Every finding on record at Lodge Nursing & Rehab Center

Based on observation, interview, and policy review, the facility failed to store and prepare food in a sanitary manner to prevent spoliage and protect against a foodborne illness. This had the potential to affect all residents residing in the facility except for the three residents (#6, #13 and #15) with diet orders of nothing by mouth. The facility census was 117.Observation on 04/06/2026 at 9:05 A.M. revealed a red plastic bucket with a liquid inside being stored in the food preparation sink. Interview with Dietary Director (DD) # 446 revealed that the red bucket contained sanitizer and that it should not be stored in the food preparation sink. Observation on 04/06/2026 at 9:05 A.M. revealed two cracked eggs were stored in a small pastic bowl on ice in the kitchen. Further observation revealed that the ice was almost completely melted. Observation on 04/06/2026 9:07 A.M. revealed DD #446 taking a temperature of the eggs. DD #446 verified that the ice had melted and the eggs were at 46 degrees F. DD #446 verified that the eggs should be stored below 41 degrees F. Observation on 04/06/2026 at 9:09 A.M. revealed that the can opener blade was unclean with a build up of food debris. Interview with DD #446 verified that the can opener blade was unclean. Observation on 04/06/2026 at 9:14 A.M. revealed two plastic containers that were stacked while wet. Interview with DD #446 verified that the pans were wet and should have been completely air dried prior to stacking. Observation on 04/06/2026 at 9:15 A.M. revealed a cooler on the tray line that was holding a variety of items such as drinks and yogurts. Further observation revealed that the thermometer in the cooler was reading 45 degrees F. DD #446 verified the thermometer was reading 45 degrees F. Observation on 04/06/2026 at 9:17 A.M. revealed DD #446 taking the temperature of a yogurt that was in the cooler on the tray line. DD #446 verified that the yogurt was at 44 degrees F and that it should be below 41 degrees F. Observation on 04/06/2026 at 9:23 A.M. revealed opened bags of dry spaghetti noodles, egg noodles, zetti noodles, and penne noodles without an open date. Interview with DD #446 verified that the bags of pasta were not dated when they were opened. Observation on 04/08/2026 at 12:09 P.M. revealed Dietary Aide (DA) #394 obtain a grilled cheese sandwich from the walk in cooler, don gloves, and proceed to prepare the sandwich. Interview wit DA #394 verified that she did not wash her hands prior to donning gloves and preparing the sandwich. Review of the undated facility policy titled, Food Storage revealed foods should be dated as required by state regulations. Refridgerated food must maintain at or below 41 degrees F. Review of the undated facility policy titled, General Food Preparation revealed employees should wash their hands prior to putting on and after removing gloves. All food equipment should be cleaned, sanitized, air dried and reassembled after each use.

Based on observation, interview, and policy review, the facility failed to treat residents with respect and dignity. This affected two (#8 and #11) of two residents reviewed for dignity. The facility census was 114. 1.Resident #11 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of base of tongue, general anxiety disorder, and delusional disorders. Review of the minimum data set (MDS) dated [DATE] revealed Resident #11 had moderate cognitive impairment. Observation on 04/06/2026 at approxiamately 12:15 P.M. revealed Resident #11 was standing in her door way and visibly agitated. Resident #11 was being argumentative with staff while they were attempting to assist her. Interview on 04/09/2026 at the same time as the observation, Registered Nurse (RN) #418 made a comment to the surveyor stating that with the way Resident #11 is acting it appears the cancer has spread to her brain. 2.Review of the medical record revealed that Resident #8 was admitted to the facility on [DATE] with diagnoses including parkinson's disease without dyskinesia with fluctuations, psychotic disorder with hallucinations, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 is cognitively intact. Resident #8's ability to hear is highly impaired. Review of the care plan revealed Resident #8 has a communication problem related to damage to the nerves in her ears causing her to be deaf. Interventions include being able to communicate by lip reading, writing, using communication board, gestures, sign language, and picture cards. Interview on 04/07/26 at 8:20 A.M. with Resident #8 revealed that she would like an American Sign Language interpreter for the interview. During an interview on 04/07/2026 at 8:38 A.M. RN #418 asked the surveyor how the interview with Resident #8 went. When the surveyor stated that Resident #8 had requested an interpreter, RN #418 stated that Resident #8 only requested an interpreter because she loves the attention. Interview on 04/09/2026 at 7:25 AM with Corporate Quality Assurance Nurse #309 verified that both comments made by RN #418 are not appropriate when speaking about a resident. Review of the facility policy titled, Dignity dated 02/28/20 revealed each resident will be cared for in a manner that promtes and enhances quality of life, dignity, respect and individuality. This deficiency represents non-compliance investigated under Complaint Number 1331410.

Based on observation, interview, record review and policy review, the facility failed to ensure residents receive psychiatric services in a timely manner. This affected one (#11) of one resident reviewed for behavioral health services. The facility census was 117. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of base of tongue, generalized anxiety disorder, depression, and delusional disorders. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #11 has moderate cognitive impairment. Review of the care plan revealed Resident #11 has impaired cognitive function/dementia or impaired thought process. Interventions include keeping family and care giver informed of Resident #11's capabilities and needs. Monitor, document and report to the physpician any changes is Resident #11's cognitive function. Observation 04/06/2026 at 12:15 P.M. revealed Resident #11 standing in the doorway of her room. Resident #11 appeared to be agitated and was untrusting of staff attempting to encourage her to use her walker to prevent a fall. Interview on 04/07/2026 at 9:04 A.M. with Resident #11 revealed that the facility has not offered her psychiatric services and that she would like someone to talk to if those services were offered. Review of the medical record revealed that a services request form for mental health services was signed by Resident #11 on 03/10/26.Review of the progress note dated 03/22/26 at 3:36 P.M. revealed Resident #11's family is concerned about her mental health and requested her to be seen by psychiatry. Review of the progress note dated 03/23/26 at 8:25 P.M. revealed Resident #11 was anxious and the family was requesting for her to be evaluated for a medication change. Review of the physician order note dated 03/25/26 at 4:56 P.M. revealed Resident #11 recieved a new order to be seen by Eventus WholeHealth for psychological/psychiatric services. Review of the progress note dated 03/26/26 at 8:59 P.M. revealed that the nurse spoke with psychiatric services about a change in medication management. The request was denied and stated that it would be reevaluated next week. Review of the care conference notes from 03/30/26 revealed Resident #11's family discussed Residents #11's frequent refusals of care and requested for her to have a psychiatric evaluation. Review of the progress note dated 03/31/26 at 2:26 P.M. revealed Resident #11's sister had recently taken her to an infusion appointment where Resident #11 refused lab draws, urine collection, hydration and medication infusion. The sister stated that Resident #11 has delusions and doesn't recognize familiar people in her life, and doesn't trust them. Review of the progress note dated 04/07/26 at 10:02 A.M. revealed Resident #11 was obsevered in bed wearing a coat and her lower extremeties uncovered with a brief in place. The writer offered to adjust room temperature, close door, and pull the privacy curtain to promote confort and safety which was declined by Resident #11. The writer stated the refusal of care may be influenced by underlying medical conditions and psychiatric conditions. Interview on 04/09/2026 at 8:34 A.M. with Corporate Quality Assurance Nurse (QCAN) #309 revealed that Resident #11 was seen by psych services on 04/08/26. QCAN #309 verified that services usually start within a week of being requested and that Resident #11 had not been seen prior to 04/08/26.Review of the facility policy titled, Behavior Management dated 01/27/21 revealed the facility will identify behaviors, implement interventions, monitor and adress changes.

Number of residents sampled:24Number of residents cited:2 Based on observation, interviews, medical record review, and policy review, the facility failed to ensure medication carts were appropriately locked while nurses administered medications. The facility identified one (Resident #31) resident residing on the Central Unit who was cognitively impaired with mobility. Additionally the facility failed to ensure eye drops were stored according to manufacturer's recommendations. This affected one (Resident #17) of one residents receiving eye drops from the Shelter-Even medication cart. The facility census was 114. Findings include: 1.Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebral infarction, unspecified vascular dementia with mood disturbance, unspecified protein calorie malnutrition, and malignant neoplasm of the colon with colostomy status. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severely impaired cognition, had no behaviors, did not wander, and occasionally rejected care. She used a walker for ambulation and required touch assistance at times. Observation on [DATE] at 9:48 A.M. revealed Registered Nurse (RN) #376 prepared medications for Resident #94, and left the medication cart unlocked before entering the room. RN #376 administered the medications in four spoonful's and gave the resident sips of water with Miralax between bites. She assessed Resident #94's pulse and blood oxygen levels using a pulse oximeter, adjusted the head of bed to the resident's comfort, and washed her hands before returning to the unlocked medication cart. During and interview on [DATE] at 9:50 A.M. RN #376 acknowledged the medication cart was unlocked and was not in sight when the nurse administered medications to Resident #94 and apologized. Review of policy titled Medication Administration dated [DATE] revealed the medication cart is locked at all times unless in use and under direct supervision of the medication nurse. 2.Review of the medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included late-onset Alzheimer's disease, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, and macular degeneration. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had moderately impaired cognition, had no behaviors, did not wander, and did not refuse care. Review of the medical record revealed Resident #17 had physician orders dated [DATE] for Cosopt PF Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate) to instill one drop into both eyes twice daily related to non-exudative age-related macular degeneration. Observation on [DATE] at 2:58 P.M. revealed the top drawer of the Shelter - Even med cart, contained a box of Cosopt PF Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate) single-use ampules packed in silver light-resistant packages of 15 ampules each. Instructions on package stated After pouch is opened, store in the single use pouch to protect from light, and throw away any unused single-use containers 15 days after opening the first pouch. Two pouches of ampules were opened. One pouch containing twelve ampules had a handwritten expiration date labeled [DATE]. The second opened pouch contained nine ampules and was not labeled or dated. During an interview on [DATE] at 3:03 P.M. Licensed Practical Nurse (LPN) #303 verified the twelve Cosopt ampules in the package labeled Expires [DATE] were outdated, and stated she did not know when the unlabeled package had been opened. LPN #303 stated nurses usually dated multi-use packages or bottles on the day they were opened. She stated she was unaware that the Cosopt ampules expired within fifteen days of opening the foil pack. Review of policy titled Medication Storage dated [DATE] revealed Medications were stored safely and securely according to manufacturer's recommendations.

