Every finding on record at Lutheran Home

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored in a sanitary manner. Additionally, the facility failed to ensure the high-temperature dishwasher reached adequate temperatures to ensure disinfection of dishes. Finally, the facility failed to ensure food was served in a sanitary manner. This affected all residents except one (Resident #1) who was identified by the facility as receiving no food by mouth. The facility census was 27.Findings include:1. Observation on 07/20/26 at 7:45 A.M. of the dry storage area of the kitchen revealed a box of sweet potatoes on top of the can storage rack. One sweet potato had a black fuzzy substance on the surface and when the box was touched, several gnats flew out.Observation on 07/20/26 at 7:50 A.M. of the walk-in cooler revealed one box of five individually wrapped cucumbers labeled as received on 06/19/26 that were mushy when touched. The following containers were opened and undated: a half-full 46-ounce box of thickened pomegranate-berry juice, a half- full 46-ounce box of thickened apple juice, a nearly full 46-ounce box of prune juice, and a one-quarter full 46-ounce box of thickened lemon water. Further observation revealed a one half-full 46-ounce box of thickened orange juice dated 05/04/26. There was a half-full two-gallon round plastic container with an unknown red substance dated 07/10/26 and not labeled with the contents and an eight-pound plastic container of fruit salad was opened and undated, with an expiration date of 07/11/26. Subsequent interview with Dietary Manager (DM) #21 verified the findings. DM #21 stated expired foods should be disposed of and food items should be dated and labeled.Observation on 07/20/26 at 8:15 A.M. of the refrigerator located across from the nurses' station on the 200-hall revealed one opened 32-ounce box of almond milk dated 10/31, one opened and undated eight ounce container of dirty soda coffee creamer, five undated four-ounce boxes of vanilla nutritional shakes, one opened and undated 46-ounce box of prune juice, one gallon zipper baggie containing three-quarters of a brown loaf that was unlabeled and undated, one opened and undated 10.5-ounce bottle of unsweet tea, and one opened can of extra creamy whipped topping with an expiration date of 04/26/26. Subsequent interview with DM #21 verified the findings and confirmed food items should be labeled and dated.Observation on 07/20/26 at 10:34 A.M. of the food storage area across from the 200-hall nurses' station revealed an opened and undated five-pound jar of peanut butter. Additionally, there was a 16-ounce bag of potato chips, a 16-ounce bag of tortilla chips, and a seven-ounce box of cheese crackers that were opened and undated.Interview on 07/20/26 at 10:42 A.M. with Certified Nurse Assistant (CNA) #40 confirmed the above findings at the food storage area across from the 200-hall nurses' station. CNA #40 verified the food was for resident consumption and further stated she was unsure of who maintained the food in the area. Interview on 07/21/26 at 8:00 A.M. with DM Manager #21 revealed food items brought into the facility by residents were to be labeled with the date it was brought in and an expiration date of five to seven days after. Continued interview revealed opened food items in the kitchen were to be labeled with the date opened, what the food item was, and an expiration date.Review of facility policy titled Food Storage, dated July 2026, revealed the facility would date items when they were opened.Review of facility policy titled Food Brought Into Facility, dated 06/09/22, revealed food items would be properly labeled.2. Observation on 07/20/26 at 8:00 A.M. of the high-temperature dishwasher revealed the wash cycle reached 158 degrees Fahrenheit (F) and the rinse cycle reached 170 F. Further observation of the labels on the dishwasher revealed the wash temperature should reach 160 F and the rinse temperature should reach 180 F. Subsequent interview with DM #21 verified the wash and rinse temperatures and stated the temperatures were not high enough to disinfect the dishware. 3. Observation on 07/20/26 at 12:25 P.M. of Dietary [NAME] (DC) #18 preparing a plate of food for the lunch meal. DC #18 touched the surface of the steam table and a plate with her gloved hands. She then retrieved a hot dog bun with her contaminated gloved hand. Utilizing a fork, DC #18 then retrieved a hot dog and used her contaminated gloved hand to remove the hot dog from the fork and place it into the bun. Continued observation revealed DC #18 began preparing a second plate, still wearing the same gloves. DC #18 retrieved a hot dog bun with her contaminated gloved hand and placed it on the plate. DC #18 then used a fork to pick up a hot dog and used her contaminated gloved hand to pick up the hot dog bun to place the hot dog into the bun. Subsequent interview with DM #21 confirmed DC #18 touched food with her gloved hand, after touching non-food items, and should not have done so. Further observation revealed DM #21 provided verbal instruction to DC #18 to not touch food directly contaminated gloved hands.Review of the facility policy titled, Sanitation Procedure-Serving, dated July 2026 revealed the facility would serve food safely to prevent contamination.

Based on observation and staff interview, the facility failed to ensure kitchen trash were covered. This affected all residents except for one (#1) resident who was identified by the facility as receiving no food by mouth. The facility census was 27.Findings include:Observation on 07/20/26 at 8:05 A.M. of the kitchen area revealed three 30-gallon trash cans without lids. One can was located next to the pot storage and was half full of garbage, one can was located next to the stove and was one-quarter full of garbage, and one can was located by the handwashing station and was one-quarter full of garbage.Interview on 07/20/26 at 8:06 A.M. with Dietary Manager #21 confirmed the trash cans did not have lids on them and they should be covered.Interview on 07/20/26 at 3:20 P.M. with the Administrator revealed the facility did not have a policy to address the need for trash cans to be covered.

