:08 P.M. RDO #549 communicated with the contracted Registered Dietitian (RD) #547 to inform her of the recent review of dietary spreadsheets and mechanically altered diet extensions with related staff education. RDO #549 observed the lunch meal service. · The facility administrator or designee ( which may include the DON, ADON, RDO #549, DTR #546, DM #508 or RD #547) will continue to audit/observe the meal tray service line to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. · The facility DON or designee which may include the ADON, Charge Nurse, Administrator, RDO #549, Regional Clinical Nurse (RCN) #553, DTR #546 and RD #547 will observe meal tray delivery service to the rooms to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. Although the Immediate Jeopardy was removed on 02/16/22 the facility remained out of compliance at a severity level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: 1. Record review was conducted for Resident #6 who was admitted to the facility on [DATE] with diagnoses including stroke, [CONDITION(S)], and oropharyngeal dysphagia (difficulty chewing and swallowing). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had no cognitive impairment, required extensive assistance of two staff for bed mobility and transfers and required set-up and one-staff physical assistance with eating. A physician order dated 07/21/21 indicted Resident #6 was to receive a mechanical soft diet with nectar consistency liquids. The plan of care with a revision date of 12/06/21 revealed the care plan indicated Resident #6 required a mechanically altered diet with nectar consistency liquids. The interventions included dietary staff and nursing staff would provide the diet as ordered and monitor the consistency of the diet served to the resident. Observation of and interview with Resident #6 in the dining room on 02/15/22 at 12:47 P.M. presented as dependent on a custom wheelchair with a head rest for mobility and positioning. Resident #6 required staff assistance to put his food on the table, set-up the meal and prepare his nectar consistency liquids. Resident #6 was alert and oriented to person, place, time, and conversation and had little eye contact with the surveyor during conversation. Resident #6 was able to verbally make his needs known to staff. 2. Record review was conducted for Resident #11 who was admitted to the facility on [DATE] with diagnosis including Alzheimer's dementia with behavioral disturbance. The MDS 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment, required extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfers and set-up help only and supervision for eating. A physician order dated 01/07/21 indicated Resident #11 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 07/15/19 revealed Resident #11 was edentulous (no teeth) by choice and required a mechanically altered diet texture. The interventions included for dietary and nursing staff to provide the ordered diet. Observation and interview were conducted 02/14/22 at 11:00 A.M. in the Resident #11's room. He presented as alert with disorientation to time, place and was not able to provide reciprocal conversation with the surveyor often making limited comments of no relevance to the questions. 3. Record review was conducted for Resident #19 who was admitted to the facility on [DATE] with diagnoses including stroke, hemiparalysis of right side and dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #19 had no cognitive impairment and required limited assistance of one staff to provide physical assistance for eating, extensive assistance of two staff for transfers and extensive assistance of one staff for bed mobility. A physician order dated 06/23/21 indicated Resident #19 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 02/15/22 revealed Resident #19 required a mechanically altered diet and the diet should be provided to him as ordered by the dietary and nursing staff. Observation and interview of Resident #19 in his room on 02/15/22 at approximately 6:00 P.M. revealed he was unable to use his paralyzed right arm to eat his meal, but he could feed himself with his left hand. Resident #19 was alert and oriented to person, place and conversation and was able to verbally make his needs known to staff. 4. Record review was conducted for Resident #30 who was admitted to the facility on [DATE] with diagnoses including stroke, right sided paralysis, and oropharyngeal dysphagia. The MDS 3.0 assessment dated [DATE] revealed Resident #30 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, total assistance by two staff for transfers and extensive assistance with one-staff physical assistance for eating. A physician order dated 07/07/21 revealed Resident #30 required a mechanical soft diet with nectar consistency liquids and low concentrated sweets. The plan of care with a revision date of 04/25/19 revealed dietary staff and nursing staff should provide the diet as ordered. Observation was conducted of Resident #30 on 02/15/22 at approximately 5:59 P.M. revealing a vulnerable man with paralysis in need of extensive assistance by staff to ensure he ate his meal. Resident #30 was alert but unable to carry a conversation nor answer questions from the surveyor. 5. Record review was conducted for Resident #31 who was admitted to the facility on [DATE] with diagnosis including Alzheimer dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #31 had severe cognitive impairment, required limited assistance of one staff for bed mobility and transfer and set-up with supervision for meals. A physician order dated 07/06/2020 revealed Resident #31 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 12/11/21 revealed Resident #31 had the potential for alteration in nutrition and hydration status due to a poor appetite and need for supplements. Interventions included for dietary and nursing staff to provide the diet as ordered and monitor diet consistency. Observation was conducted on 02/15/22 at 12:49 P.M. of Resident #31 sitting in her wheelchair in the main dining room. She was alert, able to state her name but disoriented to place and time. Resident #31 could answer simple questions with a one word reply with limited ability to express her wants and needs. Resident #31 was unable to verbalize understanding of her mechanical soft diet. 6. Record review was conducted for Resident #36 who was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance and [CONDITION(S)]. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, extensive assistance of two staff for bed mobility and transfers and set-up with supervision for eating. A physician order dated 12/10/2020 indicated Resident #36 required a mechanical soft diet with nectar thick liquids. The plan of care with a revision date of 12/11/21 revealed Resident #36 required mechanical soft texture with nectar thick liquids and interventions included to give the diet as ordered and monitor the consistency of the diet. Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #36 in his bed. He was alert but completely disoriented. When asked if the staff provided good care to him, Resident #36 gave unrelated comments about catching a bus. 7. Record review was conducted for Resident #27 who was admitted to the facility with diagnosis including dysphagia. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, and Resident #27 was totally dependent on two staff for bed mobility, transfers and needed extensive assistance of one staff for eating. A physician order dated 06/08/21 revealed Resident #27 was receiving palliative care services from hospice. On 10/24/21 her diet order was mechanical soft with pureed meats and nectar thick liquids. On 02/08/22 she was ordered a chest x-ray to rule out cough and aspiration. On 02/15/22 she was ordered speech therapy for dysphagia. Review of the chest x-ray revealed Resident #27's lungs were clear. Review of the Speech Therapy Evaluation and Treatment Plan dated 02/15/22 authored by Speech Therapist (ST) #545 revealed Resident #27's current diet texture was appropriate, and she was able to feed herself without staff assistance and with proper positioning for the meal. Observation and interview were conducted on 02/15/22 at 5:57 P.M. of Resident #27 sitting upright in her bed with her tray table at breast level and within her reach. Resident #27 presented with good positioning and demonstrated an ability to feed herself using a divided plate, double handled, lidded sip cup and built-up handled utensils. Resident #27 was alert and oriented to herself, the meal and conversation capable of giving appropriate answers to simple questions by the surveyor. Resident #27 smiled, made good eye contact with the staff and was able to verbally make her needs known to staff when they asked her what she would like to drink. 8. Record review was conducted for Resident #201 who was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and unspecified [CONDITION(S)]. The MDS 3.0 assessment dated [DATE] revealed Resident #201 was cognitively impaired, needed limited assistance of one staff for bed mobility and transfers and supervision and set-up for meals. A physician order dated 10/10/2018 indicted Resident #201 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/11/21 revealed Resident #201 required mechanical soft consistency due to difficulty chewing with an intervention for dietary and nursing staff to monitor the consistency served to him and provide the ordered diet. Observation was conducted on 02/15/22 at 1:10 P.M. of Resident #201 sitting up on the side of his bed with his meal tray in front of him. He presented as alert and oriented to person, place, and conversation. Resident #201 was visually impaired but able to point to the food on his plate, identify it and feed himself with standard utensils. He could carry on reciprocal conversation and verbally make his wants and needs known to staff. 