Based medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff received adequate activities of daily living (ADL) care. This affected three (#29, #65, and #115) of four residents reviewed ADL's. The facility census was 117. Findings include: 1. Review of the medical record of Resident #29 revealed an admission date of 02/26/26. Diagnoses included right femur fracture, type 2 diabetes mellitus, depression, and history of breast cancer. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required setup/cleanup assistance with eating, substantial/maximal assistance with bed mobility and transfers, and was dependent for toileting and bathing. Observation on 04/06/26 at 3:00 P.M. revealed Resident #29 lying in bed. Resident #29 had several chin hairs, varying in length from 1 to 1.5 inches. Interview on 04/06/26 at 3:04 P.M., Resident #29 emphatically stated she absolutely did not prefer to have chin hairs. Resident #29 stated, when she lived in the community, she would go to the spa and get dermaplaned and was embarrassed at what her chin looked like. Resident #29 stated staff had not offered to shave her. Interview on 04/06/26 at 3:16 P.M., Licensed Practical Nurse (LPN) #305 verified Resident #29 had several long chin hairs. LPN #305 offered to have staff clean her up and Resident #29 stated, she would love that. 2. Review of the medical record of Resident #65 revealed an admission date of 01/22/26. Diagnoses included type 2 diabetes, effusion of right knee, and hyperlipidemia. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required setup/cleanup assistance with eating, substantial/maximal assistance with bed mobility, transfers, and toileting and bathing. Observation on 04/08/26 at 3:24 P.M. revealed Resident #65 sitting in their chair. Resident #65 had long, grown out toenails. Resident #65's great big toe toenail curved into their index toenail on each foot. This caused irritation to the index toenail. Interview on 04/08/26 at 3:25 P.M., Resident #65 emphatically stated she was experiencing pain from her toenails rubbing against each other and getting caught on things. Resident #65 also confirmed they had requested the facility to cut them over a month ago. Interview on 04/08/26 at 3:30 P.M., Licensed Practical Nurse (LPN) #318 confirmed Resident #65 had long, grown out toenails. LPN #318 confirmed they would put in a consultation for the podiatrist and that the resident's toenails length was unacceptable. Interview on 04/08/26 at 10:05 A.M with Corporate Quality Assurance Nurse (CQAN) #309 confirmed staff should have addressed Resident #65's toenail length. 3. Review of the medical record revealed Resident #115 was admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, muscle wekaness, dementia and intervertebral disc degeneration. Review of the MDS assessment dated [DATE] revealed Resident #115 was cognitively intact. Further review of the MDS revealed Resident #115 is dependent on staff for showering. Review of the care plan revealed Resident #115 has an activities of daily living (ADL) self care performance deficit. Interventions include Resident #115 requires total dependance with shower/bathing of self and assistance with ADLs as needed. Interview on 04/06/2026 at 12:10 P.M. with Resident #115 revealed that he has not been getting his showers regularly. Resident #115 stated that recently he went about two weeks without a shower. Review of the bathing task record revealed Resident #115 is offered bathing on Mondays and Thursdays. Review of the task for Feburay 2026 revealed eight days when bathing should have been offered and all eight days were marked as not attempted. Review of the task for March 2026 revealed bathing should have been offered on nine days. Further review of the task revealed Resident #115 recieved bathing assistance on 03/13/26, 03/17/26, 03/26/26, and 03/29/26. Review of the task for April 2026 revealed 04/02/26 was blank and 04/06/26 was marked not attempted. Interview on 04/09/26 at 7:20 A.M. with CQAN #309 verified that based on documentation, Resident #115 did not recieve a shower on the days marked not attempted or blank. Review of the facility policy titled, Activities of Daily Living (ADL) Care, dated 01/2024, revealed nursing staff would assist residents with ADL needs, including basic care tasks, such as bathing, based on individual needs. This deficiency represents non-compliance investigated under Complaint Number 1331411, 2797726, 1331409, 2611291, and 2961234.