Based on medical record review, staff interview and policy review, the facility failed to notify the physician when a prescribed medication was not administered in accordance with physician orders due to a change in condition. This affected one (#13) of one resident reviewed for notification of changes. The facility census was 27.Findings include:Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included dementia, cognitive communication deficit, anxiety disorder and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/26, revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive deficit. The resident exhibited no behaviors, required substantial assistance with eating, and was dependent on others for all other activities of daily living (ADL). Review of the physician order dated 01/13/26 revealed Resident #13 was ordered lorazepam (anti-anxiety medication) one milligram (mg) to be given by mouth three times a day related to anxiety disorder. Additionally, Resident #13 was to be observed closely for significant side effects of anti-anxiety medication, including drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior. Review of the revised care plan, dated 06/15/26, revealed Resident #13 was to be monitored for adverse reactions to anti-anxiety therapy, which included drowsiness, lack of energy, clumsiness and slow reflexes. Review of the Medication Administration Record (MAR) for July 2026 revealed lorazepam was not administered to Resident #13 on 07/20/26 at 1:00 P.M. and 9:00 P.M. and on 07/21/26 at 5:00 A.M.Review of the nursing progress notes from 07/20/26 through 07/21/26 revealed no evidence Resident #13's physician was notified that lorazepam was not administered on 07/20/26 at 1:00 P.M. and 9:00 P.M. and 07/21/26 at 5:00 A.M.Interview on 07/21/26 at 2:05 P.M. with the Director of Nursing (DON) confirmed lorazepam was not administered to Resident #13 on 07/20/26 at 1:00 P.M. and 9:00 P.M. and 07/21/26 at 5:00 A.M. due to excessive sedation. Further interview with the DON verified there was no evidence the physician was notified. Review of the facility policy titled, Medication Administration, dated May 2019, revealed the physician should be notified when medications were not given, refused or other then time scheduled. and the notification documented in the resident's chart.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure residents were free from chemical restraints. This affected one (#13) of five residents reviewed for unnecessary medications. The facility census was 27. Findings include:Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included dementia, cognitive communication deficit, anxiety disorder and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/26, revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive deficit. The resident exhibited no behaviors, required substantial assistance with eating and was dependent on others for all other activities of daily living (ADL). Review of a physician order dated 01/13/26 revealed Resident #13 had an order for lorazepam (anti-anxiety medication) one milligram (mg) to be given by mouth three times a day related to anxiety disorder. Additionally, Resident #13 was to be observe closely for significant side effects of anti-anxiety medication, including drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior. Review of the revised care plan, dated 06/15/26, revealed Resident #13 was to be monitored for adverse reactions to anti-anxiety therapy, which included drowsiness, lack of energy, clumsiness and slow reflexes. Further review of Resident #13's care plan revealed no non-pharmacological measures for staff to use to redirect resident when anxiety occurs. Observation on 07/20/26 at 10:05 A.M. revealed Resident #13 was in her wheelchair in the common area. Resident #13's eyes were closed and she appeared to be sleeping. Observation on 07/20/26 at 1:42 P.M. revealed Resident #13 was laid back in her wheelchair in the common area. The resident's eyes were closed and she appeared to be sleeping. Interview on 07/20/26 at 1:42 P.M. with Licensed Practical Nurse (LPN) #30 revealed Resident #13 was awake and talking the previous day. Observation on 07/21/26 at 7:15 A.M. revealed Resident #13 was sitting in her wheelchair at the dining table with her head down and eyes closed. Activities Director (AD) #2 came over and sat next to Resident #13, spoke the resident's name and touched her left arm. Resident #13 did not wake up with verbal or tactile stimulation. Observation on 07/21/26 at 10:33 A.M. revealed Resident #13 was lying back in her wheelchair near the nurses' station with her eyes closed. Resident #13 opened her eyes when her name was called. Observation on 07/21/26 at 11:46 A.M. revealed Resident #13 in her wheelchair sitting at the dining table. Resident #13 was leaning forward with her head resting on the dining table. Resident #13 lifted her head when her name was called and then sat back in her wheelchair with her head tilted back and eyes closed. Interview on 07/21/26 at 11:55 A.M., Registered Nurse (RN) #53 stated it seemed Resident #13 did not have control of her upper body. Concurrent observation of Resident #13 revealed the resident leaned her upper body forward and laid her head back onto dining table. Observation on 07/21/26 at 1:55 P.M. revealed Resident #13 was sitting in her wheelchair in the common area with her chin down to her chest and her eyes closed. Interview on 07/21/26 at 2:05 P.M. with the Director of Nursing (DON) verified Resident #13 had been sleeping a lot the past two days. The DON confirmed Resident #13 received scheduled lorazepam due to the resident continually trying to get out out her wheelchair, and other behaviors. IA follow-up interview on 07/21/26 at 4:00 P.M. with the DON verified the reason for using scheduled lorazepam for Resident #13 was to prevent the resident from getting out of her wheelchair. The DON stated the only non-pharmacological measure used prior to scheduling the use of lorazepam was a physical therapy consultation. The DON verified there were no further non-pharmacological measures attempted. Review of the facility policy titled, Restraints, last reviewed July 2026, revealed a chemical restraint was defined as a psychopharmacological drug that was used for discipline or convenience and not required to treat medical symptoms. Additionally, chemical restraints would not be used to limit or control resident behavior for the convenience of staff. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised December 2019, revealed residents had the right to be free from abuse, neglect, exploitation and misappropriation of resident property. This included, but not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that was not required to treat the resident's medical symptoms.