9. Record review was conducted for Resident #345 who was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)]. The MDS 3.0 assessment dated [DATE] revealed he had no cognitive impairment, was totally dependent on two staff for bed mobility and transfers and totally dependent on one staff for eating. A physician order dated 12/12/19 indicated Resident #345 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 01/08/22 indicted Resident #345 was edentulous, required a mechanical soft diet and dietary and nursing staff should offer diet as ordered. Observation was conducted on 02/15/22 at approximately 6:00 P.M. of Resident #345 who presented as highly vulnerable with limited body movement. He needed the staff to feed him and was alert and oriented to the meal. Resident #345 was able to verbally make his wants and needs known to the staff. 10. Record review was conducted for Resident #37 who was admitted to the facility on [DATE] with diagnoses including moderate intellectual disability, dysphagia, and dementia with behavioral disturbances. The MDS 3.0 assessment dated [DATE] revealed Resident #37 had cognitive impairment, required extensive assistance of one staff for bed mobility, transfers and supervision and set-up for meals. A physician order dated 02/14/22 and revised on 02/16/22 revealed Resident #37 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/12/19 indicated Resident #37 had dysphagia. The nutrition risk portion of the care plan with a revision date of 01/23/22 revealed Resident #37 required a mechanical soft diet due to dysphagia and thickened liquids. The interventions were to provide the diet as ordered and monitor the consistency of the diet served to him. Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #37 in his bed. He was alert with disorientation and unable to answer simple questions from the surveyor. Record review was conducted of the menu for 02/15/22 and 02/16/22 along with the mechanical soft spreadsheets, therapeutic diets policy, and consistency modified diets policy. The mechanical soft spreadsheet for 02/15/22 revealed ground pork loin, diced oven potato, and green beans should have been served for lunch. Dinner was garden vegetable soup, three packs of saltines, ground turkey for the sandwich and pineapple chunks. The therapeutic diet policy stated crackers were allowed if softened in soups. Observation and interview were conducted on 02/15/22 at 8:51 A.M. with DM #508 who was sitting in her office writing diet orders and resident names on white pieces of paper. She informed the surveyor it was her first week on the job and the former dietary manager took the computer, so she had no computer program to print tray tickets for the residents. Observation was conducted on 02/15/22 from 12:47 P.M. to 1:13 P.M. of the lunch meal service. State tested Nurse Aide (STNA) #527 was passing trays in the main dining room. The resident tray tickets had been handwritten on approximately four-inch-wide by eight-inch-long white paper. The residents name and diet type were written in red ink on the tickets. The tray tickets for Residents #6 and #31 stated mech soft on the ticket in red ink. The ticket gave no specific instructions on the types or portions of food to be served for the meal. The meal served to both residents was diced potato, cooked green beans and a whole, regular texture, bone-in, breaded, fried chicken leg. Resident #31's lips were sunken around her gum lines presenting as edentulous and when asked by the surveyor if she could eat the chicken, she said she did not know if she could. Resident #6 said he wanted to eat the chicken. The surveyor intervened and brought the concern to the attention of STNA #527 who had been passing trays to other residents. She verified the findings. She did not attempt to offer them any alternative foods of mechanical soft consistency instead she began trying to cut the meat off the bone for Resident #31 saying the meat was dry and hard to cut up. She shredded the meat into large stringy pieces and the resident declined to eat it. In addition, Resident #6 required drinks thickened to nectar consistency. The only drink on his tray appeared too thick. STNA #527 verified the finding as she stirred his drink to check the consistency, she said it was too thick more like honey not nectar. Observation and interview on 02/15/22 at 1:10 P.M. of the kitchen tray line with Cook #516 and DM #508 revealed she did not make any mechanical soft chicken or other mechanical soft meat for the lunch meal. When asked what she served the 10 mechanical soft diets in the facility she pointed to the bone-in fried chicken pieces in the steam table pan and said that was what she served. When asked what mechanical soft consistency chicken should look like she replied it was chopped meat and she was not able to make it that way because she did not have any other chicken without bones. The surveyor proceeded to the 100 unit to check other mechanical soft meal trays and encountered the same concerns. Observation on 02/15/22 at 1:13 P.M. of Resident #36 was found sitting on the side of his bed taking a bite out of the bone-in fried chicken leg. He was unable to verbalize understanding he was ordered a mechanical soft diet and said he wanted to eat the chicken leg. STNA #541 appeared in the doorway after the surveyor had entered the room and verified the findings including the cranberry juice on his meal tray was not thickened at all but should have been thickened to nectar consistency. STNA #541 said Resident #36 did not need supervision with eating, so she had just set up his tray and he ate alone in his room. She verified the paper on his tray said mech soft nectar liquids. Interview was conducted on 02/15/22 at 3:38 P.M. with DTR #546 who revealed he was contracted to come to the facility every other week and meal rounds were not part of his contract. He verified a bone-in, regular consistency chicken leg should never be served to any resident who needed a mechanical soft diet. He said he had not done any staff education on therapeutic diets within the last year because the former dietary manager was a seasoned dietary manager and he had never noticed any problems in the facility when she worked there. He said his supervisor was RD #547 who did not come to the facility but reviewed his work with him via telephone. Interview was conducted on 02/15/22 at 4:47 P.M. with ST #545 who said she worked at the facility per diem. Her only resident on case load was Resident #27 who she was seeing because the staff told her she was having some coughing episodes. When asked what her expectation was for any resident in need of a mechanical soft diet, she explained the meat should be ground or at least chopped into small, bite sized pieces. She said she had not provided any diet guidance for mechanical soft diets to the facility, nor had she been asked to provide any. She verified Resident #27 had not aspirated and her current diet texture of mechanical soft with pureed meat and nectar thickened liquids was appropriate for her. She stated with proper positioning Resident #27 did not need to be supervised or assisted with eating her meals. Observation was conducted with the DON on 02/15/22 from 5:57 P.M. to 6:15 P.M. of the dinner trays for Residents ##6, #11, #19, #30, #31, #36, #37, #201 and #345. All residents except Resident #27 where served a ground turkey sandwich on white bread, tomato soup with three packs of whole saltine crackers and canned pineapple. None of the resident's saltine crackers had been added to their soup. Resident #27 was served pureed turkey sandwich, mashed potato, and applesauce even though her diet was mechanical soft with pureed meat and nectar thick liquids. STNA #527 brought her in a cup of red drink and said it was not thick enough because the thickener had settled to the bottom. She proceeded to add 2 scoops of thickener to the cup which made it present as more of a honey thick liquid. When asked if she followed the recipe on the can for thickening liquids, she said she does it all the time so she knew how much to add without looking. When asked if a staff member would stay with Resident #27 throughout the meal, STNA #527 expressed she did not need to be fed because she could feed herself, so they just check on her a few times. Interviews were conducted on 02/17/22 from 9:45 A.M. to 10:00 A.M. with Occupational Therapy Assistant (OTA) #548, Licensed Practical Nurse (LPN) #518, STNA #526, STNA #527, STNA #515 and STNA #506 who reported the kitchen occasionally sends out the wrong texture foods, but it did not happen often. They offered no specific dates on when wrong textured foods were sent from the kitchen. Review of the policy titled Consistency Modified Foods, dated January 2019, stated the mechanical soft diet included ground moist meats, poultry and fish without bones, canned fruits and vegetables, well cooked vegetables, soft breads, and desserts. Review of the policy titled The Importance of Dietary Tray Cards, dated 2009, indicated the tray card must be completely accurate to ensure the correct diet was served to each resident. The tray card should include the residents name, room number, diet type, portions, likes/dislikes, supplements, allergies, beverage preferences, adaptive devices, and thickened liquids order. Review of the policy titled Therapeutic Diets, dated October 2017, indicated hard crackers are to be served softened in soup or liquid.