Based on record review, interview, review of a facility Self-Reported Incident (SRI) and facility policy review, the facility failed to thoroughly investigate a resident's fall and failed to implement new fall interventions to prevent future falls. This affected one (#42) out of three Residents reviewed. The facility census was 102. Findings include: Review of the medical record for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, diabetes mellitus, atrial fibrillation, and hypotension. Review of the fall care plan for Resident #42 dated 02/10/24, revealed the resident was at risk for falls related to dementia, impaired safety awareness, resistance to care at times, fear of falling, and fluctuations of assistance with transfers and toileting assistance. The fall care plan revealed no new interventions to prevent additional falls after the resident's fall on 08/29/24. Review of the facility's incident log from 07/01/24 through 09/24/24 revealed Resident #42 had no documented incidents related to a fall on 08/29/24 during a staff transfer. Review of a nurse's progress note for Resident #42 dated 08/29/24 at 10:29 A.M., authored by Licensed Practical Nurse (LPN) #201 revealed the resident had large skin tears to right wrist, forearm, and a small tear on her right elbow and bruising. Per the night shift State tested Nurse Aide (STNA), the resident was combative with care. The night STNA stated she and the resident fell to the ground during a transfer. No other bruises or abrasions were found besides the skin tears. The resident was assessed and complained of back pain. A new treatment order was put in place for skin tears and the supervisor, the Director of Nursing (DON) and the Assistant DON (ADON) were made aware. Review of the facility's SRI created 08/29/24 at 11:43 A.M., revealed Resident #42 had an injury of unknown source. Resident #42 was noted to have three skin tears to her left upper extremity. The resident was unable to recall or verbalize what happened. Resident #42 remained at baseline and had no recollection as to how she obtained the skin tears to her left upper extremity due to cognition. Resident #42 was assessed by a nurse and had no further injuries and denied pain. The summary indicated Resident #42 had three skin tears to the left upper extremity. The resident as assessed by a nurse and bandages were removed and a treatment order was put in place. The physician and families were notified, and calls were placed to the staff working the previous shift. On 09/03/24 at 8:42 A.M., the facility completed the SRI and indicated abuse, and neglect was not suspected due to evidence being inconclusive. The investigation determined Resident #42 had fallen during a transfer earlier that morning with a STNA in the room and the incident was reported to the nurse on duty. Education was provided to the staff on abuse and areas of unknown origin and reporting of falls. Review of a Wound Nurse Practitioner (WNP) note for Resident #42 dated 09/03/24 revealed the resident presented with multiple abrasions on her left forearm. A treatment plan included Xeroform gauze with abdominal (ABD) pad and Kerlix applied to the abrasions of the left forearm daily. The note revealed no documentation related to a fall the resident sustained on 08/29/24. Review of the witness statement by STNA #326 dated 08/29/24 and narrated by the DON, revealed STNA #326 was caring for Resident #42 on 08/29/24 around 11:00 A.M. and reported everything to the agency nurse assigned to Resident #42. STNA #326 indicated the agency nurse assessed the resident and bandaged the skin tears. STNA #326 stated during her morning care, Resident #42 began to struggle against her and knocked her and the resident off balance, causing them to fall and the resident fell on top of her. STNA #326 stated Resident #42 hit her arm on the frame of the closet door which caused several skin tears. STNA #326 yelled for help and the nurse came to assist her and assess the resident. Review of the witness statement by LPN #325 dated 08/29/24 and narrated by the DON, revealed she was notified by an STNA that another STNA and the resident had fallen and needed assistance. LPN #325 stated she assessed Resident #42 and dressed her skin tears. When DON questioned LPN #325 about why an incident was not reported and why she didn't create a nurse's note, LPN #325 stated she did not know she needed to do these things. Review of Resident #42's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The resident was dependent on staff for transfers. Interview with Agency LPN # 325 on 09/20/24 at 8:13 A.M., revealed she was the nurse on duty on 08/29/24. LPN #325 stated STNA # 326 reported to her that she lowered Resident #42 to the ground and Resident #42 came down on top of STNA #326's stomach. LPN #325 stated she never considered the incident a fall because she was informed that Resident #42 never hit the floor. LPN #325 verified Resident #42 had skin tears and she bandaged the skin tears. LPN #325 stated she told the nurse supervisor who signed her timecard as she was leaving the facility. LPN #325 verified she did not notify the physician or the family because she was not aware she needed to. Interview with Assistant Director of Nursing (ADON) #200 on 09/24/24 at 4:46 P.M., verified Resident #42 had a fall during a staff transfer on 08/29/24. ADON #200 verified the facility failed to thoroughly investigate Resident #42's fall because the facility was not immediately aware of a fall until after they started the injury of unknown origin investigation. ADON #200 stated he was completing morning rounds on 08/29/24 and noticed Resident #42's had skin tears on her arm. ADON #200 stated he questioned the information that agency STNA #326 provided to him about Resident #42 being combative due to the information not being correct because Resident #42 never had a history of being combative and never displayed that type of behavior. ADON #200 stated he could not provide any related information about why the fall was not investigated. ADON #200 stated that after a resident falls, the facility will meet as a team to discuss care plans, complete a risk management report, and discuss new interventions. ADON #200 verified the facility failed to meet as a team and discuss Resident #42's fall and failed to implement any new interventions to prevent future falls for Resident #42. ADON #200 stated the investigation was more focused on an unknown injury. Review of a facility document titled, Fall Prevention and Training for Elderly Residents, undated, revealed keeping the resident safe and sound was the top priority. The facility utilizes risk assessment tools, environmental factors, medication management and assistive devices for elements to prevent falls. The facility will identify fall risk, implement and evaluate interventions utilized to aid the prevention of falls, and revise them as necessary. Review of the facility policy titled, Fall Management, dated 01/2001, revealed each resident's risk factors and environmental hazards will be evaluated with a resident's comprehensive plan of care developed along with interventions monitored for effectiveness. The facility will follow and complete the following steps: assess the resident, complete a post-fall assessment, notify physician and family, review the residents plan of care and update, document all assessments and actions, and obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Complaint Number OH00157672.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure narcotics were accurately reconciled. This affected two (Residents #64 and #404) of 19 residents with narcotics medications stored on the Shelter Hall and East Hall odd-side medication carts. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, severe vascular dementia with anxiety, type II diabetes mellitus, and other chronic pain. Review of the Minimum Data Set (MDS) assessment completed on 03/07/24 revealed Resident #64 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the physician orders dated 01/04/2024 revealed an order for Morphine sulfate 20 milligrams (mg) per (/) milliliter (ml) solution give 0.25 ml (five mg) under tongue every four hours as needed for pain or shortness of breath. Review of the Controlled Drug Record revealed Resident #64 received 0.25 ml of morphine sulfate 100 mg per five ml (20 mg/ml) solution on 04/21/24 and had 28 ml remaining in the bottle. Observation on 05/15/24 at 11:22 A.M. revealed Morphine sulfate solution for Resident # 64 held an immeasurable amount of medication between 24 ml and 28 ml marks on the bottle. During interviews conducted on 05/15/24 from 11:27 A.M. to 11:43 A.M., Licensed Practical Nurse (LPN) #207 and the Director of Nursing (DON) each verified Resident #64's bottle of morphine sulfate measured below the 28 ml mark. LPN #207 stated nurses completed narcotic counts at the beginning of every shift, and she did not notice the discrepancy that morning. 2. Review of the medical record revealed Resident #404 was admitted to the facility on [DATE]. Diagnoses included senile degeneration of the brain, dementia without behavioral disturbance, and other chronic pain. Review of the admission Minimum Data Set (MDS) assessment completed 04/22/24 revealed Resident #404 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #404 was on Hospice. Review of the physician orders dated 05/03/24 revealed an order for Lorazepam Intensol Concentrate two milligrams (mg) per (/) milliliter (ml) to give 0.25 ml sublingually twice daily for anxiety. Review of the Controlled Drug Record revealed Resident #404 received a 0.25 ml dose of Lorazepam Intensol two mg/ml on 05/15/24 at 9:06 A.M. and had 21 ml remaining in the bottle. Observation on 05/15/24 at 11:54 A.M. revealed Lorazepam Intensol two mg /ml solution for Resident #404 measured at the 20 ml marking. During interviews conducted on 05/15/24 from 11:55 A.M. to 12:05 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #204, and LPN #198 each verified Resident #404's bottle of Lorazepam Intensol two mg/ml measured at the 20 ml line and should have measured above the 20 ml line. Review of the facility policy titled Controlled Substances, Drug Count, dated 04/2021, revealed two licensed nurses counted and verified the narcotics counts for each individual at the change of shift. If the count was incorrect, the nurse on duty did not leave until the count was correct or the reason for the discrepancy was identified. This deficiency represents noncompliance investigated under Complaint Number OH00153147.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure record of meal intakes were consistently documented. This affected four (Residents #1, #3, #36, and #92) of five residents reviewed for meal consumption. The facility census was 104. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including need for assistance with personal care and nutritional deficiency. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 02/04/24 revealed the resident had intact cognition. Review of the care plan for Resident #1 dated 12/13/23 revealed the resident had nutritional problems and was at risk for malnutrition related to inadequate meal intake. Interventions included to monitor intake and record every meal. Review of the meal intake records for Resident #1 from 02/27/24 through 03/26/24 revealed there were no intakes documented for the following dates: 02/28/24, 02/29/24, 03/08/24, 03/09/24, and 03/10/24. There were only two meal intake documented on the following dates: 02/27/24, 02/28/24, 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/13/24, 03/16/24, 03/17/24, 03/18/24, 03/21/24, 03/24/24, and 03/25/24. There was only one meal intake documented on 03/11/24 and 03/22/24. 2. Review of the medical record for Resident #3 revealed and admitted [DATE] with diagnoses including nutritional deficiency and adult failure to thrive. Review of the quarterly MDS assessment for Resident #dated 03/12/24 revealed the resident had intact cognition. Review of the care plan for Resident #3 revised 02/01/24 revealed the resident had a nutritional problem or potential risk for malnutrition. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #3 from 02/27/24 through 03/26/24 revealed there were no meal intakes documented for the following dates: 02/28/24, 02/29/24, 03/01/24, 03/04/24, 03/05/24, 03/10/24, and 03/25/24. There were only two meal intakes documented on the following dates: 02/27/24, 03/06/24, 03/07/24, 03/13/24, 03/18/24, 03/21/24, 03/22/24, 03/23/24, 03/24/24. 3. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including anemia, moderate protein-calorie malnutrition, and dementia. Review of the quarterly MDS assessment for Resident #36 dated 03/02/24 revealed the resident had mildly impaired cognition. Review of the care plan for Resident #36 revised 03/08/24 revealed the resident had increased nutritional needs. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #36 from 02/27/24 through 03/26/24 revealed no meal intakes documented for the following dates: 02/28/24, 02/29/24, 03/08/24, 03/09/24, 03/10/24, and 03/22/24. There were only two meal intakes documented for the following dates: 02/27/24, 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/11/24,03/13/24, 03/16/24, 03/17/24, 03/18/24, and 03/25/24. There was only one meal intake documented for the following dates: 03/19/24, 03/21/24, 03/25/24. 4. Review of the medical record for Resident #92 revealed an admitted [DATE] with diagnoses including quadriplegia, hypertension, and anxiety disorder. Review of the quarterly MDS assessment for Resident #92 dated 01/16/24 revealed the resident was assessed to have impaired memory upon staff interview. Review of the care plan for Resident #92 revised 10/20/23 revealed the resident had a nutrition problem and a potential risk of malnutrition. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #92 from 02/27/24 through 03/26/24 revealed were no meal intakes documented for the following dates: 02/28/24, 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/16/24, 03/21/24, and 03/24/24. There were only two meal intakes documented for the following dates: 02/27/24, 02/29/24, 03/02/24, 03/06/24, 03/07/24, 03/13/24, 03/17/24, 03/18/24, 03/23/24. There was only one meal intake documented for the following dates: 03/03/24, 03/19/24, 03/22/24, 03/25/24. Interview on 03/27/24 at 10:38 A.M. with State tested Nursing Assistant (STNA) #100 on confirmed the percentage of meals consumed by residents should be documented in the residents' medical record for every meal. STNA #100 confirmed there was not always time to document every meal. Interview on 03/27/24 at 10:55 A.M. with the Director of Nursing (DON) confirmed the facility staff should consistently document resident meal intakes. The DON confirmed the facility had not consistently documented meal intakes for Residents #1, #3, #36, and #92 from 02/27/24 to 03/26/24. Interview on 03/07/24 at 2:27 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #36's family member had requested the amount of meal the resident had consumed and the ADON was unable to provide the amount due to it not being documented in the resident's medical record. Review of the facility policy titled Diet/Meal Consumption reviewed 01/26/21 revealed any resident at risk for unintended weight loss should have their meal intake recorded. This deficiency represents noncompliance investigated under Complaint Number OH00152031.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observations, closed medical record review, review of the facility investigation and witness statements, staff interviews, review of the police incident report, review of the hospital report, review of the local weather report, and review of the facility policy addressing elopement, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy and subsequent serious harm and/or injuries when one resident (Resident #115) eloped from the facility without staff knowledge, was missing approximately one hour and thirty minutes and was found approximately 0.3 miles from the facility by a police officer and was taken to the hospital and admitted with a right hip fracture and hypothermia. This affected one (#115) of three residents reviewed for risk of elopement. The facility identified 35 residents at risk for elopement. The facility census was 111. On 11/20/23 at 3:53 P.M., the Administrator, Director of Nursing (DON), Corporate Director of Clinical Services (CDCS) #200, and Corporate Clinical Support Registered Nurse (CCSRN) #201 were notified Immediate Jeopardy began on 11/01/23 at 5:30 A.M. when State tested Nursing Assistant (STNA) #305, during her morning rounds, discovered Resident #115 was missing and notified the Nurse Supervisor Licensed Practical Nurse (LPN) #279. Staff searched the facility and the facility grounds and could not locate Resident #115 and notified the local police. The resident was found in a parking lot across the street from the facility approximately 0.3 miles by a police officer. The resident was taken to the hospital for evaluation and was diagnosed with a fractured right hip and hypothermia. According to the police report the outside temperature in the area on 11/01/23 at 7:00 A.M. was 30 degrees Fahrenheit (F). The Immediate Jeopardy was removed on 11/03/23 and the deficient practice was corrected on 11/14/23 when the facility implemented the following corrective actions: On 11/01/23 at 7:03 A.M., Former Resident #115 was found by the local police approximately 0.3 miles from the facility and was transported to the hospital for evaluation and treatment by emergency medical personnel. On 11/01/23, the facility initiated a Quality Assurance Performance Improvement (QAPI) review with initial measures taken including initiating an investigation of the incident and cooperation with local law enforcement. On 11/01/23, CCSRN #201 completed an audit to confirm all resident wandering risk assessments actively reflected residents' care needs for wandering risk and placement in the facility. One resident (#09) was identified with a new increased onset of wandering behaviors. Resident #09 was placed on one-to-one supervision. Resident #09's family was contacted regarding the resident's increased behaviors and initial monitoring. The Interdisciplinary Team (IDT) recommended Resident #09 be moved to the facility's secured unit. Resident #09's physician was notified, and the resident was moved to the secured unit on 11/02/23. There were no other residents identified with an increased risk for elopement. Resident #115 did not return to the facility. On 11/01/23, Maintenance Director #312 completed an audit and confirmed all doors and alarms in the facility were functioning properly. On 11/01/23, new alarms for all entrance/exit doors to the facility and doors exiting to the courtyard on the 200 and 300 units with audible and sensory lights were ordered. The nursing staff completed resident head counts every two hours until the new alarms were installed on 11/03/23. The Administrator and DON provided education to all team members including nursing, dietary, maintenance, housekeeping, activities, social services, and leadership regarding the policy for missing residents. The education was initiated on 11/01/23 at 8:00 A.M. and was completed for all staff on 11/01/23 by 5:02 P.M. The DON/Designee will continue monitoring two times a week for three additional weeks with visual observation of missing resident drills. Monitoring and any issues identified will be addressed and reviewed in the following QAPI committee. The initial QAPI review was completed on 11/01/23. The DON is responsible for ongoing compliance. Review of the audit reports revealed elopement drills were conducted on 11/03/23 at 1:20 P.M., 11/06/23 at 3:30 P.M., 11/13/23 at 3:23 P.M., 11/14/23 at 12:45 P.M. and 11/21/23 at 2:30 P.M. There were no negative findings with any of the drills. The facility will continue with monthly elopement drills. Observations on 11/20/23 between 11:50 A.M. and 12:30 P.M. revealed the alarms on the exit doors for the front and back entrance and the doors exiting to the courtyard of the 200 and 300 units of the facility were functioning properly. When activated the alarms had to be turned off by staff manually by using a key to the alarm. On 11/21/23, review of the medical records for two additional residents (#05 and #15), reviewed for elopement, revealed no concerns. Observation of Residents #05 and #15 on 11/21/23, revealed elopement interventions were in place. On 11/21/23 between 1:30 P.M. and 2:15 P.M., staff interviews were conducted with Receptionist #307, RN #302, STNA #203, Occupational Therapist #311, Director of Rehabilitation #310, Medical Records Assistant #308, and Dietary Aide #309, confirmed staff were knowledgeable about the procedures to follow if a resident eloped from the facility and the need to reassess residents for elopement risk if they had a change in condition such as increased wandering behaviors and/or exit-seeking behaviors. Findings include: Closed medical review revealed Resident #115 was admitted to the facility on [DATE] and discharged home with his daughter on 10/13/23 and was readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, urinary tract infection, Alzheimer's disease, wedge compression fracture of T11-T12, wedge compression fracture of the fourth lumbar vertebra, occlusion and stenosis of bilateral vertebral arteries, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 was cognitively impaired and required partial to moderate assistance with toileting, dressing, and transfers and locomotion and used a wheelchair and walker for mobility. Resident #115's MDS was coded for the presence of wandering behaviors. Review of the elopement risk evaluation dated 10/13/23 revealed Resident #115 propelled himself with some assistance, was alert and oriented to person, place, and time, was happy with placement, had no attempts of elopement and was a low risk for elopement. Review of the medical record for Resident #115 revealed the resident was discharged to home with family in the community on 10/13/23. Further review revealed Resident #115 was taken to the hospital by his family on 10/19/23 and was admitted and treated for a urinary tract infection and confusion and then was readmitted to the facility on [DATE]. Resident #115 was not reassessed for elopement risk upon readmission to the facility on [DATE] and no subsequent elopement risk assessments were completed for the resident. Review of the readmission physician orders for Resident #115 dated 10/21/23 revealed the orders did not include any orders for elopement prevention interventions. Review of the care plan dated 10/24/23 revealed Resident #115 was an elopement risk/wanderer as evidenced by impaired safety awareness and was noted to wander. Interventions included the following: distract resident from wandering by offering pleasant diversions, offer structured activities, food, conversation, television, document and keep family and physician aware of resident's wandering and attempts to redirect resident. Review of the nurse progress notes dated 10/25/23 at 7:14 P.M. revealed staff observed Resident #115 wandering outside in the fenced courtyard. Staff had not seen the resident exit the facility. Resident #115 was escorted back into the facility and placed back in his wheelchair and assisted back to his room. Review of the nurse progress note dated 10/26/23 at 1:34 A.M. revealed staff observed Resident #115 pushing the back door open and attempting to exit the facility. Staff provided reorientation to the resident regarding staying at the facility and seated the resident at the nurse's station for close monitoring and prevention of elopement. Review of the nurse progress note dated 11/01/23 at 5:30 A.M. per Licensed Practical Nurse (LPN) #279 revealed Resident #115 was noted to be missing at 5:30 A.M. when STNA #305 was doing rounds. Nursing staff searched the unit three times and were unable to locate Resident #115. Next all staff in the building were notified and searched the entire building and grounds and were unable to locate Resident #115. Nursing staff notified nine-one-one (911) on 11/01/23 at approximately 6:30 A.M. regarding the missing resident. Resident #115 was last seen by staff on 11/01/23 between 3:00 A.M. and 3:30 A.M. in his bed. At approximately 7:00 A.M., the police found Resident #115 across the street on the ground in a parking lot with multiple abrasions covering his body. Resident #115 was alert and answered all questions appropriately. Resident #115 was transferred to the hospital for evaluation. Resident #115's daughter was notified of the incident and verbalized understanding. Review of the police report dated 11/01/23 at 7:03 A.M. revealed Resident #115 was located by police officers lying on the ground behind a building across the street from the facility. The outside temperature was approximately 30 degrees F. Resident #115 appeared to be in distress and was not wearing shoes and was covered with cuts as if he had been going through the brush. He was transported by emergency personnel to the hospital for evaluation. Review of the hospital notes report dated 11/01/23 revealed Resident #115 arrived at the hospital at 7:29 A.M., with his active problem list and diagnoses listed as hypothermia, intertrochanteric fracture of the right hip, and multiple abrasions. Resident's body temperature upon admission to the hospital was 89 degrees F. Further review of the hospital records revealed Resident #115 required surgical intervention, a total right hip arthroplasty to repair the right hip fracture sustained during the elopement incident. Interview on 11/20/23 at 10:24 A.M. by telephone with STNA #305 confirmed she was Resident #115's assigned aide on the morning of 11/01/23 and between 3:00 A.M. and 3:30 A.M. during her rounds she observed the resident in his room sleeping. STNA #305 confirmed at approximately 5:30 A.M. during her rounds she did not see Resident #115 in his room and immediately reported the missing resident to the Nurse Supervisor, LPN #279. STNA #305 confirmed she did not hear any exit door alarms prior to or after she observed the resident was not in his room. Further interview with STNA #305 confirmed LPN #279 instructed the aide and STNA #306 to search resident rooms to include looking in closets and under beds, but they were unable to locate Resident #115. STNA #305 confirmed she then stayed on the unit to monitor the other residents in the common area while the other staff searched the facility and grounds for Resident #115. Interview on 11/20/23 at 10:40 A.M. by telephone with the night shift Nurse Supervisor LPN #279 confirmed she was Resident #115's assigned nurse on 11/01/23 when Resident #115 eloped from the facility. LPN #279 confirmed she had observed Resident #115 ambulating in the hallway of the unit the night of 10/31/23 as he normally did and was not exit seeking. LPN #279 confirmed she was alerted by STNA #305 at approximately 5:30 A.M. on the morning of 11/01/23 that Resident #115 was not in his room, and she could not locate him. LPN #279 stated she immediately instructed STNAs #305 and #306 to search the unit including closets, under the beds and residents who were still in bed because sometimes residents would go to other rooms and get in bed if the bed was empty. LPN #279 confirmed she notified other staff in the facility to search the facility and grounds. LPN #279 confirmed she did not hear any door alarms on the unit during the night of 10/31/23 or the morning of 11/01/23. Interview on 11/20/23 at 11:30 A.M. with the DON confirmed he arrived at the facility on 11/01/23 at approximately 6:40 A.M. and a police officer standing in front of the facility notified him Resident #115 had been found across the street in the parking lot. The DON confirmed he notified the Administrator, and they went to observe Resident #115 prior to his transfer to the hospital on 11/01/23. The DON confirmed when they observed Resident #115, he was awake and alert and was being transferred to a stretcher. The DON stated Resident #115 was wearing anti-slip socks, a tee-shirt and sweatpants, and a gown over his tee shirt. The DON confirmed prior to 11/03/23 when the exit door alarms were changed as part of the facility's corrective action, the door alarms would chime when the door was opened and then stopped sounding immediately when the door was closed. The DON confirmed the new door alarms installed on 11/03/23 had a louder audible signal and required staff to go to the alarm with a key to silence them. All nurses were given a key to silence the alarms. The DON further confirmed all residents in the facility who have been assessed to be at risk for elopement were to be placed on the secured unit which had a separate alarm system. The DON confirmed Resident #115 had been assessed on 10/13/23 as not at risk for elopement and the facility did not complete an updated elopement risk assessment for the resident following his wandering and exit seeking behaviors on 10/25/23 and 10/26/23. Interview on 11/22/23 at 1:40 P.M. by telephone with the Administrator confirmed staff called her on 11/01/23 at 6:10 A.M. and notified her Resident #115 was missing and staff were outside looking for him. The Administrator confirmed she arrived at the facility on 11/01/23 at 6:15 A.M. and drove through the parking lot looking for Resident #115. The Administrator confirmed at 6:30 A.M. she entered the facility and instructed LPN #279 to call the police regarding missing Resident #115. The Administrator confirmed the local police notified her at 7:00 A.M. that Resident #115 had been located off the facility grounds. The Administrator confirmed she and the DON drove to see Resident #115 as emergency medical personnel were transferring resident to the ambulance and the resident was alert and responsive to questions. Further interview with the Administrator confirmed the facility was not able to determine which door Resident #115 had used when he exited the facility. Following the incident, the facility replaced all of the door chimes with louder door alarms which required a key to be silenced. The new door alarms were placed on all entrance and exit doors and doors exiting to the courtyard on the 200 and 300 units. Review of the online weather report at https://www.wunderground.com/history/daily/us/oh/[NAME]/KCVG/date/2023-11-1 revealed the air temperature on 11/01/23 at 6:00 A.M. was 32 degrees F, there was no precipitation, and the wind speed was approximately eight miles per hour. Review of the facility's policy titled, Missing Resident, reviewed 03/2021 revealed it was the facility policy to assist in alerting staff when a resident's location is unknown to enable a quick and efficient response by all staff. This deficiency represents non-compliance investigated under Complaint Number OH00148375.