Based on medical record review, observations, staff interviews, resident interviews, and review of facility policy, the facility failed to ensure care and services in accordance with professional standards of practice for the management of edema. This affected one (Resident #21) of one resident reviewed for edema. The facility census was 27.Findings include:Review of the medical record for Resident #21 revealed she was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, lymphedema, and heart failure.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/26, revealed Resident #21 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a walker and a wheelchair independently and was independent with transfers. She was independent with all activities of daily living (ADLs). She had medically complex medical conditions including heart failure and lymphedema.Review of the care plan focus area initiated 01/19/26 revealed Resident #21 had fluid overload related to congestive heart failure (CHF), edema, and lymphedema. Interventions included to monitor and document any signs and symptoms of fluid overload, including sudden weight gain, and compression stockings on in the morning and removed at night as tolerated. Review of a physician order dated 03/27/25 revealed Resident #21 had an order for monthly weights. Further review revealed an order dated 03/03/26 for compression wraps to be applied during the day to her bilateral lower extremities. Review of weight monitoring from July 2025 through July 2026 revealed Resident #21's weights were obtained weekly in July 2025 and August 2025, monthly from September 2025 through December 2025, daily from 01/01/26 through 01/08/26, and then monthly from February 2026 through July 2026. Review of the nursing progress notes and nursing assessments from July 2025 through July 2026 revealed edema monitoring was noted on 02/15/26 and 03/22/26. Interview on 07/22/26 at 9:55 A.M. with Licensed Practical Nurse (LPN) #30 confirmed bilateral lower extremity edema and weights were not monitored daily for Resident #21.Interview on 07/22/26 at approximately 12:15 P.M. with the Director of Nursing (DON) confirmed there was no documentation of edema monitoring for Resident #21 and weights were only monitored monthly, adding both should be monitored more frequently with the resident's diagnoses of edema and heart failure.A follow-up interview on 07/22/26 at 2:00 P.M. with LPN #30 revealed standard interventions for residents with heart failure should include monitoring daily weights, edema, and blood pressure to ensure resident stability.Observation on 07/22/26 at 2:05 P.M. of Resident #21's room revealed her compression wraps were on the floor next to her chair and not applied to her bilateral lower extremities as ordered. Concurrent interview with Resident #21 revealed she had not been asked to have her weight monitored daily nor had she refused to have her weight monitored daily. Continued interview revealed she had not had her compression wraps applied on this day.Interview on 07/22/26 at 2:10 P.M. with Certified Nurse Assistant (CNA) #47 revealed she provided bathing assistance for Resident #21 earlier in the day. CNA #47 verified the resident's compression wraps were not on when she took her to the shower room, and the compression wraps were not applied after the shower.Interview on 07/22/26 at 2:15 P.M. with LPN #30 confirmed Resident #21's compression wraps were not on as ordered.

Based on medical record review and staff interviews, the facility failed to maintain pre and post-dialysis treatment communication with the dialysis center. This affected one (Resident #6) of one resident identified by the facility as receiving dialysis services. The facility census was 27.Findings include:Review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses including osteomyelitis of the left foot, non-pressure chronic ulcer of the left heel and midfoot, end stage renal disease, peripheral vascular disease, atrial fibrillation, and Type Two diabetes mellitus.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. Review of a physician order dated 05/23/26 revealed Resident #6 had dialysis on Mondays, Wednesdays, and Fridays.Review of the care plan for Resident #6 revealed an intervention dated 03/27/26 for dialysis related to end stage renal disease.Review of the dialysis treatment communication forms for Resident #6 revealed two forms, dated 04/17/26 and 07/17/26, had been obtained.Interview on 07/22/26 at 9:50 A.M. with Licensed Practical Nurse (LPN) #30 revealed she had not seen any dialysis treatment communication forms for Resident #6 and management was working on obtaining them. Interview on 07/22/26 at 11:30 A.M. with the Director of Nursing verified the facility did not maintain pre and post-dialysis treatment communication with the dialysis center and should have been.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure appropriate hand hygiene was performed during wound care. This affected one (Resident #6) of one resident observed for wound care. The facility census was 27.Findings include:Review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses including osteomyelitis of the left foot, non-pressure chronic ulcer of the left heel and midfoot, end stage renal disease, peripheral vascular disease, atrial fibrillation, and Type Two diabetes mellitus.Review of the Minimum Data Set(MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. Resident #6 had a diabetic foot ulcer.Review of a physician order dated 07/16/26 revealed Resident #6 had an order for negative pressure wound therapy to the diabetic wound on his right foot. Instructions included: cleanse the wound and peri-wound with soap and water, dry intact skin completely, soak the wound for five minutes in hypochlorous acid wound cleanser, apply skin prep and drape to the peri-wound, apply green foam to wound bed, set negative pressure wound therapy machine to 125 millimeters of mercury (mmHg), wrap with fluff gauze, and change every Tuesday and Friday.Observation on 07/21/26 at 2:15 P.M. of Registered Nurse (RN) #53 performing wound care for Resident #6 revealed she removed the soiled dressing from his right foot, removed her gloves, and did not perform hand hygiene prior to putting on new gloves and proceeding with the soak step of his wound care. Continued observation revealed she obtained the wound vac power supply from the floor, connected the power cord to the negative pressure wound therapy machine, removed her gloves, and did not perform hand hygiene prior to putting on new gloves and proceeding with placing the sponge in the wound bed.Interview on 07/21/26 at 3:00 P.M. with RN #53 and Unit Manager (UM) #69 confirmed hand hygiene was not performed between glove changes and should have been while completing wound care for Resident #6.Review of the facility policy titled, Clean Dressing Application, dated July 2026, revealed the procedure statement was to prevent infection in an open area. Further review revealed after removing and discarding soiled gloves, wash hands before applying new gloves.Review of the facility policy titled, Hand Hygiene, dated May 2020, revealed the policy statement was the facility considered hand hygiene the primary means to prevent the spread of infections. Further review revealed hand hygiene should be performed before applying sterile gloves and after removing gloves.

