Every finding on record at Majestic Care of Bryan

Based on medical record review, facility financial account review, and staff interview, the facility failed to ensure remaining fund balances were dispersed to residents at the time of discharge from the facility. This affected two (#1, #7) of three residents reviewed for disbursement of fund account balances in a facility census of 61. Findings include: 1. Resident #1 admitted to the facility on [DATE] with the diagnoses including, coronary artery disease, type 2 diabetes melllitus, ischemic cardiomyopathy, hypertension, major depression, lumbar region spinal stenosis, chronic kidney disease, peripheral vascular disease, dysphagia, glaucoma, muscle weakness, difficulty walking, non-compliance medication regimen, and nicotine dependence. According to the most current minimum data set assessment dated [DATE] Resident #1 was assessed with intact cognition, no recorded behavior, utilized a walker and wheelchair for mobility with set-up, required supervision with activities of daily living, range of motion impairment to bilateral upper extremities, occasional urinary incontinence, no falls, and was at risk for pressure ulcer development with no skin breakdown. According to the discharge summary and instructions dated 07/02/26, Resident #1 discharged to a local assisted living. No documentation indicated Resident #1 was provided with personal fund account balance or instructions on how to transfer Social Security Account (SSA) payment to the assisted living. On 07/24/26 at 10:05 A.M. interview with the Administrator during a review of Resident #1's Resident Account Statement noted a current balance of $1,102.00. On 07/01/26 Resident #1 balance was $102.00. On 07/02/26 the facility received Resident #1's SSA payment and it was deposited in the facility Financial Management System (FMS) account. The SSA credit of $1000.00 was placed to the account with a total balance of $1,102.00. On 07/21/26 the Administrator stated the resident came to the facility and withdrew $75.00 from his resident trust account. Review of Resident Trust Account receipt dated 07/21/26 noted Resident #1 to withdraw $75.00 from the facility resident trust account. On 07/24/26 at 11:10 A.M. interview with business office manager (BOM) #402 confirmed Resident #1 discharged from the facility on 07/02/26. Resident #1 received a monthly social security credit of $1000.00 each month and $75.00 of the credit was placed into the petty cash/ resident trust account. On 07/01/26 Resident #1 was noted with a $102.00 balance contained in the resident trust account. On 07/02/26 the facility received Resident #1 social security monthly treasury check (SSA) for $1000.00. On 07/02/26 Resident #1 discharged from the facility and was not provided with the balance contained in the resident trust account. On 07/21/26 Resident #1 returned to the facility and obtained $75.00 from his account managed by the facility resident trust account. BOM#402 confirmed Resident #1 trust account was not closed following the resident's discharge and he was not given the remaining balance of his trust account. In addition, Resident #1 SSA check is still set-up to be deposited into the facility Financial Management System (FMS) account due to the resident not providing an account for the monthly SSA check to be deposited at or following discharge. BOM #402 verified Resident #1 did not receive the July 2026 SSA monthly check or trust account balance upon discharge. In addition, residents are not provided with information at the time of discharge to ensure SSA and associated checks are deposited into a specified account. 2. Resident #7 admitted to the facility on [DATE] with the diagnosis including, schizophrenia, congestive hear failure, coronary artery disease, hypertension, anxiety disorder, bipolar disorder, and anemia. According to the most current minimum data set assessment dated [DATE] Resident #7 was assessed with severe cognitive impairment, and required supervision or touching assistance with activities of daily living. Review of the discharge summary documentation noted Resident #7 was discharged home with family on 07/01/26. No documentation indicated Resident #7 was provided with the remaining balance of her Resident Trust Account. Review of Resident #7 Resident Statement Landscape noted on 07/01/26 a balance of $742.27 was contained in the account. On 07/24/26 at 11:10 A.M. interview with BOM #402 confirmed Resident #1 discharged from the facility on 07/01/26. Review of current resident trust account documentation noted Resident #7 with a current account balance of $724.27 that had not been disbursed or returned to the resident. On 07/24/26 at 12:01 P.M. interview with the Administrator verified Resident #1 and Resident #7's resident trust accounts were not closed with remaining balance provided to the residents when discharged from the facility. In addition, the facility provided no instruction to Resident #1 to ensure monthly SSA check was deposited into the admitting facility FMS account or an account established by the resident. This deficiency represents non-compliance investigated under Complaint Number 3109386.

Based on record review, staff interview, and policy review, the facility failed to ensure residents received timely copies of their medical records. This affected two (#75 and #77) of three residents reviewed for medical record requests. The facility census was 64.1. Review of the medical record for Resident #75 revealed an admission date of 10/10/25 with diagnoses of heart failure, anxiety, edema, depression, and hypertension. Resident #75 discharged to the community on 04/02/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/30/26, revealed Resident #75 had severely impaired cognition. Review of the comprehensive admission MDS assessment, dated 10/2025, revealed Resident #75 had intact cognition. Interview on 06/24/26 at approximately 4:00 P.M. with Licensed Social Worker #306 revealed she completed the cognitive assessment for Resident #75 on 01/30/26 and Resident #75 refused to participate with the assessment; therefore, LSW #306 had to mark the results accordingly. Review of an Authorization for Use or Disclosure of Protected Health Information form, signed by Resident #75 on 02/05/26 revealed a request for a copy of the entire medical record for personal use. Review of an email correspondence from the facility's corporate office, dated 02/11/26, revealed the records were attached and should be provided to Resident #75. Additionally, review of an Authorization for Use or Disclosure of Protected Health Information form, signed by Resident #75 on 05/02/26 revealed a request for a copy of the entire medical record for personal use. Review of the facility's email correspondence revealed the request was emailed on 04/02/26. Further review of the facility's email correspondence revealed the facility attempted to contact Resident #75 on 04/06/26, and left a voicemail on 04/07/26 indicating the records were available for pickup. Interview on 06/29/26 at 3:40 P.M. with the Administrator confirmed the Authorization for Use or Disclosure of Protected Health Information form, signed by Resident #75 on 05/02/26 was misdated and Resident #75 should have used the date 04/02/26. Further interview confirmed copies of Resident #75's medical record were not available within two working days of either request. 2. Review of the medical record for Resident #77 revealed an admission date of 02/27/26 with a discharge to the hospital on [DATE]. Diagnoses included epilepsy, anxiety, and depression. Review of the 5-day MDS assessment, completed 03/05/26, revealed Resident #77 had intact cognition. Review of an Authorization for Use or Disclosure of Protected Health Information form, signed by Resident #77's Power of Attorney on 03/26/26 revealed a request for a copy of the entire medical record for treatment, payment or other healthcare operations and for personal use. Review of the facility's records revealed Resident #77's records were available for pickup on 04/03/26. Interview on 06/29/26 at 3:40 P.M. with the Administrator confirmed copies of Resident #77's medical record were not available within two working days of the request. Review of the policy Release of Information, effective 05/01/25, revealed no guidance regarding the time the facility would require to provide copies of the medical record. This deficiency represents non-compliance investigated under Complaint Number 2968730.

Based on review of Self-Reported Incidents (SRIs), staff interviews, record review, and policy review, the facility failed to ensure allegations of abuse and injuries of unknown origin were thoroughly investigated. This affected two (#80 and 81) of nine residents reviewed for self-reported incidents. Additionally, the facility failed to ensure residents were timely assessed after alleging abuse. This affected one (#80) of nine residents reviewed for self-reported incidents. The facility census was 64. Findings include:1. Review of the medical record for Former Resident (FR) #80 revealed an admission date of [DATE] and a discharge with family on [DATE]. Diagnoses included cerebral ischemia, heart disease, anxiety, and malaise.Review of the 5-day Minimum Data Set assessment (MDS), dated [DATE], revealed FR #80 had impaired cognition, was dependent on staff for all mobility, and required substantial/maximal assistance for toileting hygiene, bathing, and dressing. Further review revealed FR #80 had no hallucinations or delusions during the lookback period, and rejected care one to three days.Review of a nursing progress note, dated [DATE] at 11:38 P.M., revealed FR #80 was yelling, hitting, and kicking while two aides were providing care. After FR #80 was changed, FR #80 then called the aides back in and told them that two people were in there and attacked her sexually.Review of the EIDC (Enhanced Information Dissemination Collection) website revealed SRI #274124 was created [DATE] at 12:24 P.M. and closed on [DATE] at 8:42 P.M. Interview on [DATE] at 11:04 A.M. with the Administrator and concurrent review of the facility's investigation into SRI #274124, revealed there was no evidence FR #80 was assessed by the nurse at the time of the allegation. The facility completed a full skin assessment of FR #80 during their investigation, initiated on [DATE] at 12:24 P.M. Continued interview and review of the facility staff schedules for [DATE] revealed the two Certified Nursing Assistants (CNAs) assigned to the hall were CNA #207 and CNA #208. The Administrator confirmed Licensed Practical Nurse (LPN) #209 wrote the progress note on [DATE] at 11:38 P.M. Further, the Administrator confirmed no interviews with CNA #207, CNA #208 and LPN #209 were included in the investigation into Resident #80's allegation of sexual abuse. Continued interview with the Administrator indicated CNA #207 and CNA #208 were suspended during the investigation. Interview on [DATE] at 12:05 P.M. with Staff Scheduler #304, and concurrent review of the staff schedules dated [DATE] through [DATE], revealed CNA #207 worked on [DATE] and [DATE] and CNA #208 worked on [DATE].Follow-up interview with the Administrator on [DATE] at 4:55 P.M. regarding CNA #207 and CNA #208 working while the investigation remained open revealed the staff were allowed to return to work as the investigation was concluded after the facility interviewed FR #80 and her family member on [DATE], and interviewed residents and staff on [DATE]. The Administrator stated the SRI remained open until [DATE] because staff acknowledgements of the abuse policy were outstanding.Review of the policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, effective [DATE], revealed the Procedure to Protect the Resident included assessment of the involved resident and immediate removal of Care Team Members from the facility and the schedule pending the outcome of the investigation. Further review revealed the person investigating the incident should generally take the following actions: interview the resident, the accused, and all witnesses.2. Review of the medical record for Former Resident (FR) #81 revealed an admission date of [DATE] and a discharge upon death on [DATE]. FR #81 was under the care of hospice. Diagnoses included Alzheimer's disease, osteoarthritis, venous thrombosis and embolism, and anemia.Review of the comprehensive significant change MDS assessment, dated [DATE], revealed FR #81 had impaired cognition and was dependent on staff for mobility and transfers. All other mobility assessments were marked not applicable. Review of the care plan initiated [DATE], with revisions, revealed FR #81 had an activities of daily life (ADL) self-care performance deficit related to cognitive losses, range of motion deficit to both upper extremities with active range of motion deficits. Nonambulatory. Interventions included an update [DATE] for assistance of one to two staff for toileting and bed mobility, assist of two staff with mechanical lift for transfers.Review of FR #81's nursing progress note dated [DATE] revealed the physician was rounding in the facility when FR #81 complained of right ankle pain. Swelling of +1 was noted to the right ankle. FR #81 reported pain started that afternoon. No known injury. Received an order for an x-ray.Review of a nursing progress note dated [DATE] revealed the x-ray results indicated right ankle healilng fractures of the distal tibia and fibula.Review of SRI #269494, initiated [DATE], revealed a potential injury of unknown origin was reported for FR #81. Interview on [DATE] at 10:40 A.M. with the Administrator, and concurrent review of the facility's investigation into SRI #269494, revealed staff and residents were interviewed regarding abuse and safety concerns. Non-interviewable residents had full-body skin assessments. The facility determined abuse did not occur. Continued interview with the Administrator revealed the facility's investigation contained no interviews with staff regarding circumstances which could have led to the fracture, or staff who were familiar with FR #81 to determine when the area was first observed. The Administrator further confirmed the investigation contained no evidence FR #81's record was reviewed for previous skin assessments or potential falls. The Administrator confirmed the investigation into an injury of unknown origin did not show evidence the facility attempted to determine the source/cause of the injury.Review of the policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, effective [DATE], revealed the Procedure to Investigate (an alleged incident) included the guidance: if there are not direct witnesses, the interviews may be expanded. For Injuries of Unknown Source, the investigation may generally involve talking with Care Team Members working on both the shift on duty when the injury was discovered and prior shifts as well.This was an incidental finding identified during the complaint investigation completed on [DATE].