Based on observation and staff interview, the facility failed to ensure the main laundry room dryers were free of lint build up. This had the potential to affect all residents who reside in the facility. Facility census was 86. Findings included: During observation of the laundry room on 04/22/21 at 2:33 P.M. with Maintenance Director # 78 revealed dryer #01 (far right) had a large build-up of lint in the front of the dryer where the lint trap was located. Observation revealed a large build-up of lint on top of the lint screen mechanisms, bottom of the drum and lint twisted around to the electric wires. Further observation revealed Dryer #03 (far left) had a hole in the dryer lint screen, a build-up of lint within the lint trap device and large build-up of lint within the vents leading out of the dryer. During interview with Maintenance Director #78 on 04/22/21 at 243 P.M. verified the lint build up in the dryers (#01 and #03) . Maintenance Director #78 stated he was responsible for the back of the dryers and Laundry staff was responsible for the front of the dryers where the lint traps were located. Maintenance Director #78 stated the facility had no log where they had checked or cleaned the front of the dryers where the lint trap was located. Interview with Laundry Staff #77 on 04/22/21 at 2:46 P.M. indicated laundry staff was able to clean off the lint from the screen by hand however they had no way to remove the lint off of the top of the lint trapping mechanism or off the electric wires. Laundry Staff #77 stated the facility had no log where they cheeked or cleaned the front of the dryers. Interview with the Director of Nursing (DON) on 04/22/21 at 3:00 P.M. indicated the facility had no policy for cleaning the lint areas of the dryers.