Based on observation, staff interview, and review of the menu spreadsheets, the facility failed to ensure residents received proper portions of protein and vegetables. This affected all 46 residents in the facility who receive food from the kitchen. Additionally, the facility failed to ensure residents on a pureed diet received proper portions of carbohydrate. This affected six (#2, #7, #19, #20, #32, and #36) residents identified on a pureed diet. The facility census was 46. Findings include: 1. Observation on 09/04/24 at 11:45 A.M. revealed [NAME] #157 taking temperatures of noon menu items. The chicken Philly sandwiches were already prepared with chicken, onion, and peppers portioned into the bun. Concurrent interview with [NAME] #157 stated another staff prepared the sandwiches. Interview on 09/04/24 at 11:52 A.M. with Dietary Manager (DM) #183 revealed the facility used an outside company to provide menus and spreadsheets. DM #183 stated the facility began with a new company in May 2024 and the new menus did not provide portion sizes on the spreadsheets; therefore, DM #183 did not know what portion of chicken and vegetables to provide in the chicken Philly sandwich. Interview on 09/04/24 at 12:03 P.M. with Dietary Aide (DA) #161 revealed she prepared the chicken Philly sandwich. DA #161 stated she grilled chicken slices, onions, and peppers together, then used a four-ounce scoop to portion the chicken-vegetable mixture into buns. DA #161 stated if the scoop seemed to have more vegetables than meat, she would sometimes add extra chicken to the sandwich. Interview and observation on 09/04/24 at 12:07 P.M. with [NAME] #157 revealed she already pre-portioned the cucumber salad into plastic containers. [NAME] #157 stated she used a two-and-two-thirds cup scoop to portion the cucumber salad. Observation of meal service on 09/04/24 beginning at 12:14 P.M. revealed [NAME] #157 serving one sandwich and one portion of cucumber salad to residents on a regular diet. Further observation revealed [NAME] #157 served one sandwich, with ground chicken and vegetables, with peas and carrots to residents on a mechanical soft diet, and served pureed soup, a pureed sandwich, and pureed chicken and vegetables to residents on a pureed diet. Observation and interview on 09/04/24 at 12:38 P.M. with [NAME] #157 revealed meal service was complete. [NAME] #157 verified the scoops she used during service were a three-and-one-fourth ounce scoop for pureed soup, a three-and-one-fourth ounce scoop for pureed sandwich, and a two-and-two-thirds ounce scoop for peas and carrots, and pureed peas and carrots. Interview on 09/04/24 at 12:40 P.M. with DM #183, with concurrent review of the menu and recipes revealed the chicken Philly sandwich should have included three ounces of chicken. Additionally, the recipe did not include peppers or onions. DM #183 confirmed she could not verify residents received three ounces of chicken in their sandwiches due to DA #161 using a four-ounce scoop to portion chicken mixed with onions and peppers. Further review of the menu with DM #183 revealed the cucumber salad portion should have been four ounces rather than the two-and-two-thirds ounces provided. There was no guidance for portions sizes or preparation methods for mechanical soft or pureed items. Follow-up interview on 09/04/24 at approximately 3:30 P.M. with DM #183 revealed she received a spreadsheet with portion sizes for mechanical soft and pureed menu items from the outside company who provided their menus. Concurrent review of the menu spreadsheet revealed residents on a mechanical soft diet should have received one chicken Philly sandwich with ground meat and four ounces of soft cucumber salad. DM #183 again confirmed she could not verify the portion of protein provided in the mechanical soft chicken Philly sandwich, and confirmed residents on a mechanical soft diet did not receive four ounces of cucumber salad, or four ounces of alternative vegetable. The spreadsheet revealed residents on a pureed diet should receive six ounces of pureed vegetable garden soup, four ounces of pureed chicken Philly cheesesteak and four ounces of pureed cucumber salad. DM #183 confirmed no recipe was provided for pureed chicken Philly cheesesteak and therefore she could not verify what portion of protein or carbohydrate residents on a pureed diet should have received. Additionally, DM #183 confirmed residents on a pureed diet did not receive four ounces of vegetables. 2. Observation and interview on 09/04/24 at 10:04 A.M. revealed [NAME] #157 preparing pureed chicken Philly sandwich for six residents on a pureed diet for the noon meal. [NAME] #157 placed a large, unmeasured portion of grilled chicken, onions, and vegetables with two sandwich rolls into the blender. [NAME] #157 used cheese sauce to thin the mixture to an appropriate consistency. [NAME] #157 confirmed she used two rolls for six residents to help thicken the mixture. Observation after meal service was completed on 09/04/24 at 12:38 P.M. revealed some pureed chicken/vegetable/bread mixture remained in the pan. Interview and concurrent review of the menu, spreadsheet, and recipes with DM #183 on 09/04/24 at approximately 3:30 P.M. confirmed she did not have a recipe for preparing pureed chicken Philly sandwich and could not verify residents on a pureed diet were served the appropriate portions of carbohydrate. Additionally, DM #183 confirmed the pureed preparation made by [NAME] #157 with an unmeasured amount of chicken and vegetables with two rolls was not adequate to provide the expected portion of one roll per person.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for oxygen use and upon discharge. This affected three (#15, #18, and #199) of 17 residents reviewed for MDS assessments. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD). Review of a physician order initiated 05/30/24 and discontinued 06/04/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. The physician order initiated 06/04/24 and discontinued 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four LPM via NC every shift. Review of the comprehensive MDS admission assessment dated [DATE] revealed Resident #18 did not receive oxygen therapy. Interview on 09/04/24 at 3:32 P.M. with MDS Coordinator #184 confirmed the MDS assessment completed 06/06/24 for Resident #18 was coded incorrectly and should have reflected Resident #18 received oxygen therapy. 2. Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on 08/25/24, and returned to the facility on [DATE]. Review of a physician order initiated 08/16/24 and discontinued 08/29/24 revealed Resident #199 received oxygen via NC at two to three LPM every shift. Review of the comprehensive MDS assessment, dated 08/23/24, revealed Resident #199 did not receive oxygen therapy. Interview on 09/04/24 at 3:32 P.M. with MDS Coordinator #184 confirmed the MDS assessment completed 08/23/24 for Resident #199 was coded incorrectly and should have reflected Resident #199 received oxygen therapy. 3. Review of the medical record for Resident #15 revealed an admitted [DATE] and discharged to the hospital on 03/26/24. Review of the discharge MDS assessment dated [DATE] revealed Resident #15 discharged on [DATE]. There was an additional MDS assessment dated [DATE] indicating a five-day MDS assessment was also completed on 03/26/24 and submitted on 04/08/24. Interview 09/03/24 at 4:22 P.M. with MDS Coordinator #184 confirmed Resident t#15 discharged on [DATE] and did not return to the facility. MDS Coordinator #184 confirmed the five-day MDS assessment submitted on 04/08/24 was submitted in error.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a baseline care plan reflected a resident's use of oxygen needs. This affected one (#199) of one resident reviewed for a baseline care plan. The facility census was 46. Findings include: Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on 08/25/24, and returned to facility on 08/29/24. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/23/24, revealed Resident #199 had impaired cognition. Review of a physician order dated 08/29/24 revealed Resident #199 received oxygen at six liters per minute (LPM) via nasal cannula (NC) every shift. Review of the baseline care plan for Resident #199 revealed nothing regarding his reliance on continuous oxygen therapy. Interview on 09/05/24 at 11:31 A.M. with the Director of Nursing (DON) confirmed Resident #199's baseline care plan did not reflect his need for oxygen. Review of the policy titled Comprehensive/Baseline Care Plan, reviewed 06/2023, revealed the baseline care plan would be the temporary working care plan until the comprehensive care plan was completed.