Based on observation, medical record review, interviews with residents and facility staff and review of facility smoking policy, the facility failed to provide adequate supervision and interventions with cigarette smoking and oxygen use for one resident (Resident #43). This resulted in the likelihood of actual harm that is Immediate Jeopardy on 06/06/19 when Resident #43, who utilized continuous oxygen therapy via nasal cannula and was assessed to require supervision when smoking, was found smoking in his room with the oxygen concentrator in use. This affected one of twelve residents reviewed for smoking and accident hazards. The facility identified eleven additional residents (Resident #4, #9, #12, #17, #19, #29, #30, #31, #37, #41, and #149) currently residing in the facility, who smoked. The facility census was 47. In addition, deficient practice that did not rise to level of Immediate Jeopardy was identified when the facility failed to ensure seven residents (Residents #4, #12, #30, #37, #31, #41 and #149) were assessed for smoking safety; followed smoking policies and procedures to ensure resident safety and properly disposed of smoking materials. On 08/21/19 at 2:37 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 06/06/19 at approximately 2:38 [NAME]M. when Resident #43, who utilized continuous oxygen therapy via nasal cannula and was assessed to require supervision when smoking, was found smoking in his room with the oxygen concentrator in use. The Immediate Jeopardy continued on 06/19/19 at 8:20 P.M. when Licensed Practical Nurse (LPN) #502 noted a burning smell upon entering Resident #43's room and removed the oxygen tubing and oxygen concentrator from the room. Resident #43 was educated on 06/21/19 with a video on the dangers of smoking around oxygen. The Immediate Jeopardy was removed on 08/22/19 when the facility implemented the following corrective actions: · On 08/20/19 at 3:00 P.M. the DON and Social Services Designee (SSD) #619 reviewed all residents in the facility and identified 12 residents who were smokers (Resident #4, #9, #12, #17, #19, #29, #30, #31, #37, #41,43 and #149). It was confirmed the only smoker who used oxygen was Resident #43 and no other smoking residents had roommates who used oxygen. · On 08/20/19 at 3:15 P.M. the facility updated their smoking policy to indicate any resident who failed to comply with the smoking rules and policies would be discharged immediately because they placed all residents at risk for serious harm. · On 08/20/19 at 3:30 P.M. the DON, Administrator, Corporate Administrator (CAD) #650 and Admissions Director (ADM) #600 began in-servicing staff members on the smoking policy and responsibilities of staff members during smoke breaks as well as the change to the smoking policy. All facility staff, including eight administrative staff (Administrator, DON, the assistant director of nursing Registered Nurse RN #707, Admission Director AD #600, Business Office Manager BOM #601, Social Services Director SSD #619, Dietary Manager DM #602, Maintenance Director #603), four Registered Nurses (RNs) #705. #706, #708 and #711; nine Licensed Practical Nurses (LPNs) #503, #508, #509, #510, #512, #513, #514, #515 and #516; twenty-five State tested Nurse Aides (STNAs) #409, #410, #411, #412, #413, #414, #415, #416, #417, #418, #419, #420, #421, #422, #423, #424, #425, #426, #427, #428, #429, #430, #431, #432 and #433; three activity staff members (AS) #604, #605 and #606; five dietary staff members (DS) #607, #608, #609, #610 and #611; one physical therapy assistant (PTA) #618 and six housekeeping/laundry/maintenance staff members (HK) #612, #613, #614, #615, #616 and #617 were in serviced either in person or by phone by 08/22/19 at 10:14 [NAME]M. · On 08/20/19 from 4:30 P.M. to 5:00 P.M. the DON and SSD #619 ensured all twelve smoking residents had assessments in place for smoking capabilities. Residents who did not have assessments (Residents #4, #12 and #149) were assessed and Residents #9, #17, #19, #29, #30, #31, #37 and #41 were reassessed. The assessment included cognition, vision, dexterity and smoking frequency. The assessment also included a safety assessment including if the resident could light their own cigarette or needed adaptive equipment such as a smoking apron, cigarette holder, supervision or one-on-one assistance. The assessment indicated if the residents' lighters and cigarettes needed to be stored by the facility. Additionally, the assessment indicated if a plan of care would be developed to include individualized interventions related to resident safety during smoking. · On 08/20/19 from 5:30 P.M. to 6:00 P.M., the DON completed an entire facility sweep to ensure all oxygen equipment was secured in a safe manner and all smoking materials were secure. The DON checked the rooms of all residents who smoked to ensure there was no evidence of smoking in the room, such as burn holes, smell of smoke or cigarette butts. No issues were identified. · On 08/20/19 at 5:30 P.M. SSD #619 completed a smoking assessment for Resident #43. The resident indicated he would no longer smoke in the facility. A safety assessment of Resident #43's room was completed to check for smoking materials, with none found. · On 08/20/19 at 6:00 P.M. the DON assessed the smoking area for appropriate ashtrays, approved smoking receptacles, a fire blanket and smoking aprons. All items were present and accessible. · On 08/20/19 at 6:00 P.M. the Assistant Director of Nursing, RN #707 reviewed and revised, all 12 smokers' care plans to ensure they indicated what type of assistance was required and identified all safety/adaptive equipment needed by each resident. · On 08/20/19 at 6:00 P.M. the DON observed the smoke break to ensure all residents were following their plan of care regarding smoking. The 9:00 P.M. smoke break was observed by RN #707 with no concerns · On 08/20/19 at 7:00 P.M. the DON placed list of smokers that required adaptive equipment in the box of smoking materials for all staff to review when taking residents out to smoke. · On 08/21/19 at 10:00 [NAME]M. SSD #619 educated Resident #43 on the smoking policy and obtained his signature indicating he understood and agreed with the policy. · On 08/21/19 at 10:30 [NAME]M., SSD #619 educated all residents who smoke on the smoking policy and obtained a signature from each to indicate they understood and agreed with the policy. · On 08/21/19 from 3:00 P.M. to 10:00 P.M. facility nurses (RNs #405, #406 and #407 and LPN #403) physically assessed all smokers head to toe to ensure no evidence of unsafe smoking. No issues were identified. · On 08/21/19, at 6:00 P.M., the interdisciplinary team (IDT) comprised of the Administrator, DON, RN #707 (ADON), AD #600, BOM #601, SSD #619, DM #602, and Maintenance Director #603 began audits of the entire facility to identify any unsafe smoking or violations of the smoking policy, including observations of smoke breaks. This would be completed daily for two weeks, then two times weekly for four weeks then as determined by the Quality Assurance Committee (QA). · Beginning 08/21/19, at 6:00 P.M., the DON began audits of the records of all smoking residents to identify any unsafe smoking or violations of the smoking policy. This would be done daily for two weeks, then twice weekly for four weeks then as determined by Q[NAME] · Beginning 08/21/19, at 6:00 P.M., RN #707 began audits of smoking assessments to ensure they were up to date and smoking care plans to ensure they matched the smoking assessment. The audits will continue weekly for four weeks then as determined by Q[NAME] · On 08/22/19 at 4:00 P.M. the facility developed a new procedure for smoking assessments to indicate that all residents would be assessed on admission for smoking habits by the admitting nurse, with a smoking assessment to be completed for residents who wished to smoke. The nurse would also add the resident's name and any interventions to the list in the box of cigarettes. Smokers