Based on record review, observation, staff interview, review of online resources, and policy review the facility failed to ensure staff performed proper hand hygiene during medication administration. This affected one resident (#240) of seven residents observed for medication administration. In addition the facility failed to ensure a nurse completed appropriate infection control techniques after she provided direct care to a resident in transmission based precautions/quarantined for COVID-19. This affected two residents (#196 and #245) of 24 reviewed for infection control. The facility census was 86. Findings include: Review of the medical record for Resident #240 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the April 2021 physician orders for Resident #240 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the medication administration on 04/20/21 at 11:37 A.M. for Resident #240 per Licensed Practical Nurse (LPN) #88 revealed the nurse donned gloves prior to checking the resident's blood sugar. Nurse obtained a drop of blood from the resident's finger using a lancet and placed the blood onto the glucose test strip. Immediately after checking the blood sugar LPN #88 removed her gloves and administered oral medication [MEDICATION(S)] without performing hand hygiene prior to oral medication administration. Interview on 04/20/21 at 11:39 A.M., with LPN #88 confirmed she removed her gloves after checking Resident #240's blood sugar, had not performed hand hygiene and then directly administered oral medication to the resident. Review of the facility policy titled Hand Hygiene dated February 2021 revealed hand hygiene practices should be used consistently to minimize the risk of spreading and/or acquiring infections and hand hygiene should be performed after removing gloves and after contact with inanimate objects in the resident's room or environment. 2. During observation of wound care/dressing change on 04/21/21 at 1:58 P.M., for Resident #233 who was in transmission-based precautions (TBP) due to new admission/coronavirus (COIVD-19) quarantined revealed LPN #06 arrived at residents' rooms with a N95 mask and a face shield in place. LPN #06 donned a new disposable protective gown before she entered resident's rooms and had no surgical mask covering her N95 mask. Further observation revealed LPN #06 completed the dressing change, washed her hands in the resident's bathroom then doffed her contaminated protective gown and exited the residents' room at 2:10 P.M. Further observation revealed LPN #06 did not clean her face shield or change the N95 masks after she exited Resident #233 's room. Further Observation revealed LPN #06 had a small bedside table with her computer, various paper documents and wound supplies for wound care which she used to roll around between residents' rooms. Observation revealed LPN #06 continued to touch her face shield and her N95 mask to reposition it on her face. Continued observations revealed LPN #06 would place the face shield on top of her head where the nose pieces rested on her forehead to talk to surveyor and /or doff the face shield completely and place it on the bedside table. LPN #06 was observed to do this several times while talking with the surveyor. Further observation revealed LPN #06 donned her face shield, pushed the bedside table to Resident #196's room, knocked on door, used handle to open residents' doors and asked Resident and the visitor a question. LPN #06 used the door handle to close residents' door and pushed the bedside table to the main hallway near the phone. Observation revealed LPN #06 continued to touch her N95 mask to reposition it and her face shield, then she completely doffed the face shield and placed it on the bedside table to make a phone call. Further observation revealed LPN #06 finished the phone call, donned the face shield, repositioned her N95 mask and pushed the bedside table to Resident #245 room. Continued observation revealed LPN #06 knocked on door, used door handle to enter residents' room and interviewed the resident. During interview with the resident, LPN #06 was observed to place her left hand on resident's footboard, continued to wear the contaminated face shield and the same N95 mask when she provided care to Resident #233. Observation revealed LPN #06 exited resident #245's room and went to the main nurse's desk where she was observed to touch the main counter and other items. Interview with LPN #06 on 04/21/21 at 2:25 P.M. verified Resident #233 was in quarantine due to a new admission when she completed wound care. LPN #06 also verified she washed her hands then removed her contaminated gown after she provided direct care to a resident in quarantine. LPN #06 also verified the numerous breaks in infection control after she exited Resident #233's room. LPN #06 verified she should have washed her hands after she removed the contaminated gown but forgot the sequence. LPN #06 also verified she was not aware she should have either changed her N95 mask or wore a surgical mask over top of the N95 between residents. LPN #06 also stated she was also not aware she needed to clean her face shield after she provided direct care to a quarantined resident. Review of the CDC website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2029 (COVID-19) Pandemic (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), updated 12/14/20, revealed HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Guidelines indicated HCP staff shall put on clean, non-sterile gloves upon entry into the patient room or care area, remove and discard gloves before leaving the residents room and immediately perform hand hygiene. Guidelines indicated HCP shall put on a clean isolation gown upon into the resident room or area and remove and discard the gown in a dedicated container for waste before leaving the resident's room. Review of Centers for Medicare and Medicaid Services (CMS) memo titled COVID-19 Long-Term Care Facility Guidance., dated 04/02/20, revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control. Review of 02/28/20 facility policy titled Hand Hygiene revealed hand hygiene practices should be used consistently to minimize the risk of spreading and/or acquiring infections.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to document a count/reconciliation of controlled substances each shift. This had the potential to affect ten (#14, #23, #29, #48, #50, #55, #59, #69, #79 and #195) residents with controlled substance medications stored on the Shelter Unit Odd Cart. The census was 86. Findings include: Review of the controlled substance shift to shift count on 04/20/21 at 8:55 A.M. with Registered Nurse (RN) #107 revealed neither the off going nurse nor the oncoming nurse had signed the count for 04/20/21 at 7:00 A.M. for the Shelter Unit Odd Cart. Further review revealed there were 10 (#14, #23, #29, #48, #50, #55, #59, #69, #79 and #195) residents with controlled substances medications stored on the Shelter Unit Odd Cart. Interview on 04/20/21 at 9:09 A.M. with RN #107 confirmed the off going nurse had not signed the count for 04/20/21 at 7:00 A.M. and she had not signed the count at the beginning of her shift on 04/20/21. Interview on 04/22/21 at 2:34 P.M. with the Director of Nursing (DON) confirmed nurses were supposed to count and sign the controlled substance count sheet whenever the keys to the medication cart changed hands. Review of the facility policy titled Controlled Substance Storage dated August 2014 revealed at shift change or when keys are transferred a physical inventory of all controlled substances is conducted by two licensed nurses and is documented.