Based on observation, record review, family and staff interviews, and review of the facility policy, the facility failed to ensure oxygen was administered per physician order. This affected two (#18 and #199) of two residents reviewed for oxygen use. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD). Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition and did not reject care. Review of a current physician order initiated 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. Observation on 09/03/24 at 1:54 P.M. revealed Resident #18 sitting in his wheelchair near the nurse's station. Resident #18's oxygen NC was applied and the oxygen tank gauge needle indicated the tank was empty. Interview on 09/03/24 at 1:55 P.M. with Licensed Practical Nurse (LPN) #200 verified Resident #18's oxygen tank gauge indicated the tank was empty and needed to be replaced. Observation on 09/04/24 at 7:49 A.M. revealed Resident #18 sitting in his wheelchair in the dining room. Resident #18 was wearing a NC connected to an oxygen tank in the carrier on the back of his wheelchair. Further observation revealed the oxygen tank gauge indicated the tank was empty. Interview and observation on 09/04/24 at 7:50 A.M. with LPN #194 confirmed Resident #18's oxygen tank was empty. LPN #194 stated Resident #18 used approximately five tanks of oxygen daily. 2. Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on 08/25/24, and returned to facility on 08/29/24. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/23/24, revealed Resident #199 had impaired cognition. Review of a physician order dated 08/29/24 revealed Resident #199 received oxygen at six LPM via NC every shift. Interview on 09/03/24 at 11:16 A.M. with Resident #199's family member revealed she was concerned because she observed Resident #199 sitting in his recliner in his room while his oxygen NC remained on his bed. Resident #199's family stated they placed the NC on Resident #199. Observation and interview on 09/05/24 at 7:31 A.M. with LPN #204 confirmed Resident #199 was lying in bed on his back and the NC was not in place. Further observation and interview with LPN #204 revealed Resident #199's NC was under him. Interview on 09/05/24 at 7:33 A.M. with State tested Nurse Aide (STNA) #196 revealed her shift began at 6:30 A.M. and she had not yet provided care to Resident #199. Interview on 09/05/24 at 7:34 A.M. with STNA #205 revealed her shift began at 6:30 A.M. and she had not yet provided care to Resident #199. Review of the policy titled Oxygen Administration, dated 07/2022, revealed oxygen was provided to facilitate breathing and oxygen should be provided at the prescribed amount.

Based on medical record review, family and staff interviews, and review of the facility policy, the facility failed to ensure the medical record reflected a change in condition. This affected one (#20) of 13 residents reviewed for medical record accuracies. The facility census was 46. Findings include: Review of the medical record for Resident #20 revealed a readmitted [DATE] with diagnosis including dementia. Review of the nursing progress notes dated 04/05/24 revealed a note dated 04/05/24 at 6:43 A.M. stating Resident #20 had a reddened area on her right hip and the physician was notified. The progress note dated 04/06/24 at 11:24 P.M. revealed Resident #20 was admitted to the hospital for bradycardia. There was no documentation of Resident #20 having a change in condition on 04/06/24, the physician being notified of the change in condition on 04/06/24, and the physician ordering to send Resident #20 to the emergency roiagnom on [DATE]. Review of the hospital records for Resident #20 revealed she was admitted to the Emergency Department (ED) on 04/06/24 at 5:25 P.M. and was discharged from the hospital on 04/07/24. Review of a progress note dated 04/07/24 at 12:24 A.M. revealed Resident #20's hospital admitting diagnoses were updated to include altered level of consciousness, hypoglycemia, urinary tract infection, congestive heart failure, and medication effect. Telephone interview on 09/03/24 at 2:51 P.M. with Resident #20's daughter revealed she was notified regarding Resident #20's 04/06/24 hospital admission. Interview on 09/04/24 at 3:04 P.M. with the Director of Nursing (DON) confirmed Resident #20's electronic medical record contained no details regarding the change in condition leading to her hospitalization on [DATE]. The DON further stated she would expect a progress note detailing the change in condition, including documentation regarding notification of the physician, and the order received to send the resident to the hospital, and notification of the resident's representative. Review of the policy titled Notification of Resident's Condition, dated 04/2024, revealed completed notifications would be documented in the medical record.