Based on observation, staff interview, record review and policy review, the facility failed to ensure fall interventions were in place and fall interventions were reviewed and revised as needed, and failed to accurately document the use of fall interventions. This affected one (#31) of three residents reviewed for falls. Additionally, the facility failed to implement their policy regarding post-fall procedures when a fall was reported by family. This affected one (#77) of three residents reviewed for falls. Finally, the facility failed to show evidence of investigations into a fall with injury. This affected two (#31 and #76) of three residents reviewed for falls. The facility census was 64. 1. Review of the medical record for Resident #31 revealed an admission date of 10/10/22 with diagnoses of cerebellar ataxia, dysphagia, traumatic brain injury, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/28/26, revealed Resident #31 had impaired cognition and required substantial/maximal assistance for bed mobility, and was dependent for all other mobility. Resident #31 used a manual wheelchair and needed setup or clean-up assistance to wheel 50 feet with two turns. Resident #31 had one fall since the previous assessment with no injury. Review of Resident #31's physician orders revealed an order initiated 02/24/25 for dycem mat (non-slip plastic) to the wheelchair to aid in resident safety. Check placement every shift, and an order initiated 05/20/26 for a mechanical lift to be used for all transfers. Review of Resident #31's care plan, initiated 03/24/25, with revisions, revealed Resident #31 was at risk for falls or fall related injury due to limited mobility, diplegia of upper limbs, contractures, dysarthria, and deformities of lower legs. Interventions included: dycem mat to wheelchair to aid in resident safety. Check placement every shift (initiated 03/24/25), replace dycem to wheelchair seat as needed (initiated 03/24/25), and resident specific stand-up lift with sling to be used for all transfers (initiated 05/12/25). Review of the Morse Fall Scale, completed 04/06/26, revealed Resident #31 was at high risk for falls. Observation on 06/23/26 at 11:34 A.M. revealed Certified Nursing Assistant (CNA) #203 and CNA #307 in Resident #31's room preparing to transfer Resident #31 from the bed to the wheelchair with a mechanical lift. Concurrent interview with CNA #203 confirmed no dycem was in Resident #31's wheelchair. Resident #31 was appropriately transferred using a sling pad to the wheelchair and was placed in the wheelchair with the sling pad between his body and the wheelchair cushion. Interview on 06/23/26 at 11:49 A.M. with CNA #203 and concurrent review of Resident #31's care plan revealed Resident #31 no longer used a stand-up lift for transfers as it was no longer safe. CNA #203 further confirmed the dycem mat was not in the wheelchair and further determined if the mat was in the wheelchair, Resident #31 could still slip from the wheelchair as he was sitting on top of the sling pad. Review on 06/23/26 at 2:55 P.M. of Resident #31's Treatment Administration Record (TAR) for June 2026 revealed Licensed Practical Nurse (LPN) #205 charted on the TAR to indicate Resident #31's dycem mat was in the wheelchair. Interview on 06/23/26 at 3:11 P.M. with LPN #205 confirmed she did not check to verify Resident #31's dycem mat was in place before charting it was in place. Concurrent observation in Resident #31's room revealed the dycem mat was under some items on a shelf near the window. Interview on 06/24/26 at 11:10 A.M. with the Administrator revealed the clinical team discussed falls every workday morning. Concurrent review with Resident #31's care plan confirmed the dycem mat to the wheelchair, under the sling pad, was no longer an effective intervention. Review of Resident #31's care plan on 06/25/26 revealed the intervention for the dycem mat was removed. Follow-up interview on 06/29/26 at 3:30 P.M. with the Administrator confirmed the intervention for the dycem mat was removed from Resident #31's care plan by MDS Coordinator #100. Further interview, along with review of the current physician order dated 02/24/25 confirmed the order for dycem mat in the wheelchair remained active. The Administrator confirmed the order and the care plan did not coordinate and the Administrator could not confirm whether staff were educated to place the dycem mat in the wheelchair per physician orders, or to no longer implement it because it was removed from the care plan. Review of the policy, Fall Prevention, dated 01/02/24, revealed each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed. 2. Further review of Resident #31's record revealed a nursing Change in Condition note dated 05/17/26 indicating Resident #31 was found lying on the floor face down with head under the bed. Resident #31 was noted to have a laceration to the left eyebrow and swelling to left eye. The note included a recommendation to send Resident #31 to the emergency department for further evaluation. Further review revealed vital signs were obtained on 05/16/26 at 7:27 P.M. Review of the late entry nursing progress note dated 05/17/26 at 7:31 A.M. revealed at 11:50 P.M. Resident #31 returned from the hospital via stretcher with two sutures to the left eyebrow. Review of the facility's Risk Management documentation, identified as the facility's investigation into the fall, revealed Resident #31 was found on the floor in his room on 05/16/26 at 7:23 P.M. Resident #31 was lying face down with head under the head of the bed and was noted to have a laceration and discoloration and swelling around left eye. Resident #31 stated he fell from the wheelchair. Further review revealed a Mental Status assessment indicated Resident #31 was oriented to time, place, person, and situation. Also under the Mental Status assessment, a box was checked indicating intervention(s) in place at time of incident. No additional investigation information was provided regarding the fall, including witness statements. Review of an interdisciplinary team (IDT) progress note, dated 05/29/26, stated: IDT met regarding resident fall. Resident was found laying face down with head under the head of the bed. Noted to have a laceration to left eye and discoloration and swelling around left eye. Resident sent to ER (emergency room) for eval (evaluation) and tx (treatment). No fx (fracture) noted. Education to call for assistance provided to resident, therapy eval (evaluation). All appropriate parties notified. Care plan reviewed and updated as appropriate. Interview on 06/25/26 at approximately 8:30 A.M. with the Interim Director of Nursing (IDON) confirmed no additional information or evidence of investigation was available regarding the circumstances of Resident #31's fall on 05/16/26. Concurrent review of the facility's fall policy revealed the facility would obtain witness statements in case of injury. 3. Review of the medical record for Former Resident (FR) #76 revealed an admission date of 08/13/25 with diagnoses of Alzheimer's disease, tremor, macular degeneration and dementia. Resident #76 discharged to the hospital on [DATE] and subsequently transferred to another long-term care facility in the area. FR #76 resided in the dementia unit. Review of the quarterly MDS assessment, dated 01/27/26, revealed Resident #76 had impaired cognition and required no assistive devices for walking. Resident #76 required supervision/touching assistance for all mobilities. Resident #76 had two or more falls with no injuries since the previous assessment. Review of the care plan initiated 11/03/25 revealed FR #76 required supervision and assistance as needed for ambulation and setup to supervision for eating. Further review revealed no indication or intervention FR #76 required 1:1 observation and no indication FR #76 could not be left alone. Review of progress notes dated 01/07/26 and 01/12/26 revealed FR #76 ambulated the halls independently. Review of the Morse Fall Scale, completed 01/24/26, revealed FR #76 was at high risk for falling. Review of an occupational therapy (OT) progress note dated 02/16/26 revealed FR #76 worked with OT for sitting balance and increasing her ability to sit unsupported. Review of a nursing progress note dated 02/23/26 revealed FR #76 was in the dining room when the nurse, who was in the nurse's station across the hall from the dining room, heard a loud sound and heard a coffee cup hit the floor. The nurse found FR #76 on the floor on her left side, and by the time the nurse got to the resident, FR #76 had turned herself onto her back. FR #76 was assessed and sent to the hospital for a suspected fracture of the left hip. Review of the facility's Risk Management documentation, identified as the facility's investigation into the fall, revealed FR #76 had an unwitnessed fall on 02/23/26 at 3:15 P.M. in the secured unit's dining room. FR #76 was unable to provide a description of the cause of the fall. Review of the late entry IDT progress note dated 02/24/26 at 6:05 P.M. revealed staff and residents were interviewed, FR #76 was not incontinent prior to the fall, FR #76 was clothed and with appropriate footwear at the time of the fall, and determined the root cause of the fall was impaired cognition and loss of balance. The IDT note did not include an update on FR #76's status from the hospital. The facility did not provide records regarding the hospital assessment of FR #76. Interview on 06/25/26 at approximately 8:30 A.M. with the IDON confirmed the facility could provide no evidence an investigation into the circumstances of FR #76'S fall was completed. Further interview, along with concurrent review of the policy, confirmed the facility could provide no evidence staff interviews were obtained, as indicated in the IDT progress note dated 02/24/26, in the case of a fall with injury. 4. Review of the medical record for FR #77 revealed an admission date of 02/27/26 with a discharge to the hospital on [DATE]. Diagnoses included stroke, epilepsy, anxiety, hypertension and type 2 diabetes mellitus. Review of the 5-day MDS assessment, completed 03/05/26, revealed Resident #77 had intact cognition and had one fall in the previous two to six months prior to admission. No falls in the previous month and no falls with fracture in the past six months. Further review revealed Resident #77 used a walker, had no impairments to upper or lower extremities, and was dependent on staff for all mobility including bed mobility and transfers. Walking was not attempted due to medical condition or safety concerns. Review of the care plan initiated 02/27/26 and not revised revealed FR #77 was at risk for falls or fall related injury due to a history of falls, use of blood glucose lowering medications, use of antihypertensive medications, poor safety awareness, deconditioning, and gait/balance problems. Interventions included: encourage and assist to wear appropriate non-skid footwear, keep call light and frequently used personal items within reach, assist with toileting, and assist with transfers. Review of the Morse Fall Scale assessment, completed 02/27/26, revealed FR #77 was at high risk for falling (score 50.0). Review of a nursing progress note, written by Registered Nurse (RN) #204, dated 03/21/26, revealed FR #77's family member reported FR #77 reported falling out of bed one night and getting himself up off the floor and back into bed, but could not recall what night. FR #77's family member stated FR #77 had left shoulder pain increasing since the alleged fall. An x-ray was ordered. Review of the x-ray results, dated 03/21/26, revealed FR #77 had osteoarthritis of the shoulder and AC (acromioclavicular) joint space; no evidence of a fracture or dislocation. Interview on 06/23/26 at 1:05 P.M. with RN #204, and concurrent review of the progress note dated 03/21/26, revealed she somewhat recalled the situation with FR #77's reported fall from 03/21/26 and stated she could not recall if she interviewed FR #77 about the alleged fall. RN #204 further stated if a resident reported a fall she would typically interview them and initiate a Risk Event in the electronic medical record. Interview on 06/23/26 at 3:11 P.M. with Licensed Practical Nurse (LPN) #205 revealed the fall protocol would be initiated when a resident reported a fall to nursing staff. Interview on 06/24/26 at 2:57 P.M. with the IDON confirmed the facility's post-fall protocol was not initiated for FR #77 after the fall was reported to staff. The IDON confirmed there was no evidence a physical assessment was completed, no neurological checks were initiated, no fall assessment was completed, and no incident was created. Further, the IDON confirmed the facility could provide no evidence an investigation into the incident was completed. Review of the policy, Fall Prevention, dated 01/02/24, revealed the guidance: when any resident experiences a fall, the facility will: assess the resident; completed a post-fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicated; document all assessments and actions; and obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Complaint Number 2968730 and Complaint Number 2804252.

Based on observation, staff interview, and facility policy, the facility failed to perform hand hygiene and failed to use proper technique during foley catheter care. This affected one (#51) resident out of one resident observed for foley catheter care. The census was 64. Findings include: Observation on 06/23/26 at 10:04 A.M. revealed Licensed Practical Nurse (LPN) #101 was assisting with wound care for Resident #51. After removing her gloves, LPN #101 immediately donned a new pair of gloves without performing hand hygiene between glove changes. LPN #101 verified that hand hygiene had not been performed at the time of the observation.Observation on 06/23/26 at 10:17 A.M. revealed LPN #100 was completing peri care along with Foley catheter care for Resident #51. LPN #100 placed a dirty, soapy washcloth into the wash basin containing clean water, then removed another washcloth from the same basin to wipe the resident's perineal area. LPN #100 verified water in basin was contaminated at the time of observation.Observation on 06/23/26 at 10:20 A.M. revealed Licensed Practical Nurse (LPN) #100 was completing wound care for Resident #51. After removing her gloves, LPN #100 immediately donned a new pair of gloves without performing hand hygiene between glove changes. LPN #100 verified that hand hygiene had not been performed at the time of the observation.Review of facility policy, Handwashing-Hand Hygiene, dated 03/05/25, revealed hand hygiene needs to be completed after removal of gloves and after the removal of gloves.This deficiency represents non-compliance under Complaint Number 2968730.

Based on medical record review, review of hospital records, review of investigation statements, review of interdisciplinary investigation notes, staff and resident interviews, review of a mechanical lift owner's manual, review of a mechanical lift sling owner's manual, review mechanical lift safety inspections, and review of facility policy, the facility failed to ensure Resident #02 was safely transferred using a mechanical lift resulting in an avoidable fall. This resulted in Actual Harm on 08/07/25 when Resident #02 was not safely transferred resulting in a mechanical lift tipping and the resident suffering an avoidable fall sustaining a right hip fracture requiring surgical repair. This affected one (#02) of four residents reviewed for accidents. Additionally, the facility failed to ensure safe sling utilization while using a mechanical lift to transfer a resident, which placed the resident at risk for more than minimal harm. This affected one (#12) of four residents reviewed for accidents. Furthermore, the facility failed to ensure timely assessment and initiation of safety interventions for residents who displayed exit seeking behavior, and failed to ensure a door exit alarm was responded to timely, which placed the resident at risk for more than minimal harm. This affected one (#54) of four residents reviewed for accidents. The facility census was 77.1. Review of the medical record for Resident #02 revealed she was admitted to the facility on [DATE]. Her diagnoses included morbid obesity, spinal stenosis, asthma, mitral valve insufficiency, depression, anxiety, unspecified convulsions, and difficulty walking. Review of the quarterly Minimum Data Set 3.0 (MDS) dated [DATE] for Resident #02 revealed she was cognitively intact. Resident #02 displayed no behaviors at the time of the review. She was incontinent, dependent for care with personal and toileting hygiene, bathing, bed mobility, transfers, and required oxygen therapy. Review of the care plan for Resident #02 revealed she required the use of a mechanical lift for all transfers. Review of a progress note dated 08/07/25 at 3:54 P.M. for Resident #02 revealed Licensed Practical Nurse (LPN) #288 was alerted by a Certified Nurse Assistant (CNA) that a mechanical lift used to transfer Resident #02 from her wheelchair to her bed had tipped over while in use and Resident #02 was on the floor. After immediate assessment by LPN #288, Resident #02 was taken to the local emergency room via emergency squad due to Resident #02 complaining of severe pain, rated nine out of ten, to her right hip. Review of a progress note dated 08/07/25 at 11:01 P.M. for Resident #02 revealed LPN #263 received notification from the emergency room that Resident #02 was admitted with a diagnosis of hip fracture and would have surgery in the morning. Review of a progress note dated 08/08/25 at 9:51 A.M. for Resident #02 revealed the interdisciplinary team met regarding Resident #02's fall from the mechanical lift and the lift involved in the fall had been removed from service. Review of hospital records dated 08/12/25 revealed Resident #02 sustained a right hip fracture on 08/07/25 after falling from a mechanical lift and underwent surgical repair of the fracture on 08/08/25. Further review of progress notes from physical and occupational therapy revealed Resident #02 expressed fear and/or anxiety related to being transferred in a mechanical lift on 08/16/25, 08/20/25, 08/21/25, 09/03/25, 09/05/25, 09/08/25, 09/10/25, 09/12/25, 09/15/25, 09/22/25, 9/30/25, 10/02/25, and 10/06/25. Review of interdisciplinary team meeting notes regarding Resident #02's fall from a mechanical lift revealed on 08/07/25 at 3:54 P.M. CNA #266 and CNA #269 were transferring Resident #02 using a mechanical lift. The lift tipped to one side and Resident #02 fell to the floor. Resident #02 was assessed by LPN #288 at 3:55 P.M. Due to severe pain verbalized by Resident #02, Emergency Medical Services (EMS) was contacted via 911 call, and Resident #02 was transferred to the emergency room via EMS at 4:05 P.M. At 4:15 P.M. the mechanical lift was removed from service and inspected. The mechanical lift was noted to be rated for up to 450 pounds and Resident #02's weight was 289 pounds. Upon inspection of the mechanical lift it was noted the lift wobbled when weight was applied and the legs closed slightly. Review of a statement from CNA #266 dated 08/07/25 revealed she was assisting CNA #269 with a mechanical lift transfer of Resident #02 when the lift tipped over while lifting Resident #02 out of her wheelchair. Review of a statement from CNA #269 dated 08/07/25 revealed she was assisting CNA #266 with a mechanical lift transfer of Resident #02 when the lift began to tip, attempts to prevent the lift from tipping were unsuccessful, and Resident #02 fell to the floor while attached to the mechanical lift. Interview on 12/08/25 at 9:34 A.M. with Resident #02 revealed she sustained a fall from a mechanical lift while being transferred from her wheelchair to her bed. Resident #02 could not recall the exact date of the fall and stated she broke her right hip when she landed on the frame of the mechanical lift. Interview on 12/09/25 at 11:46 A.M. with Regional Nurse Consultant #304 revealed the facility's maintenance staff performed internal monthly safety inspections on all mechanical lifts and had an external company perform safety inspections twice per year. Interview on 12/09/25 at 3:45 P.M. with Resident #02 revealed she was afraid to use the mechanical lift when she returned to the facility after her fall from the lift. Interview with Maintenance Director (MD) #244 on 12/10/25 at 12:00 P.M. revealed he completed mechanical lift safety inspections monthly and if any safety issues were noted, the lift was immediately taken out of service by placing the lift in a locked room inaccessible to staff. Interview on 12/11/25 at 8:20 A.M. with the Director of Nursing (DON) revealed on 08/07/25 at approximately 3:55 P.M. she received a call that Resident #02 had fallen during a mechanical lift transfer. The DON stated she went to Resident #02's room and found Resident #02 on the floor, in the tipped mechanical lift sling attached to the lift, being assessed by LPN #288. Resident #02 was complaining of pain to her right hip and leg, emergency services were summoned, and Resident #02 was taken to the emergency room via squad. Interview on 12/11/25 at 10:30 A.M. with the Administrator revealed the mechanical lift that tipped while transferring Resident #02 on 08/07/25 had not received an external inspection since 01/20/22. The Administrator confirmed the facility did not have the outside company inspect the mechanical lift following the incident involving Resident #02 on 08/07/25. Interview on 12/11/25 at 10:43 A.M. with CNA #266 and CNA #269 revealed on 08/07/25 at approximately 3:50 P.M. Resident #02 indicated she wanted to get back into her bed. Both CNAs stated they were assisting with the mechanical lift transfer, and the lift did not appear to be malfunctioning until they began to raise Resident #02 from her wheelchair and the lift tipped over. Interview on 12/11/25 at 10:43 A.M. with CNA #269 revealed she observed Resident #02 experienced increased anxiety when using the mechanical lift, which required additional patience and reassurance, after Resident #02 returned from the hospital. Review of the manufacturer's manual for the mechanical lift that tipped while transferring Resident #02 on 08/07/25 revealed institutional maintenance inspection safety checks of the caster base, mast, boom, swivel bar, and actuator assembly should be completed monthly. Review of the facility's internal safety inspection logs for the mechanical lift that tipped while transferring Resident #02 on 08/07/25 revealed it was inspected each of the prior 12 months by MD #244. The facility's mechanical lift safety inspection included inspection and testing of the caster base, shifter handle, mast, boom, swivel bar, lift pump assembly, all lift surfaces, battery, remote controls, control panel, and electrical cords. Review of a monthly safety inspection form for a mechanical lift completed by MD #244 revealed MD #244 completed a thorough inspection and testing of the caster base, shifter handle, mast, boom, swivel bar, lift pump assembly, all lift surfaces, battery, remote controls, control panel, and electrical cords. Review of external safety inspection documentation for the mechanical lift that tipped while transferring Resident #02 on 08/07/25 revealed the last inspection was completed on 01/20/22. Further review of the external inspection documentation revealed the lift was not inspected by the outside company following the incident involving Resident #02 on 08/07/25. Review of facility policy dated 01/02/24 and titled Transfers and Mechanical Lifts revealed the facility would ensure residents would be transferred safely to prevent the risk of injury and promote a secure experience for the resident. Additionally, the policy stated staff would perform mechanical lift transfers in accordance with manufacturer's instructions. 2. Review of the medical record for Resident #12 revealed she was admitted on [DATE]. Her diagnoses included congestive heart failure, epilepsy, hypertension, history of traumatic brain injury, and depression. Review of the quarterly Minimum Data Set 3.0 (MDS) dated [DATE] for Resident #12 revealed she was cognitively intact, experienced bilateral lower extremity functional deficits, and was dependent for care with activities of daily living and transfers. Resident #12 was incontinent of bowel and had an indwelling urinary catheter. Review of the Care Plan for Resident #12 revealed she required the use of a mechanical lift for all transfers. Observation on 12/08/25 at 11:55 A.M. of a mechanical lift transfer from bed to wheelchair for Resident #12 performed by LPN #228 and CNA #290 revealed CNA #290 secured the purple mechanical lift sling hooks on the lift boom on her side and LPN #228 secured the black sling hooks onto the lift boom on her side. CNA #290 began lifting Resident #12. Interview at the time of this observation prompted CNA #290 to stop the lift process and she confirmed the sling hooks, for safety purposes, should have been on the same color on both sides of the lift boom to ensure Resident #12 was evenly lifted. LPN #228 stated she did not understand the new mechanical lift slings and adjusted her sling hooks to purple. Continued observation of this mechanical lift transfer revealed once Resident #12 was raised from her bed, LPN #228 lined the receiving wheelchair up facing toward the mechanical lift. CNA #290 advised LPN #228 the wheelchair needed to be facing sideways with the mechanical lift. LPN #228 again expressed confusion and proceeded to follow CNA #290's instruction. Concurrent interview with LPN #228 revealed she did not recall being trained on the use of the new mechanical lift slings. Review of training records for LPN #228 revealed she was re-trained on mechanical lift use and slings on 10/09/25. Interview on 12/10/25 at 11:41 A.M. with the Director of Nursing revealed the mechanical lift and sling training that occurred in October 2025 for all nursing staff included the correct use of lifts and slings. The training elements utilized were videos from the mechanical lift manufacturer, a lecture session, live demonstration from management, and a hands-on skills check-off by each nursing staff member. Review of the mechanical lift sling owner's manual revealed sling hook strap colors should be matched on each side when attached to the mechanical lift boom to ensure the resident is lifted evenly. Review of facility policy dated 01/02/24 and titled, Transfers and Mechanical Lifts, revealed the facility would ensure residents would be transferred safely to prevent the risk of injury and promote a secure experience for the resident. Additionally, the policy stated staff would perform mechanical lift transfers in accordance with manufacturer's instructions. 3. Record review for Resident #54 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: vascular dementia (dementia related to changes in blood flow), type 2 diabetes mellitus (high sugar), repeated falls, anxiety, major depressive disorder, and obstructive and reflux uropathy (inability to urinate). Review of the MDS assessment dated [DATE] revealed Resident #54 had impaired cognition. Review of the progress note dated 11/12/25 at 12:25 P.M. revealed that writer received a report that Resident #54 was attempting to leave out of the back door by the vending machines. Further review revealed Resident #54 had to be redirected. Review of the Elopement Risk Assessment for Resident #54 dated 12/03/25 revealed a score of zero. A score of zero indicated that the resident was not at risk for elopement. Further review revealed Resident #54 was marked as No for, 'had this resident displayed exit-seeking behavior.' Review of the care plan dated 12/03/25 revealed Resident #59 had impaired cognition and required assistance with decision making and monitoring for changes. Additional review revealed no care planning or interventions for exit seeking behavior. Review of Interdisciplinary Team (IDT) notes dated 02/10/25 to 12/09/25 for Resident #54 revealed no IDT note charted regarding elopement. Interview with the Director of Nursing (DON) on 12/09/25 at 2:10 P.M. verified they were told that Resident #54 was found attempting to exit the door. The DON further stated Resident #54 reported they were hearing a sound outside and wanted to turn it off. The DON verified the elopement risk assessment for Resident #54 was completed incorrectly. The DON further verified the IDT team did not review the incident and the care plan for Resident #54 was not updated regarding the exit seeking behavior but should have been. Review of policy titled Elopement and Wandering dated 01/02/24 revealed the facility shall establish and utilize a systematic approach to monitoring risk for elopement or unsafe wandering, monitor for effectiveness, and modify interventions when necessary, and alarms should be responded to in a timely manner. 4. Observation on 12/09/25 at 11:15 A.M. revealed the door alarm at the end of the 200 hall was set off. Continued observation at 11:23 A.M. revealed no employee came to check the alarm. Surveyor was required to walk to the front desk to inform staff the alarm was going off before staff responded. Observation on 12/09/25 at 2:00 P.M. revealed the door alarm at the end of the 200 hall was set off. Further observation on 12/09/25 at 2:08 P.M. revealed the DON walked down to the door to check the alarm. Further observation revealed one staff member sitting at the front desk at the other end of the hallway who did not check the alarm. Interview with the DON on 12/09/25 at 2:10 P.M. verified the alarm was going off. The DON verified alarms should be responded to in a timely manner, in no more than two minutes, but they expect staff to respond to door alarms immediately.

Based on observation, staff interview, and review of the facility menu with spread sheets, the facility failed to ensure residents on a mechanically altered diet received the same portions as the residents who received a regular diet. This had the potential to affect the 24 residents (#9, #10, #11, #13, #15, #17, #18, #21, #22, #23, #27, #30, #35, #38, #39, #53, #54, #57, #60, #63, #64, #66, #76 and #84) who received mechanically altered diet. The facility census was 77. Findings Include: Observations on 12/09/25 at 11:17 A.M. of the texture modification process for the pureed turkey meat found ten, three ounce (3 oz) #10 scoops of turkey were added to the food processor. Dietary Staff (DS) #235 then added turkey gravy and slices of bread to thin, blend, and thicken the processed meat. Observations on 12/09/25 at 11:22 A.M. of the food temperatures and portion sizes found a 3 oz scoop was used for the pureed turkey and the mechanical soft turkey while a four ounce (4 oz) scoop was used for the residents who received a regular textured diet. Coinciding interview with the Dietary Manager (DM) #291 verified the portion size of 3 oz for the mechanical soft diet and puree diets were smaller than the portions for those who received a regular diet. DM #291 stated it did not seem correct, but it was what the menu called for. DM #3291 stated she would bring it to corporates attention. DM #291 stated the menus were created and provided to them by corporate and they followed them as written. Observation on 12/09/25 at 11:35 A.M. of the lunch tray line meal service preparation revealed 3 oz scoops were placed in the pureed turkey and mechanical soft turkey while a 4 oz scoop was placed in the regular turkey. Observation on 12/09/25 at 11:38 A.M. of the tray line lunch plating process revealed the regular meals were provided with a 4 oz scoop of turkey. Observation on 12/09/25 at 11:39 A.M. of plating of a mechanical soft lunch meal found a 3 oz scoop was used and 3 oz of turkey was plated. 3 oz of mechanical soft turkey was not equivalent to the regular textured meal of 4 oz of turkey. Observation on 12/09/25 at 11:41 A.M. found a second mechanical soft plate was put together and 3 oz of turkey were provided. All the observed regular lunches continued to be plated with 4 oz of turkey. Observation on 12/09/25 at 11:53 A.M. found a pureed diet was plated. A 3 oz scoop was used and 3 oz of the pureed turkey added to the plate. 3 oz was not equivalent to the regular textured meal of 4 oz of turkey. Review of the facility's lunch menu spreadsheet for Tuesday 12/09/25 revealed Regular herb roasted turkey 4 oz, Mechanical Soft herb roasted turkey one #10 scoop, and Pureed herb roasted turkey one #10 scoop. Review of the facility's posted scoop size conversion chart revealed a #10 scoop had a 3 oz capacity.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure wound care orders were in place for a resident's wounds upon admission. This affected one resident (#83) of four residents reviewed for wound care and treatment. The facility census was 77.Findings Include: Review of Resident #83's medical record revealed an admission date of 12/01/25 and a discharge date of 12/08/25. Diagnoses included rheumatoid arthritis, type II diabetes, chronic pain, nicotine dependence, severe protein calorie malnutrition, and cognitive communication deficit. Review of Resident #83's admission Skin assessment dated [DATE] revealed Resident #83 had a sacrum area crusted measuring 5 centimeters (cm) by 4 cm into the second layer of skin and a right gluteal fold area 1.5 cm by 1 cm into the second layer of skin. The assessment indicated the physician was notified however, no treatment orders were found. Further review of Resident #83's medical record found no evidence of an admission treatment order being written to address the two wounds identified on Resident #83's admission skin assessment. Interview on 12/08/25 at 10:16 A.M. with Resident #83 found her to be alert and aware. Resident #83 reported she just admitted to the facility a week ago and she was discharging herself today because she was not happy with the care here. Resident #83 reported she came to the facility with scabbed wound on her bottom and it had been getting better at home. Resident #83 stated there were no treatments done for the wound since she got there. Resident #83 reported the scab came off because of the lack of care and it was now open and was hurting her. An observation of Resident #83's wound was not able to be made as she was actively in the process of discharging from the facility. Interview on 12/11/25 at 8:07 A.M. with the Administrator verified there were no orders in place for Resident #83's wound treatment in Resident #83's record. The Administrator stated she would contact the physician directly to check if there had been an order written. Interview on 12/11/25 at 10:31 A.M. with Registered Nurse (RN) #229 verified she was the admitting nurse who had completed Resident #83's admission skin assessment on 12/01/25. RN #229 verified Resident #83 had two wounds on her bottom which needed a treatment ordered. RN #229 reported she had called the physician and left a message regarding the two wounds and let the Unit Manager, Licensed Practical Nurse (LPN) #297, know. RN #229 stated she had not worked on Resident #83's hall since the initial assessment and follow-up would have fallen on the Unit Manager LPN #297. Interview on 12/11/25 at 12:32 P.M. with the Administrator verified the physician had no notes pertaining to Resident #83.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents who were identified as at risk for constipation had interventions implemented when they went longer than three days without a bowel movement. This affected one Resident (#5) of three residents reviewed of constipation. The facility census was 77. Findings Include: Review of Resident #5's medical record revealed an admission date of 05/14/21. Diagnoses included spinal stenosis, history of stroke, hemiplegia and hemiparesis, bipolar disorder, fibromyalgia, constipation, and anxiety disorder. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 was dependent on staff for toilet use, bathing, dressing, bed mobility and transfers. Resident #5 displayed no behaviors during the review period. Resident #5 was occasionally incontinent of urine and always incontinent of bowel. Review of Resident #5's physician orders revealed an order dated 11/02/23 for bisacodyl EC delayed release 5 milligrams (mg) give two tablets in the morning for constipation. An order dated 12/11/24 for docusate sodium 100 mg one capsule three times a day for constipation. An order dated 11/01/23 Dulcolax suppository 10 mg insert suppository rectally every 24 hours as needed for constipation. An order dated 11/01/23 for fleet enema 7-19 grams (GM) per 118 milliliter (ml) insert one unit rectally every 24 hours as needed for constipation. An order dated 04/11/24 for milk of magnesia oral suspension 1200 mg per 15 ml give 30 ml every 24 hours as needed for constipation. Review of Resident #5's Medication Administration Record (MAR) from 11/01/25 to 12/08/25 revealed all Resident #5's scheduled medications for constipation were administered as ordered. However, there were no as needed (PRN) medications administered. Review of Resident #5's bowel tracking for the last 30 days revealed Resident #5 had no bowel movement documented from 11/27/25 to 12/03/25, for a total of six days with no bowel movements. No PRN interventions were found as being implemented in the medication administration record to address Resident #5's six days of constipation. Review of Resident #5's progress notes revealed no documentation of interventions being implemented for lack of bowel movements from 11/27/25 to 12/03/25. Interview on 12/10/25 at 9:58 A.M. with Resident #5 found him to be alert and aware. Resident #5 verified he had gone a few days, like four or five days, without having a bowel movement a week or so ago. Resident #5 stated he had issues with constipation for quite some time since he was on pain medications. Resident #5 stated he did not have any pain or discomfort when he was last constipated and had bowel movements since. Resident #5 stated he received his scheduled medications for constipation but was not aware of any additional medications being given when he was constipated. Interview on 12/10/25 at 11:06 A.M. with Licensed Practical Nurse (LPN) #224 verified Resident #5 had no documented bowel movements for six days, 11/27/25 to 12/03/25, and there were no as needed (PRN) interventions implemented after three days of no bowel movements as there should have been.

Based on medical record review, observations, and resident, staff and physician interviews, the facility failed to timely implement physician's orders for Resident #3's pressure ulcer dressing change and failed to ensure the physician/provider was notified regarding the presence of eschar to Resident #7's heel ulcer and the potential need to change the treatment plan. This affected two (#3 and #7) out of three residents reviewed for pressure ulcer care. The current census is 77.Findings include: 1. Review of Resident #3's medical records revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include pressure ulcer stage 4 on right buttock, pressure ulcer stage 3 on left buttock, heart disease, diabetes type two, spondylosis of lumbosacral region, and dysphagia. Review of Resident #3's admission orders dated 11/03/25 for wound care revealed the staff were ordered to cleanse with normal saline, pat dry, apply Hydrogel to wound, and cover with gauze. Review of Resident #3's wound care physician documentation dated 12/03/25 revealed the order given for the wound was changed to cleanse wound, apply skin protectant Cavilon advance to peri-wound area, wet gauze with normal saline and pack wound bed, cover with gauze pads and secure with medical tape. Review of Resident #3's Treatment Administration Records revealed the 12/03/25 order entered into the records was soak wound with wound cleanser solution, pat dry, apply calcium alginate to wound bed and cover wound followed by an Optilock and secure with pink tape. Review of Resident #3's progress notes dated 12/03/25 at 1:06 P.M. entered late into the record on 12/09/25 at 11:09 A.M., revealed the nurse documented Resident #3 returned from the wound care appointment with new orders. Per the note the orders were reviewed with the facility's wound care supplier and the physician and the orders were adjusted to comply with the facility's policy. Per the note the outside wound care clinic was updated on the facility's policy. Interview on 12/08/25 at 1:33 P.M. with Resident #3 revealed the resident was alert and oriented and had concerns regarding his wound care. Resident stated he has a very large pressure ulcer on one side of his buttocks. Per Resident #3 the nurses were providing care but were not following his wound physician's orders to do a wet-to-dry dressing change. Resident #3 stated he was told by the wound nurse it was against a regulation and facility policy to do a wet to dry dressing change at the facility. Resident #3 stated he was concerned the wound would not heal as fast as it could if the nurses were following the actual wound dressing order. Interview on 12/09/25 at 8:48 A.M. with the Director of Nursing (DON) stated there was no actual facility policy in regards to the facility not being able to follow the outside wound physician orders and provide a wet-to-dry. Per the DON, the facility staff were educated by the medical supplier regarding wet-to-dry dressing changes and stated the wound nurse obtained an order to change the outside provider's order in accordance with the guidance given from the medical supplier. The DON verified the wound care order from the wound physician was discontinued and a new order was obtained from the medical director. Interview on 12/10/25 at 3:45 P.M. with the Medical Director (MD) revealed the facility's physician was contacted by a nurse and he was told the wound care dressing order from Resident #3's wound care physician was being questioned by staff. Per MD, the nurse informed him the medical supplier consultant was educating the staff the type of dressing change could be considered 'cytotoxic'. MD stated he was informed by the nurse the wound care physician was refusing to change the dressing change order so he gave a new order for a new dressing change to the nurse. MD verified he did not contact the wound care physician and consult on the rationale for the new order. Interview on 12/11/25 at 11:00 A.M. with Licensed Practical Nurse, (LPN) #297 revealed the nurse was acting as wound nurse and monitoring all wounds in the facility at the time of the survey. LPN #297 stated she received the new wound order from Resident #3's wound care physician. LPN #297 verified she did not enter the wound care physician's actual order into the treatment records at the time she received due to the medical supplier consultant advising her not to follow the wound care physician's order and to obtain a new order without the wet-to-dry aspect with a different type of solution to be used. LPN #297 stated she contacted the wound care physician on 12/03/25 and was told by the wound clinic the physician did not want to change the order and stated the order sent back to the facility should be followed. LPN #297 stated she called the Medical Director, (MD) and obtained a new order for Resident #3's dressing change. LPN #297 stated she did inform the resident the order from the wound care physician was against the facility's policy but stated there was no actual policy against the dressing change. Observation on 12/11/25 at 1:30 P.M. with LPN #297 performing wound care for Resident #3 revealed the nurse notified Resident #3 they would be completing the previous wound care physician's order, a wet-to-dry dressing. During the observation LPN #297 was observed following the original wound care physician's orders for the dressing change to Resident #3's wound. 2. Review of the medical record of Resident #07 revealed an admission date of 08/12/25. Diagnoses included dementia, Parkinsonism, and diabetes mellitus type two. Review of the admission MDS assessment dated [DATE] revealed Resident #7 had no pressure injuries upon admission and required touch assistance for lower body dressing and putting on or taking off footwear. Review of the medical record revealed a deep tissue injury was noted on 10/27/25 on the right inner heel. The physician and family were notified. Skin prep was ordered on 10/29/25 to be applied to the area every shift. Review of a Skin Condition Evaluation dated 11/13/25 revealed the area to be classified as an unstageable pressure injury measuring 4 centimeters (cm) by 3.1 cm and covered with eschar. Review of the record revealed no indication the physician had been notified of the presence of eschar and no treatment change had been ordered. Review of a Wound Consultant report dated 12/03/25 revealed Resident #07 had been recommended to use skin prep to the right inner heel. Observation on 12/09/25 at 2:30 P.M. with the Director of Nursing (DON) of Resident #07's wound revealed the area to be 3.5 cm by 4 cm, covered 100 percent with eschar and left open to air. Interview on 12/11/25 at 12:20 P.M. with Certified Nurse Practitioner (CNP) #310 revealed she was aware of the wound on Resident #07's right heel but was not aware it was covered with eschar. Observation on 12/11/25 at 12:30 P.M. of Resident #07's foot with CNP #310 and DON revealed the eschar was present. Interview at the time revealed CNP #310 had not been notified of the eschar. CNP #310 stated she was not wound certified and had not examined Resident #07's foot since 10/30/25. CNP #310 stated she would have deferred to the wound treatment consultant the facility had in place. Interview on 12/11/25 at 12:40 P.M. with Licensed Practical Nurse (LPN) #297, designated by the facility as the current wound nurse, revealed she had last seen the wound on 11/13/25 along with Wound Care Consultant #311 and the skin prep order had not been altered so did not question it.

Based on observation, interview, record review, and policy review, the facility failed to ensure catheter drainage bags were maintained below the level of the bladder to allow proper gravity drainage for one resident (#54) of one resident reviewed for catheter care. The facility census was 77.Findings Include:Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes mellitus (high sugar), and obstructive and reflux uropathy (inability to urinate normally due to blockage).Record review for Resident #54 revealed the resident had impaired cognition and required partial to moderate assistance with indwelling catheter care.Review of physician orders for Resident #54 revealed order dated 07/24/25 for a suprapubic (catheter inserted directly into the bladder with surgery) catheter. Review of the care plan dated 12/03/25 directed staff to keep the suprapubic catheter drainage bag and tubing below the level of the bladder for gravity drainage.Interview with Resident #54 on 12/08/25 at 9:50 A.M. revealed the resident wore a leg bag at all times, including during the night. Further interview revealed the resident did not want to wear the leg bag.Observation of Resident #54 on 12/09/25 at 7:05 A.M. revealed the Resident #54 lying in bed with a leg bag attached. The head of the bed was flat, and the leg bag was at the level of the bladder, not below it.Observation and staff interview on 12/09/25 at 7:15 A.M. with Licensed Practical Nurse (LPN) #289 revealed Resident #54 had a leg bag in place. LPN #289 verified the leg bag was not below the level of the bladder while the resident was lying in bed. LPN #289 further stated Resident #54 always wore a leg bag.Interview with the Director of Nursing (DON) on 12/09/25 at 2:15 P.M. verified Resident #59 always used a leg bag. When asked whether a leg bag could be kept below the level of the bladder while the resident was in bed, the DON stated it was not possible. The DON verified the use of the leg bag at all times was not care planned.Review of the policy titled, Indwelling Catheter, dated 01/02/24, revealed the catheter must be secured to facilitate the flow of urine, prevent kinks, and must be positioned below the level of the bladder.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure resident's diet orders were followed as written. This affected one (Resident #9) of four residents reviewed for nutrition. The facility census was 77.Findings Include: Review of Resident #9's medical record revealed an admission date of 10/01/25. Diagnoses included abnormal weight loss, anxiety disorder, asthma, heart failure, osteoarthritis, cognitive communication deficit, and dysphagia. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #9 was cognitively intact. Resident #9 required moderate assistance with toilet use, bathing, parts of dressing, and transfer. Resident #9 displayed no behaviors during the review period. Resident #9 received a mechanically altered diet. Review of Resident #9's care plan revised 10/17/25 revealed supports and interventions for self-care deficit, risk for alteration in mood, oral/dental health problems related to chewing and potential for nutritional risk. Interventions for nutritional risk included to document food and fluid intake, honor food preferences, provide and serve diet as ordered, and provide and serve supplements as ordered. Review of Resident #9's physician orders revealed an order dated 10/07/25 for a regular diet, pureed texture, thin consistency, double eggs with breakfast, ice cream and magic cups with lunch and dinner and cottage cheese with lunch. Observation on 12/08/25 at 11:23 A.M. of Resident #9 found Certified Nursing Assistant (CNA) #283 delivered Resident #9's lunch tray. Resident #9 was observed opening the lids and smelling the items. Resident #9 was provided what appeared to be pureed green beans, mashed potatoes, and pureed peaches. No protein was found on the tray, and no ice cream or magic cup supplements were provided. Resident #9 stated he was missing some items from his lunch. Interview on 12/08/25 at 11:30 A.M. with CNA #283 verified Resident #9 had not been provided a magic cup supplement, ice cream, his cottage cheese or other protein. Interview on 12/08/25 at 11:32 A.M. with Dietary Staff (DS) #248 revealed Resident #9 did not like meat (beef or pork) with any of his meals and verified Resident #9 had not been provided the pureed pasta with red meat sauce like the other residents because of the beef content. CNA #248 requested a magic cup frozen supplement since it had not been provided on his tray. CNA #248 then delivered the supplement but Resident #9 continued to not have the additional ice cream or cottage cheese as ordered. Interview on 12/09/25 at 10:05 A.M. with Dietary Manager (DM) #291 verified Resident #9 did not eat meat (pork or beef) and was to be provided an alternate protein with each meal. DM #291 reported Resident #9 enjoyed and they provided such items as eggs, pureed grilled cheese, cottage cheese, or yogurt. DM #291 verified the kitchen also supplied Resident #9's ice cream and magic cups with his meals which were kept in the kitchen freezer.

Based on medical record review, observation of medication administration, and review of facility policy, the facility failed to ensure a seizure medication was administered as ordered which resulted in a significant medication error. This affected one (Resident #20) of nine residents observed for medication administration. The facility census was 77.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, type two diabetes mellitus, hyperlipidemia, and unspecified convulsions.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and displayed no behaviors at the time of the review.Review of admission paperwork for Resident #20 revealed a past medical history including seizures.Review of physician orders for Resident #20 revealed an order dated 11/04/25 for 300 milligrams (mg) of oxcarbazepine to be administered by mouth every evening at bedtime for seizure disorder and an order for 600 milligrams (mg) of oxcarbazepine to be administered by mouth every morning for seizure disorder.Observation on 12/10/25 at 8:00 A.M. of medication administration by Licensed Practical Nurse (LPN) #258 for Resident #20 revealed she administered 300 mg of oxcarbazepine to Resident #20 instead of the ordered 600 mg dose.Interview on 12/10/25 at 9:20 A.M. with the Director of Nursing and LPN #258 confirmed Resident #20 received an incorrect dose of 300 mg of oxcarbazepine at 8:00 A.M. and should have received 600 mg.Review of facility policy dated 01/02/24 titled, Medication Administration revealed medication would be administered as ordered by the physician.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of Self-Report Incidents (SRI), review of open and closed medical records, review of facility incident reports, staff interview and review of facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (#8 and #12) of three residents reviewed for abuse. The facility census was 79. Findings include: 1. Review of the closed medical record revealed Resident #8 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, hyperlipidemia and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 10/22/24, revealed Resident #8 was moderately cognitively impaired. Review of Self-Reported Incident #253805, dated 11/07/24 at 10:12 A.M., revealed at approximately 8:45 A.M. Resident #9 was observed to walk up to Resident #8 and touched her breast on top of her clothing. Resident #9 was placed on one-on-one staff supervision. Resident #9 remained on one-on-one staff supervision until discharge on [DATE]. Review of the resident to resident altercation incident report, dated 11/07/24 at 5:27 P.M., revealed the nurse was completing morning mediation pass and pushing the medication cart when she looked over and saw a male resident (Resident #9) with his hand down Resident #8's shirt. The male resident (Resident #9) was directed to another chair away from Resident #8. 3. Review of the medical record revealed Resident #12 was admitted [DATE]. Diagnoses included pressure ulcer of sacral region stage 4, unspecified dementia severe with anxiety, rheumatoid arthritis without rheumatoid factor, and cognitive communication deficit. Review of the MDS assessment, dated 10/29/24, revealed Resident #12 was rarely understood. Review of SRI #253810, dated 11/07/24 at 11:48 A.M., revealed it was reported Resident #9 walked away from staff and before staff could intervene, he was witnessed touching Resident #12's brief, near her crotch area. Staff immediately separated the residents and were able to redirect Resident #9 to another area of the unit with a staff member by his side to continue monitoring. Resident #9 remained on one-on-one staff supervision until discharged on [DATE]. Review of the resident to resident altercation incident report, dated 11/07/24 at 5:03 P.M., revealed, after assisting another resident and transportation personnel out the locked doors, the nurse walked back into the lounge area and saw a male resident (Resident #9) beside Resident #12, who was in her wheelchair, with his hand in her pants. The nurse proceeded to redirect Resident #9 and moved him to a different area, without other residents in his presence. Interview on 12/09/24 at 9:10 A.M. with Certified Nursing Assistant (CNA) #202 revealed she worked on 11/07/24, during the time of both incidents involving Resident #9 and Residents #8 and #12. CNA #202 verified Resident #9 was placed on one-on-one supervision after the first incident with Resident #8. CNA #202 confirmed Licensed Practical Nurse (LPN) #201 was providing the one-on-one supervision for Resident #9 when she left him unsupervised and walked down the hall to let visitors off of the unit. CNA #202 verified it was during the time LPN #201 left Resident #9 unsupervised that the second incident involving Resident #12 occurred. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. As a result of the incident, the facility took the following actions to correct the deficient practice by 11/12/24: On 11/07/24, Resident #9 was placed on one-on-one staff supervision. On 11/07/24, social services assessed Resident #12 with no negative findings. Resident #12 was at baseline. On 11/07/24, social services assessed Resident #8 with no negative findings. Resident #8 was at baseline. On 11/07/24, Resident #9 was transferred to the hospital for further evaluation and treatment. Resident #9 returned to the facility on [DATE] at approximately 12:30 A.M. and remained on one-on-one staff supervision until discharge from the facility later that day. On 11/07/24, the Director of Nursing (DON) or designee, interviewed all interviewable residents related to abuse. Residents who were not interviewable received skin assessments. No adverse findings were identified. On 11/07/24, the DON or designee completed a staff questionnaire for all staff related to witnessing abuse and inquired if this resident (Resident #9) was witnessed off the unit with any other residents with no negative findings. On 11/07/24, the DON or designee assessed all residents/care plans to ensure no residents currently had sexually inappropriate behaviors, with no negative findings identified. On 11/07/24, the DON or designee re-educated all staff on the facility's abuse policy, including reporting of abuse. On 11/07/24, the Administrator or designee re-educated all staff on the facility procedures following an incident, with an emphasis on one-on-one staff supervision and abuse prevention. One-on-one staff supervision education included: one staff member must be assigned; if a staff member goes on a break, shift change or needs to leave the one-on-one supervision to complete any task, they must have another staff member take over the one-on-one staff supervision prior to leaving the one-on-one supervision assignment; and under no circumstances should a resident who is on one- on-one be left unattended. Beginning on 11/07/24, the DON or designee will complete ten random staff competencies weekly for four weeks to ensure staff knowledge of the procedures related to one-on-one staff supervision. Beginning on 11/07/24, the DON or designee will conduct random observations one time weekly for four weeks across all three shifts to ensure staff are following one-on-one procedures. On 11/12/24, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the incidents, corrective action and relevant polices. The results of the weekly audits will be reviewed by QAPI and any concerns will be addressed by QAPI. This violation represents non-compliance investigated under Complaint Number OH00159861.

Based on observation, medical record review, and staff interview, the facility failed to ensure ongoing interventions were implemented to promote discharge from the facility were provided. This affected one (#4) of four sampled residents reviewed for discharge opportunity. The facility census was 82. Findings include: Resident #4 admitted to the facility on [DATE] with the diagnoses including, quadriplegia, cervical spinal cord injury, hypertension, type two diabetes mellitus, history of urinary tract infection, depression, colostomy, and urostomy. Review of the most current minimum data set assessment dated [DATE] Resident #4 was assessed with intact cognition, dependent on staff for activities of daily living including bed mobility, rejection of care four to six days during assessment period, received a therapeutic diet, had no identified weight loss, and admitted with a stage IV pressure ulcer. Review of the baseline care plan documentation dated 04/13/24 Resident #4 had an discharge goal to assist resident in establishing a discharge with interventions including; discuss resident desire for long-term placement, discuss resident desire for short-term placement. Resident is unsure at this time. Initiate anticipation of community resources. Involve family/resident representative as appropriate. On 04/19/24 a plan of care was developed. Resident #4's admission and documented anticipated to have a length of stay less than 90 days related to Resident/family desire to discharge home. Interventions included the following: Resident will have a post-discharge plan to meet needs after discharge. Arrange for home care services, equipment and support services as indicated prior to discharge. Assist resident / family to determine most appropriate post-discharge setting. Assist resident/family with developing realistic discharge plans related to medical, physical, emotional and other needs. Be alert for significant changes in status that could have an impact on the resident's ability to discharge per the discharge plan. Keep resident, physician, and responsible party updated as needed. Educate resident and family regarding current diagnoses and typical progression. Encourage identified post-discharge caregivers or support persons to attend discharge planning meeting with resident and Interdisciplinary Team with permission of resident and or responsible party. Identify areas of needed education and training and implement to increase resident and or family knowledge and comfort with specific care. Provide emotional support to resident and or family as the date for discharge approaches. Be alert for specific areas of anxiety or concern and attempt to address. Further review of the medical record lacked documentation assisting Resident #4 with discharge planning until Social Services notes on 06/11/24 at 11:41 A.M. which revealed Licensed Social Worker (LSW) #500 discussed discharge planning with the resident. Resident relayed her goal is to heal her wound then return home. She is on a waiver program and identified a case manager (CM). LSW advised will need to follow-up with her to consult with her services, recommended home health and assistance is available and in place, prior to discharge. On 06/19/24 at 2:54 P.M. LSW #500 documented speaking with CM and Resident #4 option to secure own residence again. CM reported Resident would need to be in facility for 60 days to qualify for a specific home agency. LSW #500 documented follow-up with home health agency with future referral and consult with CM for discharge purposes. No further documentation contained in the medical record included discharge progress or follow-up dialog. On 07/18/24 at 6:35 P.M. LSW #500 documented resident reported attempting to line up aides for when she discharged . The resident indicated she attempted to contact a home discharge agency and left a message. No documentation included attempts made by LSW #500 to assist with discharge planning. No further Social Service notes were contained in the medical record. Interview with LSW #500 on 08/28/24 at 8:51 A.M. revealed on 07/18/24 LSW provided Resident #4 information regarding a specific community agency to assist with discharge. Resident #4 is able to use computer to complete application. Resident left a detailed message with the agency. LSW #500 confirmed she had not returned to assist Resident #4 with progress toward home goal or to determine if resident needed assistance completing application process and associated discharge arrangements.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions and monitoring were provided to a resident following difficulty consuming meal. This affected one (#3) of three sampled residents reviewed for meal time assistance in a facility census of 82. Findings include: Resident #3 admitted to the facility on [DATE] with the diagnoses including, chronic obstructive pulmonary disease, vascular dementia, repeated falls, chronic kidney disease, neuropathy, hypothyroidism, depression and cognitive communication deficit. Review of the most current minimum data set assessment dated [DATE] revealed Resident #3 had moderately impaired cognition, required set-up or clean-up assistance with eating, substantial to maximal assistance with activities of daily living, was incontinent of bowel and bladder, and received a mechanically altered diet. Review of nursing progress notes revealed on 08/03/24 at 6:56 P.M. at lunch today, resident struggled to eat a burrito that was served even after being cut up. Resident had an episode of choking. Back blows were administered, and resident was able to get food up and out. Resident #3 then struggled to eat dinner that had chunks of chicken. Resident was able to eat rice that was severed at lunch and noodles at dinner. Writer is changing resident diet to dysphagia advanced. Writer spoke with State tested Nursing Assistants (STNA's), and they also felt that this was in the resident's best interest because she does not have any dentures. On 08/05/23 physician orders included Speech Therapy evaluation and treatment three-five times a week for 30 days effective 08/05/24 for dysphagia management and regular diet with mechanical soft texture and thin liquid consistency for diet. According to Speech Therapy Progress Report between 08/05/24-08/20/24 listed dysphagia therapy to include patient and staff educated on safe swallow strategies. As of 08/20/24 progress included patient tolerated diet less than 5% overt signs and symptoms of oral/pharyngeal stasis/aspiration. Patient needs minimal to moderate cueing to complete 50% or more of meals. On 08/23/24 a nursing plan of care was implemented to address Resident #3's risk for choking related to need for mechanically altered diet and recent choking episode. Interventions included: Diet to be followed as prescribed. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor, document, and report to nurse, dietitian and Physician (MD) as needed (PRN) for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Refer to Speech therapy PRN. Observation on 08/27/24 at 12:10 P.M. noted Resident #3 in her room in bed. Resident #3 bed was the second bed from the entry door and the privacy curtain was drawn, which obstructed the view of the resident from the corridor. Resident #3 was seated in bed with the head of the bed upright. The resident was attempting to eat a mechanically altered diet. No staff were in the room or observed monitoring the resident. Observation at 1:30 P.M. noted the resident with the curtain drawn, in bed seated leaning to the left. The resident's eyes were closed with spilled food debris and liquids on clothing and bed linen. 100% of meal was uneaten including burger, french fries, coffee, juice and ice cream. A container of strawberry health shake was spilled on bed linens. On 08/27/24 at 1:35 P.M. Surveyor summonsed STNA #302 to Resident #3's bedside. STNA #302 confirmed Resident #3 had not consumed the lunch meal. STNA #302 stated the tray was placed in the resident's room at 11:45 A.M. and staff had not returned to assist the resident. STNA #302 was unaware Resident #3 required monitoring with eating. On 08/28/24 at 11:57 A.M. interview with Regional Registered Nurse (RRN) #200 during a review of the medical record confirmed Resident #3 was not monitored as indicated and instructed on intake or swallowing during the lunch meal on 08/27/24.

Based on observation, medical record review, staff and resident interview, and facility bowel and bladder management policy, the facility failed to provide and implement interventions to address specific resident incontinence needs. This affected one (#1) of three sampled residents reviewed for incontinence maintenance. The facility census was 82. Findings include: 2. Resident #1 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, hemiplegia affecting left side, traumatic hemorrhage right cerebrum, hypertension, morbid obesity, dysarthria, anarthria, hypothyroidism, and dysphagia. Review of the most current minimum data set assessment dated [DATE] Resident #1 had intact cognition, limited range of motion to upper and lower extremities of one side, utilized a wheelchair for mobility propelled by staff, required substantial to maximal assistance with activities of daily living (ADL) including bed mobility, dependent on staff for transfer to and from bed, and was always incontinent of bowel and bladder. Review of nursing plans of care revealed the following: On 07/19/23 plan of care revised to address Resident #1's incontinence of bladder related to impaired mobility, cerebral vascular accident with interventions including incontinence care: frequent check and change per protocol. On 07/26/21 a nursing plan of care was revised to address Resident #1's bowel incontinence related to impaired mobility with the intervention to check resident every two hours and assist with toileting as needed, and check and change at regular intervals. On 07/30/24 a bowel and bladder assessment was completed and recorded the resident as always incontinent of bowel and bladder. Bladder history noted Resident #1 voids large amount each episode, resident doesn't request toileting, requires staff assist for toileting, and was unable to transfer to commode or toilet. The plan was to check and change. No further interventions were listed to address Resident #1's incontinence. Observations on 08/27/24 noted at 9:36 A.M. Resident #1 in bed and State tested Nurse Aide (STNA) #300 was preparing to provide the resident a bed bath. Interview with STNA #300 noted she was providing Resident #1 with morning activities of daily living including an incontinence check for the first time since assuming care at 6:00 A.M. STNA #301 also entered the room and proceeded to assist with resident care. STNA #301 stated the resident will notify staff when needing incontinence care. Observation noted Resident #1 with an adult incontinence brief which was clean. STNA #301 provided perineal care and placed a new brief with choice of clothing. At 10:37 A.M. Resident #1 was transferred to the wheelchair using a mechanical lift and the resident was propelled to the unit activities room. At 12:22 P.M. Resident #1 was observed in the unit activity room eating lunch. Resident #1 stated she sits in her wheelchair frequently up to and exceeding five hours without incontinence checks or repositioning. Continued observation noted Resident #1 to remain in the unit Activity room without repositioning or incontinence checks. On 08/27/24 at 1:40 P.M. interview with STNA #301 and Registered Nurse #402 during a review of Resident #1's point of care electronic documentation revealed no information indicating the resident required incontinence check and changes every two hours as per plan of care. STNA #301 confirmed she was unaware the resident required the two hour checks and confirmed the resident had not been repositioned or checked for incontinence since the resident was placed into the wheelchair. At 2:13 P.M. observation noted STNA #301 to propel Resident #1 to her room with assistance from RN #402 and placed the resident in bed using a mechanical lift. During the transfer STNA #301 asked Resident #1 if the resident was incontinent of bowel. Resident #1 replied she was not aware until that moment. STNA proceeded to assist the resident with incontinence care, removed the resident brief and discovered the resident incontinent of a small amount urine and medium formed stool contained in the brief. Following cleansing of the residents buttock, red areas were noted to the skin. RN #402 stated not to apply barrier cream and confirmed the reddened areas. RN #402 stated she would contact the physician for a possible treatment to the buttock. According to facility Bowel and Bladder Management policy dated 2018 the intent is to help resident maintain or improve bowel and bladder incontinence. Appropriate interventions shall be put into place when appropriate and may include: Encourage to utilize or assist resident to the bathroom at strategic periods of the day for that resident. Take in advance of need ([NAME]) if the resident is frequently incontinent of bowel and bladder and does not have the cognitive ability to follow directions, nursing will anticipate the need to void and assist resident to the bathroom more frequently. This deficiency represents non-compliance investigated under Master Complaint Number OH00156737.

Based on staff interview and review of staffing schedules, the facility failed to ensure staffing included the services of a registered nurse (RN) in-house for at least eight consecutive hours a day, seven days a week. This had the potential to affected all 90 residents residing in the facility. The facility census was 90. Findings include: Review of facility staffing schedules between 06/01/24 and 06/30/24 identified three dates lacking RN coverage for eight consecutive hours. The were no RN hours on 06/09/24, 06/20/24, and 06/27/24 during a 24-hour period. On 07/02/24 at 11:20 A.M., interview with the Director of Nursing (DON) during review of the facility staffing schedules verified three days the facility did not have an RN scheduled in the facility during a 24-hour period. The DON confirmed there was no RN hours on the 06/09/24, 06/20/24, and 06/27/24 staffing schedules for a 24-hour period. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646 and Complaint Number OH00154464.

Based on observation, medical record review, staff interview, and review of the facility wound care policy, the facility failed to ensure pressure ulcer wound dressings and preventative interventions were implemented as ordered by the physician. This affected one (#1) of three sampled residents reviewed for skin integrity and wound prevention in a facility census of 90. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including quadriplegia, cervical spinal cord injury, hypertension, type two diabetes mellitus, history of urinary tract infection, depression, colostomy, and urostomy. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #1 was assessed with intact cognition, was dependent on staff for activities of daily living including bed mobility, received a therapeutic diet, was identified with no weight loss, and was admitted with a stage three (full-thickness skin loss) and a stage four (full-thickness skin and tissue loss) pressure ulcer. Review of skin grid pressure ulcer forms dated 04/15/24 noted wound measurements of Resident #1 pressure wounds documented as present on admission and original discovery date of 11/29/23. A right ischium stage four pressure ulcer measured 1.7 centimeters (cm) long by (x) 0 .7 cm wide x 2.1 cm deep. A left buttock stage three pressure ulcer measured 1.5 cm long x 1.7 cm wide x 0.1 cm deep. Review of a nursing plan of care dated 05/01/24 revealed a care plan was developed to address Resident #1's risk for further impaired skin integrity related to immobility due to quadriplegia, varicose veins, diabetes mellitus, and being admitted with pressure wounds to the left buttock and right ischium. Interventions included to administer treatments as ordered and monitor for effectiveness, and follow facility policies and protocols for the prevention and treatment of skin breakdown. Review of physician ordered revealed on 05/26/24 the physician changed Resident #1's wound treatment to the right ischium to have staff irrigate/rinse the wound with normal saline, apply Triad (wound cream) to the periwound, pack with Vashe (wound solution) moistened gauze, and cover the wound with silicone bordered foam dressing. The dressing was to be administered every morning and at bedtime scheduled at 10:00 A.M. and 9:00 P.M. and as needed. Resident #1 was evaluated by the wound center physician on 06/21/24 and indicated the wound to the left buttock was closed. An order was give to continue treatment to the area including to irrigate or rinse with normal saline, and cover with sacral silicone. On 06/25/24 the treatment was modified to include instructions for staff to irrigate or rinse with normal saline, apply Triad to the periwound, cover with sacral silicone, and apply coconut oil to reddened and dry areas on the buttocks. On 07/01/24 at 9:59 A.M. interview with Resident #1 revealed the wound dressing treatments were not completed the previous day and were last completed on 06/29/24. Observation and interview on 07/01/24 at 10:26 A.M. with Licensed Practical Nurse (LPN) #302, State tested Nurse Aide (STNA) #204, and STNA #205 noted the dressing to Resident #1's right ischium to be soiled and pealing off the wound with no date or initials indicating when the dressing was last applied. The left hip dressing was not applied. Interview with LPN #302, during the observation, stated she was not aware the left buttock dressing was not applied as ordered and confirmed the right ischium dressing lacked a date or initials of the nurse indicating when the dressing was last changed. Interview with STNA #204 and STNA #205, at the time of the observation, stated they were not aware the right hip dressing was missing, and indicated the previous shift did not report any information related to the wound dressings to them. According to wound measurements obtained on 07/02/24, Resident #1's left buttock wound was healed and the right ischium stage four pressure ulcer measured 1.0 centimeters (cm) long x 0.8 cm wide x 1.5 cm deep. On 07/01/24 at 11:40 A.M., interview with the Director of Nursing (DON) verified Resident #1's wound dressings were not applied as ordered by the physician, and stated the facility wound treatment policy directed staff to apply initials with a date on the dressing at the time of application. Review of the facility wound care policy, revised October 2021, revealed staff are to verify there is a physician's order for the procedure, and when staff prepared to apply a wound dressing, they are to mark the tape with initials and date when the dressing was applied. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646.

Based on observation, medical record review, staff interview, and review of the facility administration and documentation of medication policy, the facility failed to ensure medications were provided as ordered by the physician. This resulted in a significant medication error when a resident was not administered an antipsychotic medication as prescribed. The affected one (#4) of three residents reviewed for medications in a facility census of 90. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including, seizure disorder, major depressive disorder with recurrent severe psychotic symptoms, type two diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, borderline intellectual functioning, delusional disorders, hypertension, and visual hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #4 with intact cognition, a depressed mood two to six days during the assessment period, the resident was independent with activities of daily living and ambulation, and received the antipsychotic, antidepressant, and hypoglycemic medications daily. Review of Resident #4's nursing plan of care dated 10/17/22 revealed a care plan was implemented, and on 05/17/24 was revised, to address Resident #4's behavior problem related to depression with psychotic features, traumatic brain injury, schizoaffective disorder, visual and auditory hallucinations, and delusional disorder. Interventions included to administer medications as ordered and to Monitor/document for side effects and effectiveness. Review of Resident #4's physician orders revealed on 11/11/22 an order was initiated for the administration of the antipsychotic medication Risperdal with instructions to give 0.75 milligrams (mg) by mouth in the morning related to schizoaffective disorder and give 1.5 mg by mouth at bedtime. Review of nursing progress notes revealed on 06/22/24 at 8:20 P.M. Risperdal 1.5 mg was not available for administration. On 06/23/24 at 8:27 A.M. Risperdal 0.75 mg was not available and documented with an, N/A, in the medical record. On 06/29/24 at 11:20 A.M. Risperdal 0.75 mg was documented as on order. Observation on 07/01/24 at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #301 obtained Resident #4's medications from the medication cart. LPN #301 was unable to locate a Risperdal 0.75 mg tablet in the cart and proceeded to the facility medication storage room which contained contingency medications. LPN #301 accessed the contingency medication storage cabinet and discovered two Risperdal drawers were empty. At 8:45 A.M., LPN #301 notified Certified Nurse Practitioner (CNP) #201 to make notification that the medication was not available in the facility for administration. At 9:08 A.M., CNP #201 confirmed the medication was not available in the facility, indicating the medication was not available in a secondary contingency medication location in the facility. On 07/01/24 at 11:45 A.M., during review of Resident #4's medical record with the Director of Nursing (DON), confirmed entries in progress notes indicating Risperdal 0.75 mg and 1.5 mg were not available for administration on 06/22/24, 06/23/24, and 06/29/24. Review of the facility administration and documentation of medications policy, revised May 2023, noted it is facility policy that every resident receives medications by the licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medications, safely, properly and in a timely manner, and that medications shall be accurately and completely documented. Documentation must be completed of medications not administered as ordered with the reason why, notifications completed and negative outcome to the resident, if any. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646.

Based on closed medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure physician ordered labs were followed-up on and completed timely to identify a urinary tract infection (UTI) for Resident #110 who had a urinary catheter. Actual harm occurred on 12/07/23 when the facility failed to properly obtain a urine specimen for Resident #110 who was symptomatic of a urinary tract infection. Between 12/07/23 and 12/14/23 no additional testing or interventions to treat a urinary tract infection were provided. On 12/14/23 Resident #110's family transported the resident to the hospital where the resident was admitted and required intravenous (IV) antibiotics for treatment of a urinary tract infection. The resident was hospitalized for four days. This affected one resident (#110) of three residents reviewed for UTIs. The facility census was 105. Findings include: Review of Resident #110's closed medical record revealed an admitted [DATE]. Diagnoses included spina bifida with hydrocephalus, anxiety disorder, pseudobulbar affect, and a tongue abscess. Resident #110 had a history of frequent urinary tract infections. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/06/23, revealed Resident #110 had moderate cognitive impairment, required maximum assistance for activities of daily living (ADLs), and had an indwelling catheter and a colostomy. Additional review of the discharge MDS, dated [DATE], revealed family notified the facility Resident #110 would not return to the facility due to being admitted to the hospital for a UTI. Review of the care plan, dated 11/07/23, revealed Resident #110 had a suprapubic catheter related to a diagnosis of spina bifida and was at risk for developing UTIs and trauma related to the catheter. Interventions included staff to monitor for signs and symptoms of frequency and discomfort upon urination, pain and discomfort related to the catheter, and monitor/record/report to the physician any signs and symptoms of a UTI, which included pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. Review of a physician's order, dated 12/07/23, revealed Resident #110 was to have a urinalysis with culture and sensitivity completed due to a family concern the resident may have a UTI. Review of Nurse Practitioner (NP) #202's progress note, dated 12/08/23 and timed 8:23 A.M., revealed Resident #110 was seen for urinary frequency. Review of the Laboratory Results Report, dated 12/11/23 and timed 1:49 P.M., revealed Resident #110 had urine collected for a urinalysis on 12/07/23 at 5:00 A.M., the urine was received in the laboratory on 12/08/23 at 8:10 A.M. and resulted on 12/11/23 at 2:45 P.M. Further review of the results revealed probable contamination with greater than 100,000 colony forming units per milliliter (CFU/ml), which is the concentration of live, viable growth bacteria cells capable of reproducing when grown on a petri plate, and mixed pathology with greater than or equal to three organisms isolated. Further review of Resident #110's medical record revealed no documentation of the facility acknowledgement of the urinalysis results or physician notification for follow-up on the contaminated urinalysis results. Review of a progress note from NP #202, dated 12/13/23 and signed on 12/14/23 at 7:38 A.M., revealed a diagnosis of urinary frequency. Additionally, it noted results of the urinalysis dated 12/11/23 suggested contamination and the specimen was to be redrawn. Review of the physician order summary, dated 12/13/23, revealed Resident #110 was to have a urinalysis with culture and sensitivity completed, to be collected on 12/14/23. Additional review of Resident #110's medical record revealed no evidence urine was collected on 12/14/23 to complete the urinalysis ordered. Review of an emergency department encounter, dated 12/14/23, revealed Resident #110 had an elevated white blood cell count of 15.5 cells per microliter (normal is four to 11 cells per microliter of blood) and an abnormal urinalysis with the urine having a cloudy appearance (normal is clear or light yellow in color), a trace of ketones (normal is none), a trace of blood (normal is none), protein 1 plus, (normal is none), nitrates were positive (normal is negative) and leukocytes were 3 plus (normal is negative). Resident #110 was admitted to the hospital due to a UTI and was treated with Rocephin (antibiotic) one gram (gm) intravenously daily. Review of the hospital discharge summary, dated 12/18/23 and timed 4:49 P.M., revealed Resident #110 had a four-day length of stay and was treated for a UTI with hematuria (blood in urine) and hyponatremia (low sodium). Resident #110 responded well to treatment and discharged to a new facility. Interview on 01/10/24 at 11:30 A.M. of the Administrator revealed on 12/14/23, Resident #110's family transported the resident to an outside appointment. The family took Resident #110 to the hospital due to concerns of the resident having a UTI. Interview on 01/10/24 at 3:45 P.M. with the Director of Nursing (DON) verified the urinalysis ordered for collection on 12/14/23 had not been collected. The DON had no knowledge of why the urine was not collected other than Resident #110 was going out for a scheduled appointment the morning of 12/14/23 and it was not obtained due to getting Resident #110 ready for the appointment. Interview on 11/11/24 at 9:40 A.M. with Corporate Registered Nurse (CRN) #203 verified the medical record for Resident #110 was silent for the urinalysis resulted on 12/11/23 being received and reviewed by the facility and further verified the medical record was silent for physician notification and follow-up on the contaminated specimen. Interview on 01/11/23 at 8:45 A.M. with NP #202 confirmed the facility did not provide notification of the contamination results for the urinalysis collected on 12/07/23 and resulted on 12/11/23. Additionally, NP #202 verified she had discovered the contamination result when seeing Resident #110 on 12/13/23, at which time NP #202 ordered a repeat urinalysis. Review of the facility policy titled Laboratory Testing Process, dated June 2018, revealed it is the responsibility of the facility nurse to process all laboratory orders for each resident in their care. Laboratory results will be reviewed, and appropriate actions taken including physician notification as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00149314.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility corrective action documents, and policy review, the facility failed to ensure a resident identified at risk for pressure ulcer development did not develop an in-house acquired stage III pressure ulcer (full thickness skin loss) and received timely interventions to promote healing. Actual harm occurred when Resident #61 was discovered with a stage III pressure ulcer to the sacrum one day after being assessed with intact skin integrity and no documented intervention was implemented to promote healing or further tissue damage until three days following discovery. This affected one (#61) of three residents reviewed for pressure ulcer care and treatment. The facility census was 109. Findings include: Review of Resident #61's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, left femur fracture, type II diabetes mellitus, hypertension, chronic kidney disease stage III, Alzheimer's disease, vitreous degeneration, depression, dysphagia, dementia, history of urinary tract infection, transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living (ADLs) including bed mobility, transfers, dressing, and hygiene, was assessed as incontinent of bowel and bladder, and was at risk for pressure ulcer development with a current stage III pressure ulcer. Review of a pressure sore risk assessment dated [DATE] revealed Resident #61 scored at risk. On 06/08/23 the resident was assessed at high risk of developing a pressure sore. Review of a weekly skin check dated 06/03/23 at 9:57 A.M. revealed the assessment noted Resident #61's skin appearance as normal with no new alteration in skin integrity. Review of a skin grid pressure assessment dated [DATE] revealed Resident #61 was assessed with a new in-house acquired pressure ulcer to the sacrum which was discovered on 06/04/23. The wound characteristics were described as a stage III pressure ulcer measuring 4.3 centimeters (cm) long by 6.0 cm wide by 0.1 cm deep. There was granulation, epithelialization, and slough tissue noted to the wound bed with moderate serous (thin, watery, clear) drainage and associated pain. The summary of care and treatment noted a treatment implemented to cleanse with normal saline or sterile water, pat dry, apply calcium alginate to wound bed, and cover with a dry clean dressing every two days and as needed for a stage III pressure ulcer with irregular shape and moderate drainage. Resident #61 had a low air loss (LAL) mattress with risk factors for pressure ulcer formation and complications to healing included type II diabetes and poor mobility. Further review of the medical record lacked documentation indicating preventative interventions and a treatment for the wound were implemented until 06/07/23. Review of a nursing plan of care was revised on 06/09/23 to address Resident #61's risk for impaired skin integrity related to decreased mobility, incontinence, morbid obesity, diabetes mellitus, chronic kidney disease, and history of moisture associated skin damage. Interventions and dates of implementations included to administer treatments as ordered and monitor for effectiveness on 05/03/23 to assess, record, and monitor wound healing measuring length, width and depth where possible; assess and document status of the wound perimeter, wound bed, and healing progress reporting improvements and declines to the physician on 05/03/23; the resident needs monitoring, reminding, and assistance to turn and reposition at least every two hours or more often as needed or requested on 05/03/23; encourage and assist with frequent repositioning in bed as tolerated on 05/03/23; follow facility policies and protocols for the prevention and treatment of skin breakdown on 05/03/23; inform the physician or nurse practitioner and resident, family, or caregivers of any new area of skin breakdown on 05/03/23; utilize a LAL mattress on 05/03/23; monitor nutritional status on 05/03/23, serve diet as ordered and monitor intake and record on 05/03/23; monitor, document, and report to the physician as needed changes in skin status on 05/03/23; notify a nurse immediately of any new areas of skin breakdown including redness, blisters, bruises, and discoloration noted during bath or daily care on 05/03/23; nutritional supplements as ordered on 05/03/23; use of a lifting device, draw sheet, and others to reduce friction on 05/03/23; and updated to float heels in bed as tolerated on 06/02/23, and utilize a Roho cushion (pressure relieving cushion) in the wheelchair on 06/25/23. Review of wound physician evaluation documentation dated 06/14/23 noted Resident #61's wound measured 4.0 cm long by 6.0 cm wide by 0.1 cm deep and assessed the wound as healing. Interventions included a treatment application of alginate and to cleanse the wound with normal saline or sterile water, apply the alginate to the wound bed, cover with a dry clean dressing, and bordered gauze every two day(s) and as needed. Further review revealed preventative wound recommendations included a LAL mattress and a pressure reduction cushion. Staff were to consult with physical therapy (PT) and occupational therapy (OT) for wound offloading needs. Weekly assessments and associated dressing changes to the wound were to continue. Review of a wound physician assessment and plan dated 08/30/23 noted Resident #61's sacrum wound was healing with wound measurements of 1.5 cm long by 1.5 cm wide by 0.2 cm deep. The treatment order included cleansing the wound with normal saline or sterile water, apply medical honey gel to the wound bed, and cover with a dry clean dressing as instructed. Additional treatment with bordered gauze every two day(s) and as needed. Preventative wound recommendations continued with a LAL mattress and a pressure reduction cushion. On 08/31/23 at 12:15 P.M., interview with the Administrator, Director of Nursing (DON), and Regional Support Registered Nurse (RN) #500, during a review of Resident #61 medical record, confirmed Resident #61 was assessed at risk for pressure ulcer development. On 06/03/23 at 9:57 A.M., Resident #61 had a skin assessment which indicated there was no skin breakdown. On 06/07/23, a skin grid pressure assessment identified Resident #61 acquired a stage III pressure ulcer to the sacrum that was discovered on 06/04/23. All staff verified there was no documented evidence of a treatment or additional interventions in place to prevent further deterioration of the wound until 06/07/23 when a treatment was documented to be implemented to the wound. Review of a wound management program policy, dated 11/2021, revealed wound management principles provide a basis for effective wound care and are considered in development of the plan of care. Provision of systemic support to reduce existing and potential cofactors included nutritional and fluid support, maintenance of physiological local wound environment including, preventing and managing infection, cleaning wound, managing exudates, protecting wound, and managing pain. As a result of the deficient practice the facility has implemented corrective action as of 07/14/23 as follows: The DON completed a wound audit of all residents residing in the facility started and completed on 06/14/23. In-service education was provided to all state tested nurse aides (STNAs) by the DON including wound management and notification to nursing when skin changes are identified and was completed 06/22/23. In-service education was provided to all nurses by the DON including the wound management program, initiation of wound observations, and proper notifications when wounds were identified, and was completed 06/22/23. On-going audits were completed by the DON/designee of wound dressing observations to ensure orders and treatments matched wound dressing change observations with three staff members weekly conducted between 06/23/23 through 07/28/23 with no concerns identified. On 07/27/23, the facility Quality Assurance Performance Improvement (QAPI) team reviewed audits, discussed corrections, and on-going education. On 08/01/14, a post survey revisit was completed regarding skin breakdown, treatment, and care, and determined a compliance date of 07/14/23. On 08/31/23, interview with Licensed Practical Nurse (LPN) #300, LPN #301, STNA #201, STNA #202, and STNA #203 confirmed corrective action in-service participation and were all knowledgeable about in-service topics. On 08/31/23, review of two (#95 and #108) additional residents identified with pressure ulcers noted effective evidence of corrective actions with no concerns noted.

Based on medical record review, review of hospital documentation, review of a death certificate, review of staffing schedules, staff interviews, and review of facility policies, the facility failed to ensure a resident (#110) was free from neglect when the facility staff failed to provide appropriate and timely treatment, care, services, and equipment, and failed to notify the physician of a change in condition. Resident #110 was admitted to the facility and physician orders for care and treatment were not processed timely, clinical assessments and follow-up of abnormal findings were not completed, a known Continuous Positive Airway Pressure (CPAP) machine (a non-invasive ventilation therapy used to facilitate breathing during sleep) for sleep apnea was not available in the facility, and the physician was not notified of a change in respiratory status when the resident's oxygen saturation declined, and the resident exhibited use of accessory muscles (muscles other than the diaphragm and intercostal muscles that are used during labored breathing) when breathing. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when the lack of timely and appropriate care, services, treatment, equipment, and notification to the physician contributed to Resident #110's untimely death when he was found unresponsive and absent of vital signs within 12 hours of admission to the facility. This affected one (#110) of three residents reviewed for death. The facility census was 108. On [DATE] at 12:24 P.M., Corporate Clinical Support Nurse (CCSN) #358, the facility Administrator, and the Director of Nursing (DON), were notified Immediate Jeopardy began on [DATE] when Resident #110 was admitted to the facility and staff failed to provide appropriate and timely treatment, care, services, and equipment, and failed to notify the physician of a change in condition. Resident #110's admitting physician orders for care and treatment were never activated in the Electronic Medical Record (EMR), there was no documentation in the medical record to show any treatment or care was provided, the facility did not ensure Resident #110 had a CPAP machine for use at night, and there was no documented evidence Resident #110's blood sugar levels were monitored, medications were administered, or notification made to the physician of Resident #110's abnormal oxygen saturation level and need for intervention. Resident #110 did not have any follow up assessments, evaluations of respiratory status, or monitoring of blood sugar levels or oxygen saturation rates through the night on [DATE] and was found unresponsive and without a pulse on [DATE] at 6:35 A.M. Cardiopulmonary resuscitation (CPR) was initiated by the facility staff until Emergency Medical Services (EMS) personnel arrived and took over CPR. The EMS personnel stopped CPR on [DATE] at 7:07 A.M. and Resident #110 was pronounced dead. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], a facility-wide audit was completed of all in-house residents by the DON and CCSN #358 to ensure all orders were processed, all residents had the appropriate equipment in house, and the physician was notified of all new admissions since [DATE]. On [DATE], Licensed Practical Nurse (LPN) #265, who admitted Resident #110 to the facility on [DATE], was suspended pending investigation. On [DATE], nursing audits were conducted by Unit Manager #338 to ensure CPAP and Bilevel Positive Airway Pressure (BiPAP) machines in house were in proper working condition and appropriate orders were in place for each resident using either a CPAP or BiPAP machine. On [DATE], oxygen audits were conducted by Unit Manager #338 to ensure appropriate equipment was in house and in working condition and each resident had appropriate orders. On [DATE], nursing audits were completed by Assisted Director of Nursing (ADON) #214 for blood sugar monitoring and administration of insulin to ensure each resident had appropriate orders in place for the monitoring of blood sugars and medications were administered as ordered. On [DATE], medication audits were completed by Unit Manager #285 to ensure all prescribed medications were in house and available. On [DATE], a supply audit was completed by Central Supply #222 to ensure the periodic auto-replenishment (PAR) levels were met and all necessary supplies were on hand for resident care. On [DATE], all new admissions audits were conducted by ADON #214 and CCSN #358 to ensure all newly admitted residents had an identified code status, orders entered, the physician was notified of the admission, the required/ordered equipment was on hand and functioning, and resident monitoring was in place. On [DATE], all staff were educated on the facility policies related to abuse and neglect, admissions to the facility, physician notification of a change in condition, and of the need to notify the manager on call of all new admissions within 60 minutes of the newly admitted resident's arrival. On [DATE], a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON, ADON #214, and CCSN #358 in attendance with the facility's removal plan and initial audits reviewed. Beginning on [DATE], the DON began weekly audits for all new admissions to ensure each resident had the necessary equipment, orders, physician notification, and assessments, and will continue until [DATE]. Results of the admission audits will be presented at daily stand-up meetings and at the monthly QAPI meeting for review and recommendations. The QAPI team will determine when compliance is obtained. Beginning on [DATE], ADON #214 will continue to provide education to all newly hired staff members and new agency staff members on the facility policies related to abuse and neglect, admissions to the facility, and physician notification and change in condition, and of the need to notify the manager on call of all new admissions within 60 minutes of the newly admitted resident's arrival. Newly hired staff and new agency staff will not be able to work until education is completed. On [DATE], interviews at random times with Registered Nurse (RN) #212, RN #215, LPN #273, LPN #283, LPN #357, State tested Nurse Aide (STNA) #261, STNA #249, STNA #327, STNA #330, and STNA #347 verified they were educated on the facility's polices related to abuse and neglect, admissions to the facility, physician notification of a change in condition, and of the need to notify the manager on call of all new admissions. All staff members interviewed were knowledgeable about the education content and felt confident the information could be applied during their work tasks. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #110 revealed an admitted [DATE] and a discharge date of [DATE] due to death in facility. Admitting diagnoses for Resident #110 included diabetes mellitus type II, chronic obstruction pulmonary disease, sleep apnea, hypertension, heart disease, and peripheral vascular disease. Review of the hospital inpatient record dated [DATE] revealed Resident #110 had diagnoses of diabetes with long term insulin use, diabetic neuropathy, chronic obstructive pulmonary disease, and obstructive sleep apnea on a CPAP machine. On assessment, Resident #110 was noted to have a normal pulmonary effort with bilateral expiratory wheezes, and was alert and oriented to person, place, and time, and cooperative. Review of the hospital referral printed [DATE] at 1:51 P.M. revealed Resident #110 was admitted to the hospital on [DATE] with hyperglycemia with blood sugars greater than 400 milligrams per deciliter (mg/dL), with the initial blood sugar in the emergency department greater than 700 mg/dL. The resident was started on an insulin drip to treat hyperglycemia. Diagnoses included anxiety, arthritis, asthma, atherosclerosis, chronic obstructive pulmonary disease, diabetes mellitus, encephalopathy, aortic valve stenosis, moderate to severe with bioprosthetic replacement [DATE], obstructive sleep apnea with use of a CPAP machine since [DATE], hyperlipidemia, paroxysmal atrial fibrillation, and peripheral vascular disease. Resident #110 also had a cardiac pacemaker placed on [DATE]. Review of the facility communication paperwork for Resident #110's planned admitted d [DATE] revealed Resident #110 had primary diagnoses of diabetes and dehydration, should have a walker, wheelchair, and CPAP machine with a comment that indicated Resident #110 had his own CPAP machine and the facility must be sure to stay on top of blood sugar checks. Review of Resident #110's hospital discharge vital signs dated [DATE] at 3:43 P.M. revealed a pulse rate of 77 beats per minute, temperature of 98.6 degrees Fahrenheit (F), 18 respirations per minute, and an oxygen saturation of 96 percent (%). Review of the hospital discharge record dated [DATE] at 4:35 P.M. revealed Resident #110 was to be admitted to an extended care facility for therapy with activity per physical therapy recommendations. The continuation of care documentation included orders for Novolog insulin six units subcutaneously (SQ) with meals plus sliding scale, call to schedule modified barium swallow study, CPAP at bedtime per home settings, notify the physician if Resident #110 gained more than five pounds in one week, and for the resident to be turned and repositioned every two hours. Resident #110 was ordered medications to treat high blood pressure including Coreg 12.5 milligrams (mg) twice a day by mouth and Hydralazine 50 mg twice a day by mouth. Resident #110 was also ordered blood sugar checks four times a day and a Freestyle Libre sensor (a device worn directly on the skin which continuously monitors blood sugar levels without the need for finger pricking). Orders to be clarified included insulin detemir 15 units SQ at bedtime, Levemir insulin 20 units SQ daily with breakfast, Novolog insulin six units SQ three times a day before meals, and Novolog 12 insulin units SQ four times a day before meals and at bedtime. Review of Resident #110's admission assessment dated [DATE] and timed 9:56 P.M. revealed Resident #110 arrived per wheelchair with an admitting diagnosis of hyperglycemia. Resident #110 was alert and oriented, was identified to be independent for bed mobility and eating, and required supervision for transfers, dressing, toilet use, and personal hygiene. Resident #110 had bruised skin throughout the upper extremities with bruising noted on his abdomen, and the assessment did not address Resident #110's overall skin color or warmth. The nutrition and oral assessment, as part of the admission assessment, contained two comments in the comment box that read diabetic and dysphagia. The respiratory assessment, as part of the admission assessment, indicated Resident #110 had regular respirations with a comment that read, No oxygen tank or CPAP brought in with resident. The cardiovascular assessment, as part of the admission assessment, revealed heart tones were audible and regular, pedal pulses were equal, normal, and palpable with edema noted to the right foot. Resident #110 was assessed with the presence of a pacemaker. Resident #110's abdomen was soft and nontender with bowel sounds present, and Resident #110 was identified to be continent of bowel and bladder with a note indicating the resident was on diuretic medications. Review of Resident #110's admission summary dated [DATE] at 11:21 P.M., written by LPN #265, revealed Resident #110 arrived via wheelchair accompanied by family. Resident #110 was an uncontrolled diabetic and had an exacerbation of chronic obstructive pulmonary disease (COPD). Resident #110's plan was to have a short stay in the facility. LPN #265 continued to encourage Resident #110 to use the call light before transferring as Resident #110 was a supervised assist with transfers. Resident #110 was resting in bed with the call light in reach. Review of Resident #110's vital signs dated [DATE] at 11:27 P.M. revealed a blood pressure of ,d+[DATE] mmHg (millimeters of mercury), a temperature of 97.7 degrees F, a pulse rate of 86 beats per minute, respirations were 20 breaths per minute, and an oxygen saturation of 89 %. Review of Resident #110's physician orders revealed one order dated [DATE] at 10:00 A.M. to release the deceased body to the funeral home. There were no other active physician orders in the medical record. Review of Resident #110's EMR revealed no Medication Administration Record (MAR) or Treatment Administration Record (TAR) existed for Resident #110 on either [DATE] or [DATE]. Review of the nursing progress notes revealed a note dated [DATE] at 7:39 A.M. which documented Resident #110's family (son) was notified of the death. Further review of the nursing progress notes revealed a note dated [DATE] at 9:48 A.M., written by LPN #361, revealed Resident #110 was checked on by the nurse aides at 3:35 A.M. and the resident was asleep in bed. The nurse checked on the resident at 4:15 A.M. and witnessed the resident in bed. The resident had no complaints of pain or discomfort noted throughout the night. At 6:35 A.M., STNA #293 called the nurse to Resident #110's room, and the resident was found to be unresponsive and without a pulse. CPR was started at 6:40 A.M. and EMS were called. EMS personnel arrived at the facility at 6:48 A.M. on [DATE] and took over CPR. EMS personnel pronounced the time of death for Resident #110 as 7:07 A.M. and the family and the physician were notified of the death. Review of the complete paper medical record and EMR from Resident #110's admission on [DATE] to discharge on [DATE] revealed no evidence the physician was contacted for physician orders to address the care and services needed for Resident #110. There was no evidence of use of supplemental oxygen or use of a CPAP machine, and no documented evidence of notification of change in condition related to an oxygen saturation of 89% on admission, no reassessment of Resident #110's condition, and no interventions to address the change in condition. Review of Resident #110's death certificate dated [DATE] revealed the cause of death to be sudden cardiac death due to complete heart block with coronary artery disease and diabetes noted as significant conditions contributing to death but not resulting in the immediate cause of death. Review of the daily staffing schedules revealed LPN #265 was assigned to care for Resident #110 on [DATE] from 3:00 P.M. to 11:30 P.M. and an agency nurse, LPN #361, was assigned to care for Resident #110 from 11:00 P.M. on [DATE] to 7:30 A.M. on [DATE]. Interview on [DATE] at 12:30 P.M. with LPN #265 verified she admitted Resident #110 to the facility and provided care on [DATE]. LPN #265 stated Resident #110 arrived at the facility on [DATE] at approximately 6:00 P.M. with family, and confirmed he had no supplemental oxygen tanks or CPAP machine with him. LPN #265 stated Resident #110 was alert and oriented with labored breathing. LPN #265 stated Resident #110's vital signs were obtained on admission and verified his oxygen saturation was 89 %. LPN #265 verified no supplemental oxygen was applied and the physician was not notified of the low oxygen saturation rate at that time. LPN #265 stated a blood sugar check was completed on [DATE] around dinner time and Resident #110 had a blood sugar level of 160 mg/dL. LPN #265 stated she could not find the ordered parameters for when Resident #110 was to receive insulin coverage, so she called the physician and received orders. LPN #265 stated insulin coverage was provided to Resident #110 but was unable to state what type of insulin was given or how many units were administered. LPN #265 further stated Resident #110's vital signs were rechecked on [DATE] between 9:30 P.M. and 10:00 P.M. and Resident #110's oxygen saturation at that time was 88 %. LPN #265 stated Resident #110 was sitting in a wheelchair and used accessory muscles to breathe. LPN #265 stated Resident #110 was short of breath with any exertion, so she applied supplemental oxygen via nasal cannula on Resident #110 at a rate of three liters per minute. LPN #265, again, verified she did not communicate the change in condition to the physician, did not obtain orders for supplemental oxygen, and further verified there were no further interventions attempted. LPN #265 further verified she did not address or inquire about the supplemental oxygen or the absence of a CPAP machine with Resident #110, his family, or the physician, and did not communicate Resident #110's low oxygen saturation levels to Resident #110, his family, or the physician. LPN #265 stated physician orders were not activated in Resident #110's medical record to allow for care and treatment to be completed, and confirmed documentation or any care or treatment could not be entered into the medical record as a result. Interview on [DATE] at 1:12 P.M. with Physician #360 verified he was called once by the facility and was notified of Resident #110's admission and to review orders. Physician #360 stated Resident #110's orders were reviewed with LPN #265. Physician #360 stated he was not aware Resident #110 had difficulty breathing, was not aware his CPAP was not available at the facility and was not aware of Resident #110's oxygen saturation rates once in the facility. Physician #360 stated he was surprised by Resident #110's death as the resident was only at the facility for approximately 12 hours. Interview on [DATE] at 2:41 P.M. with STNA #293 verified Resident #110 was checked at 3:30 P.M., oxygen was in place, and Resident #110 appeared to be sleeping. STNA #293 stated she entered the resident's room at 6:30 A.M. and verified it appeared Resident #110 had passed away. STNA #293 immediately called the nurse. STNA #293 verified Resident #110 did not have a CPAP machine in place. Interview on [DATE] at 2:45 P.M. with STNA #243 verified Resident #110 was checked on at approximately 3:30 A.M. on [DATE] and appeared to be sleeping. STNA #243 stated she did not recall the resident having supplemental oxygen on, and further confirmed there was not a CPAP machine on Resident #110. Interview on [DATE] at 3:56 P.M. with LPN Supervisor #359 stated she was called by Agency LPN #361 to assist with Resident #110 when he was found unresponsive and without a pulse on [DATE]. LPN Supervisor #359 stated she called a code and started CPR on Resident #110. LPN Supervisor #359 stated upon arrival to the resident's room, Resident #110 did not have supplemental oxygen in his nose as the nasal cannula was around his neck below the [NAME]. LPN Supervisor #365 verified Resident #110 did not have a CPAP machine on or at the bedside. Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated [DATE], revealed residents have the right to be free from neglect and further revealed neglect is the failure of the facility, its employees or facility services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the policy titled, Admission Assessment and Follow Up: The Role of the Nurse, dated [DATE], revealed the nurse is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the Minimum Data Set (MDS) assessment. The nurse is required to reconcile the list of medications from the medication history, admitting orders, the previous medication administration record (if available), and the discharge summary from the previous institution, contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings and notify other disciplines and departments of the resident's admission. The nurse is also responsible for reporting immediate needs of the resident to the supervisor and the attending physician. Review of the policy titled, Notification of Change in Condition, with a revision date of February 2022, revealed the primary care physician and the resident representative should be notified in a timely manner with a significant change in status. Review of the policy titled, Documentation Guidelines: All Departments, dated [DATE], revealed the following information should be recorded in the resident's medical record: the date and time the assessment was performed, information provided to the resident during the assessment, and orders obtained from the physician. Additionally, any observations or interactions with the resident relevant to care and services should be outlined in an episodic note containing the relevant information, any physician communication, or orders as a result of the observation/interaction. This deficiency represents non-compliance investigated under Complaint Number OH00143177.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of The Department of Health and Human Services, review of the Centers for Disease Control and Prevention (CDC) COVID Data tracker and guidance, review of posted COVID-19 signage regarding Personal Protective Equipment (PPE), observations, review of the facility policies and procedures, and staff interviews, the facility failed to implement effective and recommended infection control practices, including a system to ensure the appropriate use of PPE by staff to prevent the spread of COVID-19 in the building, a system to ensure staff was donning and doffing PPE when required, ensure residents who tested positive for COVID-19 remained in their room or were wearing appropriate PPE outside of the room, a system in place to ensure contaminated trash was disposed of properly, a system to ensure the appropriate signage was posted outside of required PPE for isolation rooms, a system in place to ensure potentially contaminated dishes from isolation rooms were transported in a manner to prevent the spread of COVID and failure to ensure the dishwashing machine ran at the appropriate temperature to sanitize dishes to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes and/or life-threatening harm when 38 residents (#03, #05, #08, #12, #16, #20, #21, #28, #31, #34, #38, #39, #42, #46, #52, #53, #55, #57, #61, #63, #64, #66, #68, #69, #74, #79, #82, #86, #88, #90, #93, #94, #97, #106, #108, #109, #111 and #114) and nine staff including Nurse Practitioner (NP) #505, Dietary Manager (DM) #600, State tested Nurse Aide (STNA) #104, Licensed Practical Nurse (LPN) #204, STNA #105, STNA #106, STNA #107, STNA #108, and Housekeeping Director #402, tested positive for COVID-19 without the aforementioned systems in place to prevent the spread of COVID-19 to the vulnerable residents in the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 114 residents at potential risk for the likelihood of harm, negative health complications and/or death. The facility census was 114 residents. On 10/25/22 at 5:31 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO) #501, were notified that Immediate Jeopardy began on 10/19/22 when 16 residents (#03, #05, #12, #34, #42, #52, #53, #55, #57, #69, #74, #79, #82, #86, #106 and #108) tested positive for COVID-19 and the facility failed to implement appropriate and recommended infection control practices during a COVID-19 outbreak at the facility, including inappropriate donning and doffing of PPE when entering and exiting a COVID-19 isolation room, appropriate signage was posted outside of required PPE for isolation rooms, placing contaminated trash from a COVID-19 isolation room on the floor in the hallway, allowing residents diagnosed with COVID-19 to walk through the facility without any PPE and/or sit in hallways and having a system in place on how to transport used dishes from a COVID positive room to prevent the transmission and spread of COVID-19 to the vulnerable residents in the facility. Upon entrance to the facility on [DATE], a total of 34 residents had tested positive within a six-day time frame since 10/19/22. The Immediate Jeopardy was removed on 10/26/22 when the facility implemented the following corrective actions: On 10/25/22 at 3:30 P.M., the Administrator and Maintenance Director #502 added a COVID-19 smoking area for use by smokers currently diagnosed with COVID-19. Residents who smoked and were positive with COVID-19 were educated on the area and educated on wearing mask when leaving room. The education was completed by the DON. On 10/25/22 at 6:00 P.M., RDCO #501 educated the management team on proper use of PPE, transmission-based precautions, proper signage on doorway of isolation rooms and proper disposal of trash. On 10/25/22 at 6:30 P.M., the management team notified all staff of their department, on the proper use of PPE; transmission-based precautions; proper signage on doorway of isolation rooms; proper disposal of trash; redirections/education of residents who are COVID positive and sitting in their doorways or walking in hallways to wear appropriate PPE which was completed at 8:06 P.M. Agency staff will be educated upon entrance to the building via a read and sign on all policies and will sign off on the education. This was set up by and monitored by Unit Manager #500, and education began on 10/25/22. On 10/25/22 at 7:30 P.M., Medical Records Staff #504 updated all signage on doorways of COVID-19 isolation rooms to encourage proper use of PPE. On 10/25/22 at 7:47 P.M., the clinical management team started assessing all residents not diagnosed with COVID-19 for potential negative effects from alleged deficient practice, and completed the assessments at 8:40 P.M. On 10/25/22 at 7:47 P.M., the DON contacted the doctors for the residents and updated the doctors on the residents ' conditions who were diagnosed with COVID-19. Notification was completed at 9:10 P.M. On 10/25/22 at 7:47 P.M., the DON contacted the doctor for the residents and updated on residents ' conditions who were not diagnosed with COVID-19 and had the potential to be affected by alleged deficient practice. Notification was completed at 9:10 P.M. On 10/25/22 at 8:47 P.M., RDCO #501 provided additional education to all staff through on shift messaging system (electronic message system) on PPE and changing PPE, and proper disposal of trash. This was completed at 8:56 P.M. On 10/26/22, the facility was informed the dish machine rinse temperature was 112 degrees Fahrenheit (F). The Administrator, Regional Administrator #503 and Maintenance Director #502 assessed the dish machine and found the booster heater was off. The heater was turned on and the temperature returned to the appropriate temperature to ensure proper sanitation of dishware and utensils. This was completed by 12:00 P.M. On 10/26/22 at 12:33 P.M., RDCO #501 sent education to all staff via OnShift computerized system on not using Styrofoam for residents in isolation for COVID-19. Beginning on 10/26/22, audits to be completed by DON/designee on proper Donning/Doffing of proper PPE for four random staff members and random shifts, three times a week for four weeks. Beginning on 10/26/22, audits to be completed by DON/designee on proper signage on doorway to alert staff on proper PPE to use in isolation rooms, three times a week for four weeks. Beginning on 10/26/22, audits to be completed by DON/designee on all PPE being utilized when entering an isolation room of four random staff members and on random shifts, three times a week for four weeks. Beginning on 10/26/22, audits to be completed by Dietary Manager/designee on monitoring of dish machine temperatures and heater booster, two times a day for four weeks. Deficiencies will be submitted to the Quality Assurance Performance Improvement (QAPI) committee monthly at the next two QAPI meetings for review and further recommendations. Although the Immediate Jeopardy was removed on 10/26/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings include: Observations on 10/25/22 between 7:50 A.M. and 8:31 A.M., revealed residents diagnosed with COVID-19 were spread throughout the facility, and the facility did not have a designated COVID-19 unit. Review of the CDC's County Transmission rate dated 10/25/22 revealed the facility was in a red county indicating a high county transmission rate. Observation on 10/25/22 at 8:37 A.M., revealed Resident #108 coming out of his COVID-19 isolation room and walking through the hallway out to the smoking area. Resident #108 was observed not wearing any type of PPE. Continued observation revealed Resident #108 walking from the smoking area back to his room without wearing PPE. Observation on 10/25/22 at 8:54 A.M., revealed Resident #108 walking from his room to the smoking area without wearing any PPE. Continued observation revealed Resident #108 sitting outside in the smoking area with Resident #83 and Resident #24 (who are not on isolation status). Interview at the time of the observation with STNA #102 confirmed Resident #108 was currently diagnosed with COVID-19, was not wearing any PPE, and was sitting with Resident #83 and Resident #24. STNA #102 was observed not to provide any guidance to Resident #108 at that time regarding PPE or returning to his room. Observation on 10/25/22 at 8:56 A.M., revealed STNA #101 coming out of a COVID-19 isolation room wearing a gown, gloves, goggles, and an N95 mask. STNA #101 then picked up a breakfast tray off the cart and entered a different COVID-19 isolation room without changing PPE. Continued observation revealed STNA #101 coming out of the second isolation room with a trash bag in her hands that contained her soiled PPE. Interview at the time of the observation with STNA #101, confirmed she did not doff PPE before exiting the first COVID-19 isolation room. Further observation and interview confirmed STNA #101 set her trash bag on the floor during the interview. Continued observation revealed residents not diagnosed with COVID-19 also resided on the hallway. Observation on 10/25/22 at 9:22 A.M., revealed Housekeeper #401 cleaning a COVID-19 isolation room wearing a gown, gloves, goggles, and a surgical mask below her nose. Continued observation revealed her cleaning cart was on the opposite side of the hall from the room she was cleaning. Housekeeper #401 then exited the COVID-19 isolation room wearing PPE to access her cart to empty trash, then reentered the same room. Further observation revealed Housekeeper #401 came out of the room again, still wearing PPE, to get a mop head from her cart, and went back into the room to mop. Housekeeper #401 was observed to come back out of the room wearing the same PPE to dispose of the soiled mop head at her cart across the hallway, then she reentered the room. Housekeeper #401 then removed the gown and gloves and exited the COVID-19 isolation room. Interview at the time of the observation with the Housekeeper #401, confirmed she wore a surgical mask below her nose into a COVID-19 isolation room, and confirmed she exited the room several times to access her cart across the hallway without doffing the contaminated PPE. Observation on 10/25/22 at 9:37 A.M., revealed LPN #201 exiting a COVID-19 isolation room after doffing gloves and a gown, not changing her N95 mask or cleaning her goggles, then performing hand hygiene. Continued observation revealed LPN #201 left the hall, entered a different hall, and administered Resident #111 her medications. Resident #111 was not diagnosed with COVID-19 and was not in isolation. Interview at the time of the observation with LPN #201, confirmed she did not change her N95 or clean her goggles upon exiting a COVID-19 isolation room and before assisting Resident #111. Further interview revealed LPN #201 was unsure of when to change her N95 mask. Observation on 10/25/22 at 9:43 A.M. of Housekeeper #400, revealed she was cleaning a COVID-19 isolation room wearing a gown, gloves, goggles, and N95 mask. Continued observation revealed she exited the room without doffing the PPE to access her cleaning cart which was located across the hall from the room she was cleaning. Subsequent interview with Housekeeper #400 confirmed she exited the room without doffing the contaminated PPE. Observation on 10/25/22 at 9:44 A.M., revealed Resident #74 sitting in a wheelchair in the hallway outside her room with a sign to indicate her COVID-19 isolation status. Resident #74 was observed not wearing any PPE. Physical Therapy Assistant (PTA) #300 was standing nearby and was observed not to provide redirection or encouragement for Resident #74 to reenter her room. Observation on 10/25/22 at 9:58 A.M., revealed Housekeeper #401 exiting a COVID-19 isolation room wearing a gown, gloves, goggles, and a surgical mask, and walking in the hallway to access her cleaning cart. Interview at the time of the observation with LPN #203, confirmed Housekeeper #401 was in the hallway wearing contaminated PPE from a COVID-19 isolation room and was wearing a surgical mask. Observation on 10/25/22 at 10:55 A.M., revealed Resident #74 sitting in a wheelchair in her doorway. Interview at the time of the observation with Housekeeper #400, confirmed Resident #74 often sat in her doorway, and further confirmed the posted signage indicated Resident #74 was in isolation. Housekeeper #400 was observed not to encourage Resident #74 to return to the interior of her room. Observation and interview on 10/25/22 at 12:41 P.M. with STNA #104 revealed she was wearing her surgical mask below her nose and was wearing glasses without goggles and carried a meal tray from a COVID-19 isolation room down the hall to the dining cart. Further interview revealed STNA #104 was unsure whether glasses were adequate eye protection and was unsure of what PPE was required to enter a COVID-19 isolation room. STNA #104 stated residents in isolation received regular meal trays (not Styrofoam) and STNA #104 had received no guidance regarding special handling of meal trays from isolation rooms. Observation on 10/25/22 at approximately 1:40 P.M., revealed the posted signage outside the COVID isolation rooms indicated: Droplet Precautions. Everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. No additional signage was posted to indicate use of N95 masks upon entrance, or any additional PPE such as gowns or gloves. Interview on 10/25/22 at 1:53 P.M. with Dietary Manager (DM) #600 revealed he received guidance from regional staff to stop using Styrofoam trays for residents in isolation. Observation at that time, revealed DM #600 was wearing glasses and a surgical mask. Further interview revealed he understood glasses were adequate to wear as eye protection in common areas in the facility. Interview on 10/25/22 at 2:22 P.M., with RDCO #501 and the Administrator revealed the facility's COVID-19 outbreak began on 10/10/22 when NP #505 tested positive. The facility began twice weekly testing of staff and residents. DM #600 tested positive for COVID-19 on 10/17/22, STNA #104 tested positive on 10/17/22, and LPN #204 tested positive on 10/19/22. Additionally, on 10/19/22, 16 residents (#03, #05, #12, #34, #42, #52, #53, #55, #57, #69, #74, #79, #82, #86, #106 and #108) tested positive for COVID-19. On 10/20/22, STNA #105, STNA #106, and STNA #107 tested positive. On 10/21/22, Resident #88 tested positive. On 10/23/22, STNA #108 tested positive, and six residents tested positive (#63, #66, #97, #38, #08, and #39). On 10/24/22, nine residents tested positive (#114, #68, #64, #94, #46, #21, #61, #109, and #16). On 10/25/22, prior to the surveyor's entrance to the facility, two additional residents tested positive on 10/25/22 (#90 and #28). Upon entrance to the facility, 34 residents had tested positive for COVID-19, and eight staff tested positive for COVID-19 since 10/10/22. Further interview on 10/25/22 at 2:22 P.M., with the RDCO #501 confirmed the signage posted outside the COVID-19 isolation rooms did not include language addressing the use of N95 masks, gowns and gloves upon entering the room. Continued interview on 10/25/22 at 2:22 P.M. with RDCO #501 and the Administrator revealed staff were expected to wear goggles and a surgical mask in common areas of the facility when the Community Transmission Level was high, and during outbreak. Interview on 10/25/22 at 3:40 P.M., with Infection Control Preventionist #500 revealed no audits were conducted to monitor the staff's use of PPE. Observation on 10/25/22 at 5:08 P.M. of the high-temperature dish machine revealed a wash temperature of 172 degrees Fahrenheit (F), and a rinse temperature of 112 degrees F after three cycles of the dish machine were run. Interview at the time of the observation with Dietary Aide #603 confirmed the rinse temperature was below the required 180 degrees F in order to effectively sanitize dishware and utensils. Interview on 10/26/22 at 10:10 A.M. with DM #600 revealed meal trays from isolation rooms should be placed in garbage bags before being placed on the cart to return to the kitchen so they can be separated from other trays on the cart. Observation on 10/26/22 at 10:11 A.M. of the dishwashing machine revealed a wash temperature of 148 degrees F and a rinse temperature of 112 degrees F. Interview at the time of the observation with Dietary Aide #604 confirmed she had washed several loads of dishes and confirmed the dishwasher temperatures. Further interview revealed she had worked in the position for approximately three months and was unaware of a dishwashing machine temperature log or what the temperatures should be. Interview on 10/26/22 at 10:17 A.M. with DM #600 confirmed a dishwasher temperature log was supposed to be completed; however, he further confirmed he could not locate a current log. DM #600 confirmed the dishwashing machine did not reach 180 degrees F on the rinse cycle at that time (which is the temperature recommended to ensure dishware and utensils are properly sanitized). Interview on 10/26/22 at 10:24 A.M. with DM #600 revealed he was unsure his staff was complying with performing additional sanitizing on dishes from an isolation room. Further interview at that time revealed he could not provide the current facility policy that provided guidance for not using Styrofoam containers in isolation rooms. Interview on 10/26/22 at 11:45 A.M. with the Administrator and RDCO #501 revealed two additional residents (#31 and #20) and Housekeeping Director #402 were diagnosed with COVID-19 on 10/25/22. The facility does not require special handling of dishes coming from an isolation room. Interview on 10/26/22 at 4:23 P.M. with the Administrator revealed two additional residents (#93 and #111) tested positive for COVID-19 that day. Review of the policy titled Infection Control Guidance, revised October 2022, revealed when the Community Transmission level of COVID-19 was high, the staff should use eye protection during all patient care encounters. Further review revealed staff were required to wear an N95 mask, goggles or face shield, a gown, and gloves upon entering a COVID-19 isolation room. The policy provided no guidance regarding the use of masks for Health Care Professionals (HCP) in common areas of the facility. The policy provided no guidance regarding doffing PPE upon exit from a COVID-19 isolation room. The policy provided no guidance regarding the handling of meal trays/dishes for residents in COVID-19 isolation rooms. Review of the undated policy titled Use of Disposable Dishes/Flatware revealed resident meals shall be served using reusable dishes and flatware. Appropriate exceptions did not include residents on transmission-based precautions or COVID-19 isolation. Review of the CDC guidance for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated Sept. 23, 2022, revealed under Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. As community transmission levels increase, the potential for encountering asymptomatic or pre-symptomatic patients with [CONDITION(S)]-CoV-2 infection also likely increases. In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by HCP during patient care encounters. For example, facilities located in counties where Community Transmission is high should also consider having HCP use PPE as described, NIOSH-approved particulate respirators with N95 filters or higher used for: All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings?). NIOSH-approved particulate respirators with N95 filters or higher can also be used by HCP working in other situations where additional risk factors for transmission are present, such as the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated [CONDITION(S)]-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. To simplify implementation, facilities in counties with high transmission may consider implementing universal use of NIOSH-approved particulate respirators with N95 filters or higher for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. Patient Placement: Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. [CONDITION(S)] ([CONDITION(S)]) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 infection when the number of patients with [CONDITION(S)]-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with [CONDITION(S)]-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134) Environmental Infection Control: Dedicated medical equipment should be used when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [CONDITION(S)]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures (AGPs) are performed. Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. This deficiency represents the continued noncompliance from the survey dated 08/16/22 and the noncompliance investigated under Master Complaint Number OH 247 and Complaint Number OH 921.

Based on review of the facility's self-reported incidents (SRI), medical record review, observation, staff interview and policy review, the facility failed to ensure adequate supervision of a wandering resident. This resulted in actual harm when Resident #6 sustained a right ulnar styloid fracture (fits into the cartilage of the wrist joint) following an unwitnessed incident of Resident #2 wandering into Resident #6's room. The facility identified 15 residents residing on the memory care unit. The facility census was 101. Findings include: Review of the medical record for Resident #6 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had impaired cognition. Resident #6 had short and long-term memory problems with impaired cognitive skills for daily decision making, was rarely or never understood and exhibited delusions and wandering behaviors. The resident required limited to extensive assistance of one staff for bed mobility and transfers. Review of the plan of care revealed Resident #6 to have a mood/behavior problem related to [DIAGNOSES REDACTED]. The focus indicated Resident #6 becomes easily agitated with mood and behavior fluctuations with associated combative behaviors with staff when redirected. Interventions included administering medications as ordered, allowing the resident time to answer questions and verbalize feelings, perceptions and fears, offering extra snacks and fluids on the Alzheimer's unit, frequent checks and one-to-one supervision as needed, observe and medicate for pain as needed, refocus to something positive and remove the resident to a calm and safe environment when conflict arises and allow the resident to share feelings. Review of the medical record for Resident #2 revealed and admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 07/30/19, revealed the resident had severely impaired cognition. Review of the behavior and mood revealed delusions, verbal behaviors occurring one to three days of the look back period and daily wandering. The resident required extensive assistance of one person for bed mobility and transfers. Walking on the unit was identified as supervised. Review of the plan of care for Resident #2 revealed the resident to have a mood/behavior problem related to anxiousness, sadness and a fluctuation in sleep patterns. The focus indicated Resident #2 wandered in and out of other's rooms, crawled into other's beds, paced on the secured unit and was exit seeking at times causing disruption with other residents by invading their space. Interventions included frequent checks and one-on-one as needed, monitor conditions that may contribute to mood/behavior state, notify the physician of any changes related to mood/behavior, observe for signs of pain and medicate as needed, provide environment that was conducive to the resident's ability to rest/sleep with quietness, snacks, toileting needs and darkness, provide psychiatric services as needed/ordered, refer to general psychiatry as needed and remove and redirect the resident when invading others space or exit seeking. New interventions were implemented on 08/11/19 with one-to-one supervision initiated until 2:00 [NAME]M. until the resident fell asleep on 08/11/19 and then 15-minute checks for 24 hours and the Certified Nurse Practitioner (CNP) to evaluate the resident. On 08/12/19, the resident was moved to a room that was distance without adjoining bathroom and signage posted for room identification. On 08/13/19, the intervention was added to approach the resident in a calm, unhurried manner and provide reassurance as needed and on 08/14/19, the resident was sent to the psychiatric hospital for evaluation and treatment related to incident on 08/13/19. Review of the facility's SRI, dated 08/11/19, revealed Resident #2 had wandered into Resident #4's room on 08/11/19 at approximately 9:45 P.M. causing Resident #4 to bump her head. Review of the medical record for Resident #2 revealed nursing documentation dated 08/11/19 at 10:40 P.M. of Resident #2 being placed on a one-on-one supervision at that time until 2:00 [NAME]M. on 08/12/19 for an incident of wandering into Resident #4's room. Resident #2 then was placed on 15-minute checks for 24 hours through 08/12/19 at 10:45 P.M. Review of the CNP note, dated 08/12/19, revealed Resident #2 was assessed this date. The resident was not able to recall the incident occurring on 08/11/19 when she wandered into Resident #4's room. Resident #2 was able to follow simple commands and was pleasant, cooperative, laughing and smiling during the exam. Prognosis was listed as guarded. Short-term goals were to monitor Resident #2 closely to ensure resident safety and to prevent further episodes of aggression. The CNP documented the aggression as being resolved at the time of this assessment and that Resident #2 did not appear to be a threat. CNP documented to continue with the room move for Resident #2 for safety and to continue to monitor and notify the provider for new or worsening symptoms. Review of the facility's SRI initiated on 08/13/19 revealed the nurse found Resident #2 standing over Resident #6. Resident #6 was lying on the ground and Resident #6 stated Resident #2 pushed her. Review of the nursing progress notes for Resident #6, dated 08/13/19, revealed that at approximately 7:00 P.M. Licensed Practical Nurse (LPN) #32 was attending to another resident when screaming was heard from Resident #6's room. LPN #32 had indicated the door had been closed and upon entering, she found Resident #6 on the floor next to the bed with Resident #2 standing over Resident #6. Resident #2 had stated Resident #6 had pushed her. Continued review of the nursing note revealed LPN #32 had attempted to redirect Resident #2 when Resident #2 hit LPN #32 in the side with a closed fist. LPN #32 summoned staff assistance and conducted a physical assessment of Resident #6 and arranged transport to the local emergency room for evaluation of a right wrist injury. The nursing note indicated Resident #2 was placed on one-on-one supervision for the remainder of the evening. Review of the local hospital record, dated 08/13/19, revealed Resident #6 was evaluated and treated for [REDACTED]. Review of an x-ray of the right wrist, dated 08/13/19 at 8:22 P.M., revealed the impression of an ulnar styloid fracture. Resident #6 was placed in a splint to the right wrist with a scheduled orthopedic follow up for the fracture. Continued review of Resident #2's medical record revealed one-on-one supervision on 08/13/19 from 7:00 P.M. through 08/14/19 at 11:30 [NAME]M. when Resident #2 was transported to a psychiatric hospital for evaluation and treatment. Review of the psychiatry notes dated 08/13/19 revealed Resident #2's targeted symptoms included paranoia, confusion, agitation, [MEDICAL CONDITION], delusions and wandering. The assessment on this date revealed Resident #2 was not stable but staff moved the resident in hoping to reduce risks of another alleged altercation. The psychiatrist note indicated a resident-to-resident altercation with reports that Resident #2 pushed Resident #6 when she wandered into the room. There were episodes of medication refusals, intrusiveness, restlessness, pacing, agitating others, paranoia, anxiousness and restlessness throughout Resident #2's stay at the facility. During observations made on 09/06/19 at 8:05 [NAME]M., Resident #6 was observed to be sitting in the memory care dining room finishing her breakfast at a table with two other female residents. The resident was observed to have a wrist splint to the right hand and smiling at staff. Observation of Resident #2 revealed her to be sitting at an adjacent table with two female residents. The resident was calm without adverse behaviors at the time of this observation. Interview on 09/06/19 at 8:30 [NAME]M. with Licensed Practical Nurse (LPN) #30 confirmed Resident #2 was sent to a special facility for medication adjustment in hopes to have a more stable mood. LPN #30 reported neither Resident #2 or Resident #6 recalled the incident. LPN #30 confirmed Resident #2 was a wanderer and liked to keep busy and doesn't sit for long periods of time. LPN #30 confirmed Resident #2 tends to wander more frequently in the evening hours. Interview on 09/06/19 at 2:00 P.M. with LPN #32 revealed she was the unit manager for the memory care unit and was involved in the after review of the residents for the 08/11/19 and the 08/13/19 incidents. LPN #32 confirmed Resident #2 was known to wander at night. Interview on 09/06/19 at 3:15 P.M. with CNP #60 revealed Resident #2 had not shown any negative behaviors towards herself or others. No anger or aggression. The CNP reported examining Resident #2 on 08/12/19 and did not feel Resident #2 was a threat. CNP #60 reported Resident #2 still paced the hallways but never targeted anyone and that the resident would occasionally wander into other resident rooms but was easily redirectable and always very pleasant. Review of the facility policy titled, Memory Support Program, dated 04/02/18, revealed the residents of the memory Support Program will be able to wander safely within the Memory Support Program and secured outside areas. Wandering behavioral symptoms will be documented and forms will be reviewed to determine triggers associated with the behavior and effectiveness of non-pharmacological interventions. Behavioral symptoms will be addressed in the care/service plan. Review of the facility policy titled, Risk Management (Accident) Interventions, dated 04/01/19, revealed its purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This was an incidental finding during the course of the investigation.