Based on medical record review, observations, staff interview and policy review, the facility failed to provide privacy to residents while in their rooms regarding the use of a video monitoring device and the facility failed to ensure private medical information was secured and kept confidential. This affected four (#3, #72, #74 and #233) out of four residents reviewed for privacy. The facility census was 86. Findings include: 1. Record review of Resident #72's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; major depressive disorder, respiratory disorders in diseases classified elsewhere, chronic respiratory failure with [CONDITION(S)], hypertension, unspecified dementia without behavioral disturbance, gastro [CONDITION(S)] reflux disease without esophagitis, overactive bladder, heart failure, other chronic pain and hypertensive retinopathy. Review of Resident #72's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and eating. Review of Resident #72's fall care plan dated 12/16/20 revealed resident would have video monitoring in his room. Review of Resident #72's chart revealed no written consents for continuous video monitoring in his chart. Review of Resident #72's progress note dated 04/06/21 revealed resident was found sitting on the floor mat with his back against his bed in his room. The resident continues to be monitored with a camera was the intervention for his fall. Resident #72's resident representative was notified. Review of Resident #72's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #72's room on 04/21/21 at 2:06 P.M. revealed Resident #72 had a camera monitor in his room that provided continuous video footage to a monitor at the nurses station. Interview with the Director of Nursing (DON) on 04/21/21 at 2:06 P.M. verified Resident #72 had a camera monitor in his room that provided continuous video footage to a monitor at the nurses station. Interview with the Administrator on 04/21/21 at 3:11 P.M. verified the facility did not have a policy on using continuous video in resident rooms. The Administrator also verified Resident #72 and Resident #72's representative did not sign consents for there to be continuous video in his rooms. The Administrator stated Resident #72's representative was notified of continuous video being used as a fall intervention on 04/06/20. 2. Record review of Resident #74's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; Alzheimer's disease, dementia in other diseases classified elsewhere with behavioral disturbance, type two diabetes mellitus without complications, anxiety disorder, major depressive disorder, hypertension and [CONDITION(S)]. Review of Resident #74's quarterly MDS assessment dated [DATE] revealed resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident also required limited assistance with eating. Review of Resident #74's fall care plan dated 02/09/21 revealed resident would have video monitoring in her room. Review of Resident #74's chart revealed no written consents for continuous video monitoring in his chart. Review of Resident #74's progress note dated 02/09/21 revealed Resident #74 was found lying on the right side of the floor in her room. The intervention for the fall was to have a video monitor in Resident #74's room at all times. Resident #74's representative was notified. Review of Resident #74's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #74's room on 04/21/21 at 2:06 P.M. revealed Resident #74 had a camera monitor in her room that provided continuous video footage to a monitor at the nurses station. Interview with the DON on 04/21/21 at 2:06 P.M. verified Resident #74 had a camera monitor in her room that provided continuous video footage to a monitor at the nurses station. Interview with the Administrator on 04/21/21 at 3:11 P.M. verified the facility did not have a policy on using continuous video in resident rooms. The Administrator also verified Resident #74 and Resident #74's representative did not sign consents for there to be continuous video in her room. The Administrator stated Resident #74's representative was notified of continuous video being used as a fall intervention on 02/09/21. 3. During observation of 300 hall on 04/20/21 at 12:10 P.M. revealed a computer affixed to the 300 Hall medication cart which displayed an active medications list for Resident #233 and no staff members present in the area. Further observation at 12:13 P.M. revealed a visitor for Resident #240 walked in the immediate area where Resident #233's private health information was being displayed on the computer. Interview with Licensed Practical Nurse (LPN) #88 on 04/20/21 at 12:21 P.M. verified she left the medication list displayed for Resident #233 unsecured on the computer and verified a visitor walked by her computer where private health information was displayed. LPN #88 stated she forgot to close the screen when she administered medications. 4. Review of the medical record for Resident #3 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment for Resident #3 dated 04/02/21 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Observation on 04/21/21 at 1:59 P.M. revealed the electronic medical record (EMR) for Resident #3 was left open on top the the 200 hall medication cart with private health information visible. Interview on 04/21/21 at 2:04 P.M. with Licensed Practical Nurse (LPN) #94 confirmed she had left Resident #3's EMR open on top of the 200 hall medication cart with private health information visible. Review of a facility policy titled Confidentiality dated 02/28/20 revealed the facility honored the resident's rights to secure and confidential personal and medical records.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure fall interventions were in place in accordance with a resident's fall care plan. This affected one (#73) out of 19 residents reviewed for care planning. The facility census was 86. Findings include: Record review of Resident #73's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; [CONDITION(S)], unspecified fracture of lower end of left radius initial encounter for closed fracture, Alzheimer's disease, unspecified dementia with behavioral disturbance, essential hypertension, generalized anxiety disorder, irritable bowel syndrome without diarrhea, and nutritional deficiency. Review of Resident #73's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be severely cognitively impaired and required limited assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #73 also required supervision with transfers and eating. Review of Resident #73's fall care plan dated 04/20/21 revealed resident was to have fall mats to both sides of the bed to reduce the risk of injury. Observation of the facility on 04/20/21 at 11:59 A.M. revealed Resident #73 was lying in a low bed with no fall mats to the side of the bed. Interview with the Director of Nursing (DON) on 04/20/21 at 11:59 A.M. verified Resident #73 was lying in bed with no fall mats to the side of the bed. The DON also verified Resident #73 was ordered to have fall mats to the side of his bed. The DON also verified Resident #73 care plan stated Resident #73 was to have fall mats to the side of his bed. The DON reported that Resident #73 had the fall mats to the side of his bed as intervention prior to 04/20/21 but the care plan and orders were all removed from the electronic record. Review of the undated facility's comprehensive care plans policy revealed it was the policy of the facility to develop and implement a comprehensive person centered care plan for each resident. Review of the facility's fall management policy dated January 2021 revealed each resident will be assessment for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

Based on record review and staff interview the facility failed to ensure resident's medical record accurately reflected the resident's advanced directive for a selected code status. This affected one (#8) of one residents reviewed for advanced directives. The census was 86. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the online dashboard in the electronic medical record for Resident #8 revealed resident's code status was listed as DNRCC-Arrest Review of the care plan for Resident #8 dated 06/07/18 revealed resident's advanced directive was for her code status to be DNRCC-Arrest. Interventions included: advanced directives should be kept on the resident's chart and updated quarterly and as needed. Review of the state of Ohio DNR form dated 06/06/18 for Resident #8 under the advanced directive tab on the resident's chart signed by the physician and resident's representative revealed resident was to be a DNRCC. The box on the form for DNRCC-Arrest was not checked. Interview on 04/20/21 at 3:59 P.M. with Social Worker (SW) #19 confirmed Resident #8's orders, care plan, and electronic record list her code status as DNRCC-Arrest and advanced directive form in the chart signed by the physician indicated the resident was to be a DNRCC. SW #19 confirmed the DNRCC-Arrest box on the form in the resident's chart was not checked and there were no other advanced directive forms on the resident's chart.

Based on medical record review, staff interviews, review of facility policy, review of Licensed Practical Nurse (LPN) job description and review of online resources from Ohio Board of Nursing, the facility failed to ensure resident received ordered intravenous (IV) medications and accommodating IV flushes via peripherally inserted central catheter (PICC). Additionally, the facility also failed to ensure an LPN was appropriately licensed to administer IV medications when she recorded medications administered through a PICC line. This also affected one (#61) out of one residents reviewed for IV medications. The facility identified only one resident in the facility on IV medications. Facility census was 86. Findings include: Review of the medical record for Resident #61, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact, had no behaviors, did not reject care, did not wander, was two person assist, dependent or required extensive assistance with activities of daily livings (ADL's). Section-O (special treatments, procedures, and Programs) revealed Resident #61 received intravenous (IV) medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M. and 10:00 P.M.) for PICC line maintenance via the saline administration saline [MEDICATION(S)] (SASH) method. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M. and 10:00 P.M.) for PICC maintenance via SASH method. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M. and 10:00 P.M.) for [CONDITION(S)] related to [CONDITION(S)] of vertebra, sacral and sacrococcygeal region. Review of the plan of care for Resident #61 dated 03/23/21 revealed resident had compromised skin integrity due to sacral [CONDITION(S)] and received IV antibiotics. Interventions included administer medications as ordered. Review of March 2021 Medication administration records (MAR) for Resident #61 revealed no documented evidence resident received ordered [MEDICATION(S)] on 03/23/21 at 10:00 P.M. March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of April 2021 MAR for Resident #61 revealed no documented evidence resident received ordered [MEDICATION(S)] Solution IV medication on 04/12/21, 04/13/21 and 04/15/21 at 6:00 A.M. and 04/19/21 at 10:00 P.M. MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 04/19/21 at 10:00 P.M. Review of he April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., and 04/19/21 at 10:00 P.M. Further review of April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 04/04/21 04/05/21, 04/07/21 and 04/14/21 at 10:00 P.M. Review of the April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., and 04/04/21 04/05/21, 04/07/21 and 04/14/21 at 10:00 P.M. Review of nurse's progress notes for Resident #61 from 03/22/21 through 04/15/21 revealed no documented evidence the resident refused IV antibiotics and PICC line flushes or other reasons why resident missed her ordered antibiotic medications and PICC line flushes on the above dates and times. Nurses progress notes also revealed no documented evidence any additional staff member(s) administered IV medications on the dates listed above. Interview with Director of Nursing (DON) on 04/22/21 at 3:00 P.M. verified Resident #61's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON also verified LPN #87 documented she administered IV medications and IV flushes to Resident # 61 on the dates and times recorded above. DON further verified LPN #87 did not have a certification attached to her LPN license which permitted her to administer IV medications. Interview with LPN #87 on 04/22/21 at 4:01 P.M. verified her LPN license did not contain a certification for administering IV medications. LPN #87 further stated she did not administer the IV medications to Resident #61. LPN #87 stated she may have seen the doses were open on the electronic medical records (EMR) and clicked on them to close out the doses. LPN #87 stated she did not know who administered the IV medications and/or if the medications were administered when she documented they were given. Review of job description for LPN #87 dated 09/05/17 revealed staff nurses were responsible for providing total quality care to all residents in a professional and timely manner while meeting quality nursing practice standards and the standards of state and federal regulatory agencies. Review of online resources Ohio elicense Ohio Professional license at https://elicense.ohio.gov/oh_verifylicense revealed LPN #87 had an active, unrestricted LPN license for medications with no certifications for IV medications. Review of a facility policy titled Catheter Insertion and Care dated 12/01/13 revealed midline and central line IV catheters will be flushes to maintain patency; to prevent mixing of compatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. Policy also revealed under general guidelines, indicated staff were to consult State Nurse Practice Act for Registered Nurse (RN)/LPN scope of practice and functions. Review of 02/05/20 facility policy titled Medication Administration revealed medications will be administered in a safe and effective manner.