Based on medical record review, review of immunization records, resident and staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to offer the residents the COVID-19 vaccination per CDC recommendations. This affected three (#18, #29, and #45) of nine residents reviewed for COVID-19 vaccination. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition. Review of the immunization record, dated 09/05/24, revealed Resident #18 last COVID-19 vaccine was 10/03/22. There was no record of Resident #29 being offered the COVID-19 vaccination since admission. Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #18 was not offered or educated regarding the COVID-19 vaccination. 2. Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses type two diabetes mellitus with diabetic neuropathy and inflammatory disorders of scrotum. Review of the MDS assessment, dated 06/25/24, revealed the resident was cognitively intact. Review of the immunization record, dated 06/28/24, revealed Resident #29 last COVID-19 vaccination was on 12/20/21. There was no record of Resident #29 being offered the COVID-19 vaccination since admission. Interview on 09/05/24 at 1:29 P.M. with Resident #29 verified not being offered the COVID-19 vaccine. Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #29 was not offered or educated regarding the COVID-19 vaccination. 3. Review of the medical record revealed Resident #45 was admitted on [DATE]. Diagnoses included dementia. Review of the MDS assessment, dated 06/25/24, revealed the resident was severely cognitively impaired. Review of the immunization record, dated 06/28/24, revealed Resident #45 last COVID-19 vaccination was on 12/20/21. There was no record of Resident #29 being offered the COVID-19 vaccination since admission. Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #45 was not offered or educated regarding the COVID-19 vaccination. Review of the facility's Vaccination Policy, reviewed August 2023, revealed new, current residents and staff will be offered vaccines that aid in prevention infectious diseases unless the vaccine is medically contraindicated or the resident or staff member has already been vaccinated. Review of the CDC guidance titled Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated 08/23/24 and located at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html, revealed the CDC recommends that people receive all recommended COVID-19 vaccine doses. Vaccination is especially important for people at highest risk of severe COVID-19, including people ages [AGE] years and older; people with underlying medical conditions, including immune compromise; people living in long-term care facilities; and pregnant people to protect themselves and their infants.

Based on personnel file review and staff interview, the facility failed to ensure one of four State tested Nursing Assistants (STNA) received an annual performance review. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of the personnel file of STNA #195 revealed a hire date of 05/19/23. The file was absent of any yearly performance review having been completed. Interview on 09/05/24 at 11:00 A.M. with Human Resources #202 verified there was no yearly performance review completed for STNA #195.

Based on medical record review, family and staff interview, and facility policy review the facility failed to notify the family of a residents change of condition and transfer to local hospital for evaluation and treatment of stroke symptoms. This affected one resident (#44) reviewed for notification of change of condition. The facility census was 48. Findings include: Review of the medical record for Resident #44 revealed a re-admitted [DATE] with a diagnosis of cerebral infarct (stroke). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of the facility form titled HIPAA/PHI Authorization and Consent Form dated 12/23/23 from admission revealed Resident #44 identified his brother as his emergency contact. Review of the nursing progress noted dated 01/13/24 at 3:23 P.M. for Resident #44 revealed the nurse was called to the resident's room and was noted to have right sided facial droop. Resident #44 complained of feeling right sided numbness and tingling. Resident #44 was able to move his right hand some and able to squeeze with both hands. Vital signs for Resident #44 revealed a blood pressure of 171/95 millimeters of mercury (mm/Hg), a pulse of 90 beats per minute, a respiratory rate of 18 breaths per minute, and his oxygen saturation was 95%. The nurse called on-call physician for Resident #44's primary physician and left a message. The nurse then called the emergency number 911 on 01/13/24 at 9:00 A.M. two Emergency Medical Services (EMS) personnel arrived, and Resident #44 was transported to the nearest hospital for evaluation and treatment. Review of the nursing progress notes revealed no documentation of notification of the family or representative for Resident #44 following discharge from the facility for a change in medical condition. Interview on 04/22/24 at 2:15 P.M. with a family member of Resident #44 revealed the facility did not contact any family member regarding the transfer to the hospital for a change of condition. Interview on 04/22/24 at 3:40 P.M. with the Director of Nursing (DON) verified the family for Resident #44 was not notified of change of condition or transfer to hospital for stroke symptoms. Review of the facilities policy titled Notification of Residents Condition revised 09/20 revealed the facility will notify POA or representative will be notified by nursing when there is a significant change in the residents physical, mental, or psychological status. This deficiency represents non-compliance investigated under Complaint Number OH00152599.