would be re-assessed with [REDACTED]. The belongings of all new admissions would be checked for smoking materials with any materials removed and stored at the nursing station. · On 08/22/19 at 4:40 P.M., the DON began in-service of all nurses on the new procedure for smoking assessments. By 08/24/19 at 7:00 P.M., four RNs (#705, #706, #708 and #711) and nine LPNs (#503, #508, #509, #510, #512, #513, #514, #515 and #516) were in serviced either in person or by phone. · On 08/22/19 at 9:00 [NAME]M., 1:00 P.M. and 3:30 P.M. and on 08/23/19 at 9:00 [NAME]M., 1:00 P.M. and 3:30 P.M. observation of smoke breaks by the surveyor revealed staff were present. Staff handed out cigarettes one at a time to the residents. No residents exhibited unsafe behaviors or attempted to keep smoking materials in their possession. · On 08/22/19 and 08/23/19, LPN #508, RNs #705 and #707 and STNAs #409, #410, #411 and #428 were all interviewed and indicated they had participated in the in-service regarding smoking breaks and verbalized knowledge of the smoking break procedures. Although the Immediate Jeopardy was removed on 08/22/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan, including their new policy and procedure and were monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing note dated 04/11/19 at 5:15 P.M. revealed the resident did not use oxygen. Resident #43 was started on oxygen after a fall on 06/02/19. Resident #43 had been admitted to the hospital and on his return to the facility on [DATE] was utilizing oxygen at three liters, However there was no physician order for [REDACTED]. Review of the medical record revealed Resident #43 was assessed on 04/12/19 at 3:49 P.M. for smoking. He was cognitively intact with no visual deficit or dexterity problems, smoked five to ten cigarettes throughout the day and could safely light his own cigarette. The assessment indicated he did not need adaptive equipment to smoke but did need the facility to store his lighter and cigarettes for him. The assessment indicated a plan of care would be developed to ensure the resident was safe while smoking. Review of the resident's record did not reveal a care plan for smoking. The resident was not assessed for smoking safety when he was started on oxygen on 06/04/19 until 07/02/19. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/18/19 revealed Resident #43 was assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. He required supervision of one staff member for his activities of daily living, including bed mobility and transfer and mobility in his wheelchair. Medical record review revealed Resident #43 signed a smoking consent form on 04/27/19 which indicated he had received the facility's smoking policy and list of scheduled smoking times and agreed to abide to the policies. A nursing note dated 5/20/19 at 11:23 [NAME]M. by LPN #509 revealed Resident #43 was given a cigarette for smoke break. He only smoked half, put it out and placed the remainder of the cigarette in his pocket. Resident #43 initially denied having the half cigarette but did eventually give it to the staff member. The nurse also noted another cigarette sticking out of his pocket and placed it in a pouch at the nursing station. Review of a nursing note written by LPN #501 on 06/06/19 at 2:38 [NAME]M. revealed Resident #43 was smoking in his room. The note indicated the resident had an oxygen concentrator in his room that was in the on position. Resident #43 was educated about the importance of not smoking in his room and the seriousness of it. The note indicated Resident #43 denied smoking, but the resident's roommate complained about him smoking in their room. The note indicated the DON and RN #707 were notified and after the incident, Resident #43 went outside (to smoke) with his cigarette and lighter that were in his room that he denied having. A note from SSD #619 on 06/06/19 at 2:57 P.M. revealed she educated Resident #43 on 06/06/19 on the importance of not smoking in his room and the seriousness of it. He stated OK and that he understood. SSD #619 said that was all she could remember about educating Resident #43, and she could not provide any documentation of the education. There was no evidence the resident was educated about oxygen use and smoking. Review of Resident #43's care plans revealed a care plan for non-compliance was originated on 06/14/19 and updated on 07/01/19 through 10/08/19. The care plan indicated the resident refused medications, care and services, and refused safety measures, especially related to smoking and had a history of [REDACTED]. The interventions included educating the resident and the family or responsible party on negative outcomes of non-compliance, explain all procedures and the benefits of them before starting the procedures, document educational attempts made with the resident and notify the physician or nurse practitioner of non-compliance. Review of a nursing note written by LPN #502 on 06/19/19 at 8:20 P.M. revealed she noted a burning smell upon entering Resident #43's room. She asked the resident if he had any cigarettes or had been smoking in his room, which he denied. The note indicated Resident #43 had oxygen via nasal cannula applied to his face and the oxygen tank was running. LPN #502 indicated she turned off the tank and removed it from the room and the resident self-propelled out of the room. The note indicated a short time later, another resident told LPN #502 Resident #43 was outside on the patio with two cigarettes and was asking for a light. The nurse and an STNA went out to investigate and found the resident with two cigarettes. He was informed of the facility rules regarding smoke breaks and the need for staff to supervise smoke breaks. The nurse's note indicated Resident #43 became angry, stating he would check himself out of the facility the next day. The note indicated the nursing supervisor was notified and instructed LPN #502 to check Resident #43's room for cigarettes or lighters. No smoking materials were found. Review of a note dated 06/21/19 at 10:48 [NAME]M. written by SSD #619 revealed Resident #43 was educated on the dangers of smoking around oxygen with a video. The note indicated he was alert and oriented. There was no evidence found the resident was educated about the dangers of smoking around oxygen from 06/06/19, when he was first found smoking with oxygen, until he was provided the education by video on 06/21/19. A smoking assessment was completed again on 07/02/19 at 9:45 P.M. The assessment indicated the resident had cognitive loss at the time of the assessment and could no longer light his own cigarette. He was assessed to need a smoking apron and supervision for smoking. No other items on the assessment had changed from 04/12/19. Review of Resident #43's care plans did not reveal a care plan specific to smoking was completed after the assessment on 07/02/19. LPN #501 no longer worked at the facility. Attempts to contact her by phone were made on 08/21/19 at 3:50 P.M. and 4:10 P.M. and on 08/23/19 at 8:45 [NAME]M. She did not answer the phone, messages were left, no return call was received. An attempt was made to contact LPN #502 by phone, as she was no longer employed by the facility, however, her phone had been disconnected. The nursing assistant mentioned in the note could not be identified by the facility. Observation and interview with Resident #43 on 08/20/19 at 2:45 P.M. revealed him lying in bed. The resident said he had not smoked in about four days because he did not feel well. He was asked about reports of him smoking in his room in the past, but became irritated when asked, stopped talking, and did not answer the question. When asked if he was permitted to keep smoking materials in his room or if he had any cigarettes or lighters in his room, he waved his hand in dismissal and closed his eyes. An interview with the DON on 08/20/19 at 4:00 P.M. revealed she was made aware of the resident smoking in his room by the nurse on the