Based on record review, staff interview, and review of the facility policy, the facility failed to notify resident physician of elevated resident blood sugar. This affected one (#3) of seven residents reviewed for unnecessary medications. Additionally, the facility failed failed to ensure the facility physician or advanced provider was notified when a resident had a weight gain of five pounds. This affected one (#241) of three residents reviewed. Facility census was 86. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 04/02/21 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #3 dated 11/16/18 revealed the resident had diabetes mellitus and received insulin and was at risk for hyper/hypoglycemic episodes and secondary complications related to the disease process or potential for adverse effects related to medication usage. Interventions included the following: diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by the doctor. Review of the March 2021 monthly physician orders for Resident #3 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., routine [MEDICATION(S)] insulin to be given at 9:00 P.M. and to check the residents blood sugar (BS) at 6:00 A.M. and 9:00 P.M. daily and call physician if blood sugar is less than 60 or greater than 350. Review of the March 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. -BS of 364; 03/05/21 at 9:00 P.M. -BS of 368; 03/15/21 at 9:00 P.M. -BS of 369; and 03/18/21 at 9:00 P.M.-BS of 387. Review of the March 2021 MAR for Resident #3 revealed no blood sugar was recorded on 03/12/21 at 6:00 A.M. on 03/18/21 at 6:00 A.M. Review of the nurse progress notes for Resident #3 dated 03/03/21 through 03/18/21 revealed the notes contained no documentation regarding a call to the physician regarding blood sugars over 350 for Resident #3. The notes contained no documentation regarding a rationale for no blood sugar recorded for 03/12/21 and 03/18/21 at 6:00 A.M. Interview on 04/22/21 at 2:30 P.M. with the Director of Nursing (DON) confirmed Resident #3's record did not reflect physician notification of blood sugars over 350 nor did they reflect an explanation for no blood sugar obtained on 03/12/21 and 03/18/21. Review of the facility policy titled Change of Resident Condition dated 01/2021 revealed the facility staff would notify the resident's attending physician of a change in condition and the nurse would document notification of changes in the medical record. 2. Review of the medical record for Resident #241 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed MDS assessment dated [DATE] revealed Resident #241 was cognitively intact, had no behaviors, did not reject care, did not wander, was one person assist and required extensive and limited ADL's. Review of baseline plan of care for Resident #241 dated 04/09/21 revealed resident had CHF and was to be weighed as ordered. Review of physician orders for Resident #241 dated 04/09/21 revealed the resident was ordered to be weighed daily in morning before breakfast and physician was to be notified for weight gain greater than three pounds in 24 hours or five pounds in one week related to CHF. Physician orders also revealed no documented orders or new interventions for five-pound weight gain from 04/10/21 through 04/12/21. Review of weights reveled resident weighed 97 pounds on admission on 04/10/21 and 102 pounds at the next recorded weight on 04/12/21. Nurses notes also revealed no documented evidence the physician or advanced provider was notified when resident had a five-pound weight gain from 04/10/21 to 04/12/21. Interview with Director of Nursing (DON) on 04/22/21 at 2:50 P.M. verified there was no documented evidence Residents #241's physician was not notified of a weight gain of five pounds from 04/10/21 to 04/12/21. Review of a facility policy titled Weight Changes dated 01/25/21 revealed changes in weight will be monitored, addressed and communicated to the physician without detriment to the resident. The policy indicated when weight changes were indicated, physician was to be notified.

Based on medical record review and staff interview, the facility failed to send a copy of the transfer or discharge notice to the Ombudsman for a resident that discharged to the hospital. This affected one (#73) out of three residents reviewed for hospitalization s. The facility census was 86. Findings include: Record review of Resident #73's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; [CONDITION(S)], unspecified fracture of lower end of left radius initial encounter for closed fracture, Alzheimer's disease, unspecified dementia with behavioral disturbance, essential hypertension, generalized anxiety disorder, irritable bowel syndrome without diarrhea, and nutritional deficiency. Review of Resident #73's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be severely cognitively impaired and required limited assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #73 also required supervision with transfers and eating. Review of Resident #73's progress note dated 03/30/21 revealed Resident #73 was discharged to the hospital on 03/30/21 after having a fall with wrist pain. Further review of Resident's progress note dated 03/30/21 revealed Resident #73 readmitted to the facility on from the hospital on this date. Review of Resident #73's notice of transfer or discharge date d 03/30/21 revealed Resident #73's resident representative was notified of Resident #73's discharge from the facility on 03/30/21. There was no documentation that the Ombudsman was notified or was sent a copy of Resident #73's transfer or discharge notice for his 03/30/21 hospitalization . Review of Resident #73's progress note dated 04/07/21 revealed Resident was transferred to the hospital on 04/07/21. Further review of Resident #73's progress note dated 04/09/21 revealed Resident #73 returned to the facility from the hospital on 04/08/21. Review of Resident #73's notice of transfer or discharge date d 04/07/21 revealed Resident #73's resident representative was notified of Resident #73's discharge from the facility on 04/07/21. There was no documentation that the Ombudsman was notified or was sent a copy of Resident #73's transfer or discharge notice for his 04/07/21 hospitalization . Interview with the Administrator on 04/21/21 at 12:57 P.M. revealed the Administrator last notified the Ombudsman of transfers and discharges from the facility on 02/16/21. The Administrator confirmed the Ombudsman was not notified of Resident #73's discharge/transfer to the hospital on 03/30/21 and 04/07/21.

Based on record review, staff interview and review of facility policy, the facility failed to ensure residents were weighed according to physician orders. This affected two (#1 and #241) of the three residents reviewed. Facility census was 86. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, had no behaviors, did not reject care, did not wander, was one person assist and required extensive and limited assistance with activities of daily livings (ADL's). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's progress notes for Resident #1 from 03/30/21 through 04/20/21 revealed no documented evidence resident refused to be weighed or other documented reasons why resident was not weighed as ordered. Review of the plan of care for Resident #1 dated 03/31/21 revealed resident had potential for nutritional problem related to CHF and medications (Lasix) may cause weight fluctuations. Interventions included weigh resident as ordered. Review of weights for Resident #1 revealed no documented evidence resident was weighed on 04/05/21, 04/10/12, 04/11/21, 04/15/21, and 04/17/21. Review of weights from 03/21/21 through 04/19/21 revealed resident weighed 110 pounds on admission, and 106 pounds on 04/19/21. Review of April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Registered Dietician (RD) notes for Resident #1 dated 04/07/21 revealed resident was on regular diet, underweight, and had weight fluctuations due to CHF and diuretics. Notes indicated the RD's plan included resident to be weighed as ordered. 2. Review of the medical record for Resident #241 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed MDS assessment dated [DATE] revealed Resident #241 was cognitively intact, had no behaviors, did not reject care, did not wander, was one person assist and required extensive and limited ADL's. Review of baseline plan of care for Resident #241 dated 04/09/21 revealed resident had CHF and was to be weighed as ordered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's progress notes for Resident #241 from 04/09/21 through 04/22/21 revealed no documented evidence resident refused to be weighed or other indications why resident was not weighed as ordered. Review of weights for Resident #241 revealed no documented evidence resident was weighed on 04/10/21, 04/11/21, 04/14/21, 04/15/21, 04/17/21, 04/18/21, 04/19/21, and 04/20/21. Review of April 2021 MAR for Resident #241 revealed no documented evidence resident was weighed on 04/10/21, 04/11/21, 04/14/21, 04/15/21, 04/17/21, 04/18/21, 04/19/21, and 04/20/21. Review of RD notes for Resident #241 dated 04/12/21 revealed resident was on regular diet, underweight and had daily weights due to CHF. RD notes indicated resident would be weighed daily as ordered. Interview with Director of Nursing (DON) on 04/22/21 at 2:50 P.M. verified there was no documented evidence Residents #1 and #241 were weighed in accordance with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility policy titled Weight Changes dated 01/25/21 revealed changes in weight will be monitored, addressed and communicated to the physician without detriment to the resident.