Based on medical record review, resident interview, staff interview, and review of policy, the facility failed to safely transfer a resident using a mechanical lift device. This directly affected one (#48) of three residents reviewed for assistance with transfers. The facility identified five additional residents (#14, #21, #41, #45, and #49) utilizing a mechanical lift devices. The facility census was 48. Findings include: Review of the medical record of Resident #48 revealed an admitted [DATE]. Diagnoses include chronic obstructive pulmonary disease, rheumatoid arthritis, type II diabetes mellitus, venous insufficiency, and neuromuscular dysfunction of bladder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance for activities of daily living and transfers. Review of the care plan dated 08/19/22 revealed an intervention for falls to include the use of a stand-up lift. A second intervention dated 08/19/22 for basic needs revealed a mechanical lift to assist with transfers, type: total lift. Review of the progress note dated 11/22/23 at 6:53 A.M., revealed Resident #48 was being transferred to a reclining chair, by State tested Nursing Assistants (STNA), using a mechanical lift device. Resident #48 was suspended over the recliner when the device tipped over onto Resident #48. An ice pack was applied, and pain medications administered. A second note at 11:13 A.M., revealed Resident #48 continued to have a knot on her forehead and remained alert with pupils equal, round, and reactive to light, hand grasp and pedal push equal. A note dated 11/24/23 at 6:33 A.M., revealed bruising noted to right forehead and below right eye with pain upon palpation or moving eyebrows. Interview on 12/18/23 at 9:00 A.M., with Resident #43 revealed she had fallen from the mechanical lift some time ago. Resident #43 stated she fell into her recliner and had a black eye and bruise on her forehead. Resident #48 stated the lift had not been used properly but didn't feel as if the staff had done it on purpose. Interview on 12/18/23 at 9:05 A.M., with Assistant Director of Nursing (ADON) #151 revealed Resident #48 was moved to a bigger room to safely use the mechanical lift. The lift went to tip and the aides tried to hold it. Both STNAs were adamant the legs were completely open, one STNA in front and one working the lift. The mechanical lift was pulled immediately from use and the maintenance staff inspected the lift and found nothing wrong. The investigation revealed no definite conclusion as to how the lift tipped, possibly the legs were not completely opened to ensure a stable base. Both STNAs were agency. The agencies were all alerted to ensure STNAs received education on the use of mechanical lifts. Review of a typed statement from the Administrator after talking with agency STNA #145 revealed Resident #48 was almost over to the recliner when the lift tipped onto resident. Review of the policy titled, Mechanical Lift dated May 2023, revealed one step to include widen the legs of the lift and raise the resident to a level high enough to perform a safe transfer. Once the resident is raised, close the legs of the lift, and carefully move the lift to transfer the resident to the desired location such as a chair. Lower the lift to properly position the resident. This deficiency represents non-compliance investigated under Complaint Number OH00149183.

Based on observation, review of facility resident list, staff interview and policy review, the facility failed to ensure medications were properly stored when a medication cart was left with a drawer open, the cart unlocked, and unattended. This had the potential to affect two residents (#33 and #34) identified as being independently mobile and confused. The facility census was 48. Findings include: Observation and interview on 12/14/23 at 7:39 A.M., the medication cart was unlocked, the top drawer was open, medications were visible and no staff was in attendance. Licensed Practical Nurse (LPN) #100 exited the room of Resident #37 and verified the cart was unattended and unlocked. Review of a facility identified list revealed two residents (#33 and #34) are independently mobile and have confusion. Review of the policy titled Security of Medication Cart dated 04/12 revealed the medication cart is to be locked when out of view of the nurse.

Based on observation, staff interview, review of facility resident list and review of policy, the facility failed to ensure the shared glucometer was disinfected between residents. The facility further failed to ensure the correct disinfecting solution was used to cleanse the glucometer. This had the potential to affect two residents (#36 and #37) identified as using the glucometer. The facility census was 48. Findings include: Observation on 12/14/23 at 7:39 A.M., revealed Licensed Practical Nurse (LPN) #100 was carrying a glucometer when exiting the room of Resident #37. LPN #100 proceeded into the room of Resident #36 with the glucometer and proceeded to perform a fingerstick to obtain a blood glucose reading. LPN #100 had not disinfected the meter between residents. Interview with LPN #100, at the time of the observation verified not having disinfected the glucometer between resident use. Continued observation revealed LPN #100 was using an alcohol prep pad to clean the glucometer; after this surveyor questioned her about not cleaning the meter between residents and thought that was an acceptable cleanser. Review of a facility identified list revealed two residents (#36 and #37) utilize a glucometer. Review of the policy titled, Disinfecting Glucometer's and other reusable patient equipment dated May 2020 revealed the glucometer is to be cleansed between residents using sanitary wipe.

Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect all 58 residents in the facility. Findings include: Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and 06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21. Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA meetings during the third and fourth quarters of 2021.

Based on review of personal fund accounts, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#39) out of 26 residents with personal fund accounts. The facility census is 58. Findings include: Review of the personal fund accounts revealed Resident #39 had an account managed by the facility. Review of the most recent quarterly statement revealed as of 06/27/22 Resident #39's remaining balance was $29.95. Observation on 06/27/22 at 12:27 P.M. revealed Resident #39 requested $10 of personal funds from Activities Assistant #429. Activities Assistant #429 asked numerous questions to Resident #39 of why she needed the money and what she planned to purchase. Resident #39 avoided the question for a couple of instances and made a short joking remark. Activities Assistant #429 stated the Business Office Manager was out that day and Resident #38 could not obtain her funds until tomorrow. Medical Records Clerk #432 offered to loan Resident #39 $10 until the next day. Interview on 06/27/22 at 12:30 P.M. with Resident #39 verified she was told she could not access $10 from her account because the Business Office Manager was out of the building. Interview on 06/27/22 at 1:31 P.M. with Activities Assistant #429 verified telling Resident #39 the Business Office Manager was out of the office and she could not access her money. Activities Assistant #429 reported Resident #39 had an appointment with transportation and often attempts to get the driver to stop so she can purchase candy. Activities Assistant #429 reported Resident #39 has diabetes and should not eat candy. Interview on 06/30/22 at 10:53 A.M. with Business Office Manager #434 verified she was not working on 06/27/22. Business Office Manager #434 stated there is a process in place to ensure residents have access personal funds at all times, even when she is out of the office. Review of the facility policy titled Resident Funds, revised June 2020, revealed the facility will provide a means for the resident to access his or her funds.

Based on record review, observation, resident interview, staff interview, review of the supply order form, review of Resident Council meeting minutes, and review of facility policy, the facility failed to ensure a resident with incontinence had their choice of incontinent brief type and supplies respected. This resulted in actual psychosocial harm when Resident #30 confined herself to her room for fear of leaking through the facility issued brief which she felt did not fit correctly, which was not what she was comfortable in, and which made her feel like an infant. This affected one (#30) of five residents reviewed for incontinence. The facility identified 45 residents who were incontinent. The facility census was 65. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 11/04/19, revealed Resident #30 was cognitively intact. Resident #30 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #30's care plan, revised 12/14/19, revealed supports and interventions for urinary and bowel incontinence. Interventions included to provide adult incontinent products per preference. Review of Licensed Social Worker (LSW) #390 typed note dated 12/13/19 revealed LSW #390 was aware of Resident #30's concerns including her briefs not always being the briefs she was used to. LSW #390 indicated Resident #30 related she had briefs in her room and she felt comfortable with what they were using at the time. Interview on 12/14/19 at 8:27 [NAME]M., Resident #30 reported the facility ran out of her powder, incontinence briefs, and incontinence pads. The facility said they would supply her with the personal care items she needed but her daughter had to buy them. She had bladder incontinence issues for many years and recently has had a lot of diarrhea. Resident #30 reported she required more pads and briefs and the facility ran out of the kind she had used for years. Resident #30 reported she preferred the brief style pull ups and the facility no longer would get them. The facility now would only get the adult diapers with the tabs. Resident #30 stated she did not like the adult diapers, stating they made her feel like a baby. Resident #30 reported the adult diapers did not fit right and they were not comfortable. She let the facility know her preferences, but nothing seemed to change. Resident #30 reported the facility also no longer had any incontinence pads available and she would like those to help protect her when she leaked through. Observation on 12/14/19 at 8:32 [NAME]M. of Resident #30's supplies in the bathroom revealed one bag of adult diapers which was three quarters full. Resident #30 had an open bag of incontinence pads in her closet, which Resident #30 said her daughter purchased for her along with her powder. Interview on 12/14/19 at 11:15 [NAME]M., State tested Nurse Aide (STNA) #118 revealed Resident #30 was incontinent. STNA #118 verified there were no pads available for residents who preferred to use them and verified Resident #30 had to wear tabbed briefs even though it was known she preferred, felt more comfortable in, and historically only used pull up briefs. STNA #118 stated Resident #30 had to use the tabbed briefs because that was all the facility had available. STNA #118 verified the facility had even run out of the tabbed briefs recently and had to take wrong size briefs from other residents to use. STNA #118 reported the staff were informed resident supplies were cut back due to budget cuts. Interview was conducted on 12/14/19 at 1:43 P.M. while Resident #30 was lying down in bed. Resident #30 reported she was lying down because she felt more relaxed with a pad under her. Resident #30 reported her daughter bought her the pads because they facility no longer had them. Resident #30 stated they also ran out of her size diapers, so staff were using two of the smaller ones with the tabs. Resident #30 reported she had bladder problems for a long time but with also having diarrhea for about four months now she had been going through a lot more supplies. Resident #30 stated she used less supplies if she stayed in her bed. Resident #30 reported the tabbed diapers the facility had been using that were supposed to be her size did not fit right and she was worried they would not hold everything if she was incontinent. Resident #30 stated she had been staying in her room and in her bed because of this. Interview on 12/14/19 at 1:56 P.M STNA #118 revealed the facility quit ordering the bariatric briefs and verified Resident #30 was wearing the wrong size tabbed brief right now because that was all the facility had available. Interview on 12/14/19 at 4:08 P.M. with the Administrator, Regional Clinical Nurse (RCN) #400, MDS Nurse #380 and LSW #390 revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) had done a lot of the ordering or coordination of the ordering but currently those positions were vacant. LSW #390 reported she had interviewed Resident #30 on 12/13/19 on her concerns and at the time Resident #30 said she was comfortable with what the facility had available for incontinent supplies. Review of the supply order form, dated 12/12/19, revealed the facility placed an order which included for seven bags of extra-large tabbed briefs, seven bags of large tabbed briefs, two bags of medium women's pull ups, two bags of large women's pull ups, two bags of extra-large women's pull ups, two packages of men's small pull ups and two packages of men's large pull ups. No incontinence pads were listed on the order form. Review of the Resident Council meeting minutes dated 11/13/19 revealed residents expressed concerns the facility had been out of medium size incontinence pads for three weeks. Residents stated the long pads were uncomfortable. Review of the facility policy titled Resident Rights, revised (MONTH) 2019, revealed the facility was to respect the rights of their residents and provide them with reasonable and practicable services/accommodation that provide dignity without exploitation. The resident rights included the right to be treated with courtesy, respect, and full recognition of dignity and individuality. The right to have all reasonable requests and inquires responded to promptly. The right to participate in all decisions that affect the resident's life. This deficiency substantiates Complaint Number OH 735.