night shift on 06/06/19. She stated she told the nurse to check the resident's room for cigarettes. She did not have interviews of staff or the resident's roommate or any investigation about the incident. She verified the record indicated the resident had been educated after the incident, but also verified he was cognitively intact and had been educated on admission. She could not provide any evidence of any other interventions put in place to ensure the resident did not have access to smoking materials when he had his oxygen on or that changes were made to supervision when he was smoking to ensure he did not keep extra cigarettes. The DON stated he had been roommates with Resident #19 at the time of the incident and she thought she remembered that Resident #43 may have taken cigarettes from his roommate that night. She stated she remembered making sure both residents were educated about the dangers of smoking in their rooms. Review of a printed text conversation between the DON, RN #707 and LPN #501 revealed on 06/06/19, LPN #501 texted at 2:37 [NAME]M. indicating Resident #43 was smoking in his room and has an oxygen concentrator in there and his roommate (Resident #19) was complaining about him smoking to staff and he is putting everyone at risk. The text continued by LPN #501 (Resident #7, who resided in the room next door) is on oxygen as well. The DON responded to the text at 5:03 [NAME]M. to ask if the nurse had searched his room and removed cigarettes and lighters and LPN #501 indicated she got the lighter and cigarette because he wanted to go outside after the incident and smoke but gave the items to her when he came back in. The text indicated he used his roommate's lighter. The DON responded to take the roommate's lighter as they aren't supposed to have them, and LPN #501 indicated it was in the box. An interview with Resident #19 on 08/20/19 at 4:45 P.M. revealed he remembered an incident involving his prior roommate, who he identified as Resident #43. He stated he did not know exactly when the incident occurred but that he could not sleep and could smell cigarette smoke coming from the bathroom in their room. He stated Resident #43 was in the bathroom and he called for the nurse. He stated he thought the resident was wearing oxygen. He did not remember any specific actions taken by the nurse, and stated he thought Resident #43 was smoking cigarette butts. An interview with SSD #619 on 08/22/19 at 10:50 [NAME]M. revealed she did not recall specific details about Resident #43's actions, other than he used oxygen in his room and had reportedly smoked in his room. She said she educated him on the dangers of smoking near oxygen. An interview with RN #707 on 08/22/19 at 11:25 [NAME]M. revealed she remembered receiving the text from LPN #501 but stated since the DON responded, she did not respond. She stated she did not remember any additional details about the incident. An interview with the DON on 08/23/19 at 12:00 P.M. confirmed she was notified of the burning smell in Resident #43's room by phone on 06/19/19. She stated she talked with the nurse and then replied to the nurse by text. Review of printout of the text dated 06/19/19 at 8:39 P.M. revealed the DON texted the nurse to check the resident's oxygen saturation after he has been off the oxygen for 20 to 30 minutes and if he does well, take the oxygen out of his room and put it in the clean utility room so it's close if he needs it. She verified there was no further evidence of interventions. Interview with the DON on 08/23/19 at 4:02 P.M. confirmed she did not know if the resident's oxygen was held just for that night or for longer. She verified the resident's record did not contain an order from the physician to indicate the oxygen could be discontinued as an intervention to prevent him from smoking with the oxygen in use. She verified the resident had not been smoking recently due to a decline in medical condition, but that the condition was expected to improve. She verified if the resident wanted to smoke, he currently could, with assistance of staff to transfer out of bed and that his mobility and independence could improve to a point of independently transferring out of bed. The DON verified there had been no interventions put in place after the incidents to ensure Resident #43 remained safe with smoking materials and smoking habits while ordered oxygen therapy. An interview with SSD #619 on 08/22/19 at 10:50 [NAME]M. revealed she showed Resident #43 a video about the dangers of smoking around oxygen. She stated other residents who smoked also watched the video. An interview with the facility medical director who was Resident #43's personal physician on 08/23/19 at 12:20 P.M. revealed he was aware Resident #43 was non-compliant with smoking. He verified Resident #43's behavior of smoking with oxygen in place was dangerous and although it was difficult to control, the facility policy of keeping resident smoking materials at the nursing station should be enforced. Review of the facility Smoking Policy and Procedure, dated 08/09/18, revealed all residents who smoke would be assessed for needed assistance upon admission, quarterly and with a significant change. The policy indicated facility staff would supervise residents while smoking, if they were indicated to need supervision. Staff members were also to light all smoking products and provide other assistance and protective devices as needed. Smoking was only allowed in designated smoking areas and all smoking materials were to be kept in a secured area and distributed by staff for all residents. The policy indicated failure to comply with the rules places others at risk for injury, and the facility may find it necessary to assist a resident in finding alternative placement if smoking and safety rules are not followed. 2. Observation of smoking break at 1:05 P.M. on 08/20/19 revealed four residents outside in the smoking area unsupervised. The residents were identified by RN #405 at 1:10 P.M. as Residents #4, #12, #30 and 37. RN #405 verified the residents were all smoking in the smoking area and were not supervised by a staff member. She stated the residents kept cigarettes on them and probably had cigarettes and lighters that they utilized on their own. RN #405 walked with the surveyor toward the nurses' desk, still in view of the smoking area, and after checking the assignment book, stated STNA #410 was supposed to be outside with the residents during that smoke break. As the surveyor and RN #405 were talking, the four residents in the smoking area came back into the unit and an employee identified as STNA #410 went out the door at 1:15 P.M. with three other residents, identified by RN #405 as Resident #'s 31, 41 and 149. STNA #410 lit cigarettes for the residents in the smoking area. She did not pass cigarettes out to them or have the box of cigarettes in her possession. On 08/20/19 at 1:18 P.M. interview with STNA #410 in the smoking area revealed she had told the residents at 1:00 P.M. she had to help another employee and would be a little late to supervise the smoke break. She stated she did not give any residents cigarettes and did not know where they had gotten them. STNA #410 said sometimes they have extras, but she said many residents kept their own cigarettes and some kept them at the nurse's station. Medical record review for the seven residents observed during smoke break on 08/20/19 revealed the following. Review of the medical record of Resident #4 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record revealed he had not had a smoking assessment completed since his admission to the facility and did not have a smoking care plan. He was not named on the list of smokers provided to the surveyors on entrance to the facility. Review of the medical record of Resident #12 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record did not reveal a completed smoking assessment since her admission to the facility and the resident did not have a care plan for smoking. Review of the medical record of Resident #30 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His most recent smoking assessment was completed on 04/12/19. He was marked to need supervision for smoking and needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #37 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His most recent smoking assessment was completed on 04/12/19. He was assessed to need supervision for smoking, was to wear a smoking apron and needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #31 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent smoking assessment was completed on 04/12/19. She was not indicated to need any adaptive equipment for smoking but needed to leave her smoking materials at the nursing station. Review of the medical record of Resident #41 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His most recent smoking assessment was completed on 04/12/19. He was not indicated to need any adaptive equipment for smoking but needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #149 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record revealed he had not had a smoking assessment completed since his admission to the facility and did not have a smoking care plan. He was not named on the list of smokers provided to the surveyors on entrance to the facility. Observation of the smoke break on 08/20/19 at 3:30 P.M. revealed STNA #412 with several residents in the designated outdoor smoking area. She had a large box with her from which she obtained cigarettes which she passed out to the residents. Resident #37 was smoking, but was not wearing a smoking apron, as indicated in his smoking assessment. An interview with STNA #412 on 08/20/19 at 3:45 P.M. after the completion of the smoking break, revealed an apron was in the box of smoking materials that she had taken out with her. She stated the only resident she knew of that used an apron was Resident #17, who had not gone out for the smoke break. She stated she was unaware of any other residents who needed an apron. She stated she did not know of a list of residents who required aprons to smoke, but stated she was just told about Resident #17 by other staff. Review of the medical record with RN #705 on 08/20/19 at 3:50 P.M. confirmed Resident #37 was assessed on 04/12/19 to need a smoking apron. RN #705 stated she was not aware Resident #37 needed to wear a smoking apron. An interview with the DON on 08/20/19 at 4:00 P.M. confirmed the observations of the smoking breaks. She verified she was not aware Resident #4 or #149 were smokers and had not been assessed. She stated she thought the assessment for Resident #37 must have been a mistake, as the resident had no indication she was aware of that would necessitate a smoking apron but did verify the assessment indicated the apron should be used. The DON also verified the facility did not have a system to easily identify residents who needed adaptive smoking equipment. In addition, the DON verified she knew some residents kept cigarettes in their rooms. She stated the policy indicated the smoking materials should be stored at the desk but stated family members bring in new supplies of cigarettes or residents hang on to extra cigarettes if they don't smoke them during a break. The DON verified all residents should be supervised during smoke breaks and should not be smoking in the smoking area without staff supervision. The DON indicated all residents should be assessed as to their safety prior to smoking at the facility with a care plan in place to ensure assessed interventions were put in place to prevent possible injury. 3. Observation of the front entrance to the facility on [DATE] at 10:55 [NAME]M. by two surveyors revealed countless numbers of cigarette butts along the curb, sidewalks and near two tall smokeless cigarette butt discarding receptacles. One of the smoking receptacles had a broken foot pedal that did not allow the can to be opened hands-free. Observation by the life safety code surveyor during tour with Director of Maintenance (DM) #603 on 08/22/19 at 8:30 [NAME]M. revealed cigarette butts in the landscaping adjacent to the building, on the sidewalk and driveway at the facility's main entrance. Interview with DM #603 indicated he was unaware of the butts being disposed of improperly and that housekeeping handled disposal of cigarette butts. DM #603 verified the above findings at the time of the observation. An observation on 08/26/19 at 7:00 [NAME]M. revealed continuing observations of cigarettes butts near the front entrance. This observation was verified with the DON on 08/26/19 at 8:30 [NAME]M. She verified cigarette butts should be disposed of properly to prevent accidental fires.

Based on observation, record review and interview the facility failed to ensure Resident #24 maintained acceptable parameters of nutrition, failed to ensure the resident did not sustain a severe weight loss and failed to ensure the resident's enteral feeding was provided as ordered. Actual Harm occurred when Resident #24, who received all of her nutrition/hydration via gastrostomy tube was assessed to sustain a 13.4 pound/8.4 severe weight loss in 30 days without evidence the weight loss was timely identified and/or interventions were implemented to prevent additional weight loss. In addition, the resident was observed with her enteral feeding not being administered at the physician ordered rate. This affected one resident (Resident #24) of two residents reviewed for nutrition. Findings include: Record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24 had a care plan dated 01/16/16 for nutritional needs due to altered nutritional status as evidenced by history of diabetes mellitus, nothing by mouth and enteral feedings. Interventions included diet per the dietician recommendation and physician order. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident weighed 161 pounds and received tube feeding for 51 percent or more of her total calories. She had current physician's orders [REDACTED]. The tube feeding was to be off daily from 2:00 A.M. to 6:00 A.M. Review of the monthly weights for Resident #24 revealed her weights were 160.8 pounds (lbs) on 03/10/18, 160 lbs. on 05/11/18 and 146.6 lbs on 06/06/18. The weight on 06/06/18 was an 8.4 percent loss, which indicated a severe weight loss in 30 days. The medical record for Resident #24 was reviewed, including the medication and treatment administration records for May, (MONTH) and (MONTH) (YEAR). There was no documentation of the administration of the tube feeding type or rate during that time frame. On 07/01/18 at 12:16 P.M. Resident #24 was observed in the common area in her wheelchair with tube feeding of [MEDICATION NAME] running at 65 cc per hour per pump. On 07/02/18 at 5:10 P.M. the resident was observed in bed with tube feeding of [MEDICATION NAME] running at 65 cc per hour. On 07/02/18 at 5:22 P.M. it was verified with Licensed Practical Nurse (LPN) #9 the tube feeding for Resident #24 was running at 65 cc per instead of 70 cc per hour as ordered. On 07/03/18 at 11:00 A.M. interview with Registered Dietician (RD) #7 revealed the weights she was provided by the facility were 03/2018-160.8 lbs, 04/2018- 159 lbs, 05/2018- 160 lbs and 06/2018 146.6 lbs. She said she reviewed the residents' weights by the third week of each month. She said she reviewed the (MONTH) (YEAR) weights and did not initially see the (MONTH) weight for Resident #24 because it was a single entry at the top of a page. She verified the resident's weight loss from 05/11/18 of 160 lbs to 146.6 lbs on 06/06/18 was an 8.4 percent loss in one month. During the interview, RD #7 verified she had not addressed the resident's weight loss, assessed why the weight loss had occurred or implemented new interventions to promote weight gain or prevent additional weight loss. RD #7 provided the most current weight for Resident #24, dated 07/02/18 which reflected a weight of 146.6 lbs.

Based on observation, record review and interviews, the facility failed to ensure Resident #62 was provided the appropriate level of assistance and supervision at meals. This resulted in actual harm on 06/17/17 when Resident #62 spilled a cup of hot chocolate onto his lap sustaining second degree burn/blisters to his right thigh. This affected one of three residents reviewed for accidents. Findings include: Review of the medical record indicated Resident #62 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was moderately impaired for cognition based on a brief interview of mental status (BIMS). The MDS assessment revealed Resident #62 required the limited assistance of one person for eating. A plan of care (originally created on 05/03/11) identified Resident #62 with a self-care deficit for activities of daily living (ADLs) due to a stroke, [DIAGNOSES REDACTED] and limited mobility. The ADL care plan included an intervention, (in place since 04/13/15) for Resident #62 to be provided assistance, as needed, with ADLs, including eating. A plan of care for impaired cognitive function was created on 05/15/12, revised on 04/13/15 and was current at the time of discharge. The plan of care identified Resident #62 with impaired cognitive function and thought processes related to vascular dementia. Review of a Nurses' Progress Note dated 06/06/17 at 10:09 A.M. revealed Resident #62 was having difficulty feeding himself. The note indicated the dining room staff reported spillage of food and decreased oral intake due to difficulty with hand mobility for this resident. A Therapy Referral Form was dated 06/06/17 and signed by the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #1. Review of the Therapy Referral Form revealed RN #1 made a referral to Occupational Therapy (OT) for Resident #62 related to his identified difficulties with feeding himself, spillage of food and decreased food intake when he was not assisted by staff. The OT Evaluation and Plan of Treatment was dated 06/07/17 and was signed by Occupational Therapist, Registered, Licensed (OTR/L #2). Review of the OT Evaluation revealed OTR/L #2 confirmed Resident #62 was afflicted with left [DIAGNOSES REDACTED] and hemiparesis following a cerebral infarction and generalized muscle weakness. OTR/L #2 indicated Resident #62's prior level of function (PLOF) had been independence with self-feeding. OTR/L #2 wrote Resident #62 had a decline with self-feeding activity at that time and would benefit from OT services. OTR/L #2 justified the reason for skilled services as Resident #62 was not at his PLOF. Under the Functional Skills Assessment of the evaluation, OTR/L #2 wrote Resident #62 required minimal assistance with self-feeding. A goal was set for Resident #62 to increase his self-feeding activities. OTR/L #2 recommended OT services three to five times per week, for 30 days with a certification period from 06/07/17 through 07/06/17. Listed under the Functional Limitations Addendum, OTR/L #2 wrote the patient (Resident #62) required assistance with self-feeding. Review of Nurse's Progress Notes dated 06/17/17 at 9:00 A.M. revealed a State tested Nurse Aide (STNA) reported Resident #62 had spilled hot chocolate on both of his lower extremities/legs. The note indicated Resident #62 was assisted to bed and a red circular area was observed on his right upper thigh but no measurements were documented. The note indicated the nurse applied a cold compress. The facility's incident investigation was dated 06/17/17 at 9:00 A.M. and mirrored the aforementioned Nurses' Progress Note. The investigation indicated a STNA reported to the nurse that Resident #62 had spilled hot chocolate on himself during breakfast. As a result, the resident was assisted back to bed and his legs were assessed. The nurse observed a circular reddened area on his upper right thigh (no measurements provided) and a cold compress was applied. A witness statement was dated 06/17/17 and signed by STNA #71. STNA #71 wrote he was asked by Resident #62 to heat his coffee. The statement indicated the STNA asked the resident to be careful. STNA #71 wrote Resident #62 dropped the coffee into his lap. Review of a summary of the investigation was dated 06/17/17 and signed by the Director of Nursing (DON). The DON statement confirmed Resident #62 spilled hot chocolate on his lap and said a 3 centimeter (cm) by 4 cm reddened area was noted on his right thigh. The DON's statement acknowledged the facility staff had heated food and liquids in the microwave oven for Resident #62 and revealed the resident verbalized mild pain relief with cold compresses. Review of Nurse's Progress Note dated 06/18/17 at 6:53 A.M. revealed blisters were observed to Resident #62's right upper thigh. A blister is consistent with a second degree burn. A second degree burn is a partial thickness burn, affecting the epidermis (outer layer of skin) and the dermis (lower layer of skin). A physician's orders [REDACTED].#62's right upper thigh two times per day and report any abnormal findings, every morning and at bedtime. The treatments were provided to Resident #62's leg as ordered by the physician and the Nurses' Progress Note dated 07/04/17 at 1:56 A.M. indicated the blisters were dry and intact. The Nurse's Progress Note dated 07/05/17 at 4:00 A.M. revealed the blisters to Resident #62's upper thigh had ruptured and reabsorbed. A physician's orders [REDACTED].#62's absorbed blisters twice a day and leave them open to air. Resident #62 was discharged from the facility on 07/12/17 at 1:15 P.M. On 11/21/17 beginning at 11:40 A.M., residents were observed gathering in the main dining room for lunch. STNA #71 was observed pushing two beverage carts from table to table serving residents both hot and cold drinks. STNA #71 was observed preparing hot chocolate and hot tea for multiple residents. STNA #71 used hot water from two white carafes, located on the top of the cart. On 11/21/17 at 12:39 P.M., Dietary Aides #76, #77 and #78 indicated the white carafes for the hot beverage cart were filled with water from the large commercial coffee maker/hot water dispenser. The dietary staff explained the coffee maker/hot water dispenser electronically controlled the temperature of the water. Observation of the digital readout on the dispenser indicated the hot water was 193 degrees Fahrenheit (F). The dietary staff agreed 193 degrees F was the typical temperate reading on the unit. During an interview on 11/27/17 at 1:05 P.M., STNA #71 recalled the incident on 06/17/17 involving Resident #62. STNA #71 reported Resident #62 asked for hot chocolate that morning before breakfast. STNA #71 acknowledged he had been aware Resident #62 had been spilling food on himself, and he was not supposed to have hot chocolate. However, when STNA #71 explained to Resident #62 that he could not have hot chocolate, he became irate and began yelling and demanding hot chocolate. STNA #71 indicated he reported this to the nurse (STNA #71 was not able to recall which one of the nurses he spoke with) and she instructed STNA #71 to give Resident #62 the hot chocolate to calm him down. STNA #71 indicated he gave Resident #62 a cup of hot chocolate, (prepared with hot water from the carafe), but the resident complained it was too cold. STNA #71 again reported this to the nurse and she instructed STNA #71 to warm it up for Resident #62. STNA #71 revealed he warmed it up in the microwave oven and gave it to Resident #62, who again said it was too cold, and began yelling. After conferring with the nurse, STNA #71 warmed the hot chocolate up a second time in the microwave oven and gave it to Resident #62. STNA #71 acknowledged there was no lid on the cup and revealed he had no idea of the temperature of the hot chocolate. STNA #71 reported that soon afterward, Resident #62 spilled the hot chocolate on his lap. During an interview on 11/27/17 at 2:17 P.M., the Administrator verified on 06/06/17 the facility identified Resident #62 was experiencing difficulty feeding himself and spilling food on himself at meals. The Administrator acknowledged on 06/17/17 Resident #62 was given hot chocolate, heated in a microwave, and subsequently spilled it onto his lap. The Administrator confirmed Resident #62 sustained a burn with blisters, as a result of the spilled hot chocolate. This deficiency substantiated Complaint Number OH 613.

Based on observation, interview and record review the facility failed to assess, provide timely treatment and notification of the physician for five unstageable pressure ulcers, one Stage 3 pressure ulcer and five additional ulcers for Resident #2. The facility failed to complete comprehensive pressure ulcer assessments, ensure pressure relieving interventions were in proper working order and provide appropriate wound care for Resident #6. The facility failed to provide adequate incontinence care and treatment for [REDACTED]. This affected three of three residents reviewed. The facility census was 53. Actual harm was sustained by Resident #2 evidenced by failure to assess skin integrity risk and failure to perform skin assessments resulting in the development of 11 pressure ulcers of various stages. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ((MDS) dated [DATE] and 04/15/13 revealed the resident had severe cognitive impairment. Resident #2's responsible party and power of attorney was listed as her daughter. Resident #2 was discharged from the facility on 04/20/13. Review of Resident #2's pressure ulcer and skin integrity care plans revealed the initiation date and revision dates were 06/06/13, after Resident #2 was discharged . The facility provided no evidence they had developed a comprehensive care plan to address Resident #2's risk for developing skin alterations/pressure ulcers or for her actual skin alterations/pressure ulcers. Corporate Registered Nurse (RN) #13 was interviewed on 06/06/13 at 1:25 P.M. and the pressure ulcer/weekly wound documents, physician orders [REDACTED]. RN #13 indicated Resident #2 was found with pressure ulcers on 03/21/13 as follows: a) right buttocks ulcer, Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough and may also present as an intact or open/ruptured blister) on her right gluteal fold measuring 2.0 centimeters (cm) long by 0.5 cm, with no depth measurement recorded. b) second right gluteal fold Stage II ulcer with the same measurements c) right gluteal fold ulcer listed as a Stage II measuring 3.0 cm long by 0.4 cm wide with no depth measurement recorded d) right gluteal fold ulcer listed as a Stage II measuring 0.5 cm long by 0.5 cm wide and no depth measurement. RN #13 indicated there were no further weekly wound assessments completed for the pressure ulcers. RN #13 indicated on 04/15/13 the physician gave an order for [REDACTED].#2's responsible party was notified. There was no documentation as to why the wound consult was ordered. Physician orders [REDACTED]. Review of nurse's note dated 04/18/13 timed 12:05 P.M. indicated Resident #2 had "ongoing wounds, see weekly wound documentation". RN #13 verified there was no weekly wound/ulcer documentation completed. RN #13 indicated Resident #2 was found with multiple pressure ulcers on 04/18/13 and the physician order [REDACTED]. RN #13 provided the pressure ulcer assessments completed on 04/19/13 as follows: a,) Sacrum- documented as unstageable measuring 2.8 cm by 2.0 cm with eschar with no percentage of eschar documented. b.) Sacrum- documented as unstageable measuring 0.6 cm by 0.6 cm with eschar with no percentage of eschar documented. c.) Left Sacrum- Stage III (a full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon or muscle is not exposed; Slough may be present but does not obscure the depth of tissue loss and undermining or tunneling may be present) measuring 0.7 cm by 0.7 cm and 0.1 cm deep. A note indicated this was one of the pressure ulcers originally found as a Stage II on 03/21/13, but had not been tracked weekly. d) Coccyx-documented as a Stage III measuring 4.5 cm by 1.0 cm by 0.2 cm with slough present. No percent of slough documented. e.) Left coccyx - documented as Stage II measuring 2.0 cm by 6.0 cm by 0.1 cm. f.) Left coccyx - documented as Stage II measuring 1.5 cm by 1.0 cm by 0.1 cm. g.) Left buttocks- documented as Stage II and measuring 1.3 cm by 0.5 cm by 0.1 cm. h.) Left lower buttocks- documented as unstageable measuring 3.8 cm by 1.0 cm with eschar with no percentage of eschar documented. i.) Left buttocks- documented as unstageable measuring 0.9 cm by 0.1 cm with eschar with no percentage of eschar documented. j.) Left buttocks- documented as a Stage II measuring 0.5 cm by 1.0 cm by 0.1 cm. k.) Left inner buttocks- documented as unstageable measuring 4 cm by 1 cm with eschar with no percentage of eschar documented. RN #13 verified the wound assessments did not document the percentage of eschar (dead tissue) or slough present and for many the assessment section for the periwound area was left blank. She verified that of the 11 pressure ulcers, five were found unstageable and one was a Stage III with slough present. RN #13 verified treatment was not initiated immediately. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] indicated Resident #6 was admitted with a pressure ulcer on his coccyx. The assessment contained no documentation of the measurements or description of the pressure ulcer until 04/09/13. Documentation of the coccyx pressure ulcer dated 04/09/13 revealed it was 9.0 cm long by 11 cm wide by 1.0 cm deep and was unstageable with 60% of the wound having slough, (dying tissue in the process of separating from the viable portions of the body). The lack of assessment was reviewed and verified with RN #13 on 06/06/13 at 3:40 P.M. Review of physician orders [REDACTED]. Wound treatment was observed with Licensed Practical Nurse (LPN) #15 and State tested Nursing Assistant (STNA) #16 on 06/05/13 at 12:55 P.M. LPN #15 indicated the coccyx area had separated and there were now two pressure ulcers documented as one to the coccyx and one on the left buttocks. Resident #6 was in bed on his left side and the air mattress was observed in the off position. The old dressing was removed and was observed with a moderate amount of serosanguinous drainage. LPN #15 cleansed the wounds with normal saline and dried the areas. She measured each wound and then LPN #15 obtained a cotton swab and inserted it into the deepest part of the coccyx ulcer and indicated it was 2.0 cm deep. Using the same cotton swab, LPN #15 then measured the depth of the left buttock ulcer at 1.0 cm deep. This ulcer was observed with some light yellow slough on the wound bed. LPN #15 continued to use the same cotton swab, inserted it into the undermining area of the coccyx ulcer and indicated there was 2.8 cm of undermining from 9 to 12 o'clock. LPN #15 completed the dressing change and she and STNA #16 repositioned Resident #6 in the bed. At that time the surveyor asked them to check the air mattress and STNA #16 turned the air mattress to the on position and verified it had been turned off. After both wound treatments were observed LPN #15 was interviewed at 1:45 P.M. on 06/05/13. She verified she used the same cotton swab to go back and forth between Resident #6's two pressure ulcers and verified the pressure relieving air mattress had been turned off. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 was identified as being at risk for alteration in skin integrity and a care plan was initiated on 02/10/11. Interventions included directions to staff to provide incontinence care and apply a protective barrier after each incontinence episode and to cleanse the gluteal folds with soap and water after each incontinence episode, pat dry, and apply Hydraguard skin barrier per the doctor's orders. The physician's orders [REDACTED]. Resident #7 was identified by the facility as having an unstageable pressure ulcer on her left gluteal fold. The wound treatment was observed being completed with LPN #15 and STNA #16 on 06/05/13 at 1:20 P.M. Resident #7 was in bed on her side and did not speak during the observation. Resident #7 was observed with a small soft bowel movement at her rectal area. LPN #15 used four inch square gauze pads and scooped off the stool and then used the adult brief to wipe the rectal area and wrap up the soiled gauze. LPN #15 disposed of the soiled brief, removed her gloves and washed her hands. She returned to the bedside, applied new gloves and completed the dressing change to the unstageable left gluteal fold pressure ulcer. Resident #7 is dark skinned African American and she was observed with large areas of light pink scar tissue on her buttocks from healed skin areas. There was a small hole observed in the scar tissue. LPN #15 cleansed the area with normal saline and dried the area. She measured the pressure ulcer at 1.0 cm long by 1.4 cm wide with 1.2 cm depth. The treatment was completed and a new adult brief was applied to Resident #7 and repositioned on her right side. STNA #16 left the room at 1:42 P.M. and LPN #15 left the room at 1:45 P.M. and began wheeling her treatment cart down the hallway. Neither the LPN or the STNA provided any incontinence care to Resident #7, including the use of soap and water and the application of a protective barrier as ordered. This was verified with LPN #15. This citation substantiates Complaint Number OH 315.