Based on medical record review, observation and resident and staff interview the facility failed to ensure residents wore splints as ordered by the physician to treat contractures. This affected one (#25) of three residents reviewed for limited range of motion. The census was 86. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 02/03/21 revealed resident was cognitively intact, required extensive assistance of two staff with activities of daily living (ADL's) and had contractures to her upper extremities. Review of the care plan for Resident #25 dated 02/09/21 revealed resident had an ADL self-care performance deficit due to [CONDITION(S)] (CVA) with left [CONDITION(S)], limited ROM, muscle weakness, and left hand contracture. Interventions included resident was to wear a palmar grip splint in left hand at all times except for hygiene and bathing. Review of the care plan for Resident #25 dated 02/05/21 revealed resident had a behavior problem and behaviors included refusal to wear left hand splint at times. Interventions included the following: explain all procedures before starting and allow the resident an appropriate amount of time to adjust to changes and upon resistance to care reapproach after appropriate amount of time. Review of the occupational therapy (OT) note for Resident #25 dated 02/01/21 revealed resident tolerated wearing of left hand splint Review of the occupational therapy (OT) note for Resident #25 dated 02/02/21 revealed resident was compliant in wearing splint to her left hand Review of the occupational therapy (OT) note for Resident #25 dated 02/03/21 revealed resident told therapist she planned to wear her left hand splint for 24 hours every day to prevent further contracture to her hand, but therapist recommended resident remove splint for hygiene and bathing and resident agreed. Review of the occupational therapy note for Resident #25 dated 02/17/21 revealed therapist donned resident's left hand splint and educated resident to ask for staff assistance with donning splint if they did not offer to don splint. Review of the occupational therapy (OT) discharge summary for Resident #25 dated 02/19/21 revealed Resident #25 was wearing her left hand splint consistently and the therapy discharge recommendations were always for resident to wear the left hand splint except for hygiene and bathing. Review of the April 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April 2021 Treatment Administration Record (TAR) for Resident #25 revealed it contained no documentation regarding splint to resident's left hand. Observation on 04/19/21 at 8:47 A.M. of Resident #25 revealed resident's left hand was contracted and there was no splint or device in place. Resident was feeding herself breakfast with her right hand. Interview on 04/19/21 at 8:48 A.M. with Resident #25 confirmed her left hand was contracted related to a prior stroke. Resident #25 further confirmed she was supposed to wear a left hand splint at all times except for bathing Resident #25 confirmed she was not able to don the splint without assistance and no one had offered to place her splint on. Observation on 04/19/21 at 1:30 P.M. of Resident #25 revealed resident in the hallway in her wheelchair and was not wearing her hand splint. Interview on 04/19/21 at 1:30 P.M. with Licensed Practical Nurse (LPN) #104 confirmed Resident #25 was not wearing her splint. LPN #104 further confirmed the resident was supposed to wear the splint at all times to prevent further contracture to the left hand, but the facility did not have a written record of splint application Interview on 04/21/21 at 12:39 P.M. with Occupational Therapist (OT) #114 confirmed Resident #25 was discharged from therapy on 02/19/21 with recommendations to wear a left hand palmar grip splint at all times except for bathing and hygiene to prevent further contracture to her left upper extremity. OT #114 confirmed Resident #25 could not don the splint independently. Observation on 04/21/21 at 1:30 P.M. of Resident #25 revealed resident was in her room watching television and did not have her splint on. Interview on 04/21/21 at 1:30 P.M. with Resident #25 confirmed she did not have her splint on, and no one had offered to put the splint on her. Observation on 04/21/21 at 4:27 P.M. of Resident #25 revealed resident was wearing her left hand splint. Interview on 04/21/21 at 4:28 P.M. with State tested Nursing Assistant (STNA) #40 confirmed she had placed Resident #25's splint on her left hand a couple hours prior to the interview on 04/21/21. STNA #40 confirmed the facility did not have a record of splint application for Resident #25. STNA #40 further confirmed Resident #25 was supposed to wear the splint at all times removing only for showering. Interview on 04/22/21 at 2:30 P.M. with the Director of Nursing (DON) confirmed Resident #25's medical record contained no documentation regarding donning and doffing of splint to left hand and/or regarding resident refusals of splint.

Based on observation, medical record review, staff interview and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed ensure pressure ulcer interventions were in place resulting in Actual Harm when Resident #33 developed multiple avoidable pressure ulcers on the left heel including the development of a suspected deep tissue injury (SDTI) and the subsequent development of a a Stage 2 Pressure Ulcer. Additionally, the facility failed to accurate identify Resident #33's pressure ulcer upon discovery, failed to accurately assess Resident #33's skin wounds including measurements upon discovery and failed to have a pressure ulcer policy and procedure in place. This affected one (#33) out of three residents identified as having pressure ulcers. Facility census was 104. Findings include: Resident #33 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status of a three out of 15 indicating severe cognitive impairment. She usually made herself understood, sometimes understood others, but was severely impaired for daily decision making. She displayed signs of [MEDICAL CONDITION] such as fluctuating inattention. She had verbal behaviors directed toward others one to three days of the seven day assessment. She did not have signs of [MEDICAL CONDITION], reject care, or wander. Resident #33 required total dependence of two staff for bed mobility. The MDS documented she was at risk for pressure ulcers but she did not have any pressure ulcers and did not have any other skin wounds. Review of Resident #33's impairment of skin integrity care plan dated 07/11/16 documented interventions to float heels, pressure reduction mattress, off load heels while in bed, and skin prep to left heel scabbed area as ordered on [DATE]. Review of Resident #33's medical record revealed the following documentation: - 09/06/17 Nurses Note documented blood blister found on left heel. - 09/07/17 Nurses Note documented re-absorbing blood blister to left heel. - 09/12/17 Wound Specialist documented abrasion on the left heel. - 09/18/17 Wound Specialist documented abrasion to left heel resolved. - 10/07/17 Nurses Note documented previously healed blood blister to left heel now has superficial less than one centimeter (cm) red open area. Resident complains of discomfort. - 10/08/17 Nurse Note documented left heel dressing change with scant amount of blood. complained of discomfort. - 10/10/10 Wound Specialist documented abrasion/mechanical irritation to the left heel possibly from shoes. Measured 0.2 cm by 0.5 cm with 0.1 cm depth - 10/12/17 Nurses Note documented the resident complained area was sore during the wound treatment - 10/14/17 Nurses Note documented a purple unopened area was found on the resident's buttock. There were not any measurements. - 10/17/17 Wound Specialist documented abrasion/mechanical irritation to left heel remains, possibly from shoes. Patient present with tinea cruris to bilateral buttocks. -10/24/17 Wound Specialist document the left heel abrasion was healed. - 11/14/17 Wound Specialist documented documented the resident continues with an intact callus to the left foot. - 11/15/17 at 4:03 P.M. Nurses Note documented left heel abrasion resolved. New area identified to left lateral heel, abrasion. There were no measurements. Observation on 11/15/17 at 10:25 A.M. with Nurse Aide (NA) #203 revealed the resident was lying in bed with a pillow under her knees and lower legs. Both heels were still on the mattress. NA #203 stated they off load her heels but admitted both heels were still on the mattress. He adjusted the pillows to raise her heels off the mattress. Her left heel had a small purplish red calloused area. Right heel was unremarkable. NA #203 stated its the nurses and not the NA's that put skin protectant on her heel. Observations on 11/15/17 at 10:35 A.M. Licensed Practical Nurse (LPN) #200 was called into Resident #33's room. She applied skin protectant to the resident's left heel. LPN #200 stated a callous did not necessarily mean a SDTI. She stated normally a SDTI are very painful and the resident was not in any pain. LPN #200 described the area on Resident # 33's heel as calloused and discolored, scarlet and purple. Observation with LPN #200 on 11/15/17 at 3:06 P.M. of Resident #33 in bed revealed Resident #33 was on a scooped perimeter mattress. LPN #200 stated the resident should be on a pressure mattress but was not. She stated she was on a perimeter mattress instead. LPN # 200 stated the discoloration on Resident #33's heel was new today. She stated that she had worked and done her treatment the last three days and today was the first time she had seen the discoloration. Interview with LPN #204 on 11/15/17 at 3:20 P.M. stated Resident # 33 now had a new area on her left heel. She stated she had the discolored calloused area yesterday but today they found a new abrasion. She did not think a callous was a pressure ulcer or a SDTI according to the MDS but stated according to the Nurse Practitioner (NP) it wasn't. LPN #204 stated a blood blister was a pressure ulcer. She reviewed the medical record and agreed the resident had a blood blister on 09/07/17. She also agreed five days later when the NP seen the blood blister area that she documented it was an abrasion. LPN #204 stated the facility goes with what the NP says and documents. She stated in the case the wound was named an abrasion by the NP. Observation on 11/16/17 at 9:15 A.M. of Resident # 33's wound care treatment performed by LPN #204 revealed the resident had two areas on the left heel. LPN #204 described the new area discolored with some tissue loss in the center. She stated as with she measured the new wound as 2.0 cm by 1.6 cm discolored with some tissue loss in the center. She stated it appeared as an abraded area meaning it rubbed against something. She agreed rubbing against something meant pressure. The new discolored wound measured 2.0 centimeters (cm) by 1.6 centimeters. She did not measure depth but stated some tissue loss in the center of the wound. She described the old area as measuring 0.3 cm by 0.5 cm with intact, firm, callous skin. She admitted the old wound had started as a blister. She agreed a blister was a Stage 2 pressure ulcer per the MDS assessment. She stated she doesn't name/characterized the wound, only the Nurse Practitioner (NP) does. She stated the NP did not call the blister a pressure ulcer but a mechanical abrasion. LPN #204 explained a mechanical abrasion as coming into contact with something. She stated in this case it would be the mattress. She agreed that wounds were not always measured or described in great detail upon finding them. She stated sometimes they wait until the wound NP came to measure them and document the details. Interview with the Director of Nursing (DON) on 11/16/17 at approximately 2:00 P.M. stated the facility did not have policy or procedures for pressure ulcers or other skin wounds. He stated they went with what the wound NP said and wanted. He stated they had standing orders pertaining to wounds but he did not produce them when asked for a copy of the standing orders. The DON produced a document from the NPUAP that was titled Friction Induced Skin Injuries that was dated 11/20/14 and documented the skin injuries caused by friction are not to be considered pressure ulcers. When asked, the DON stated the MDS assessment had been upgraded in 2014 and still included that pressure ulcer was defined as localized injury to the skin or underlying tissues usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. Further review of current information from the NPUAP revealed Stage 2 Pressure Injury are partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Further review of the NPUAP revealed a Deep Tissue Pressure Injury is persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. According to the NPUAP staff should ensure that the heels are free from the bed and to use heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers.