Every finding on record at Majestic Care of New Lexington

Based on record review, observation, staff interview and review of facility policy, the facility failed to dispose of expired medications. One of two medications rooms and two of four medications carts were reviewed. This had the potential to affect all 70 residents residing at the facility. Findings include:Review of the most recent consulting pharmacist report dated 03/02/26 revealed audits were completed for medication rooms, medication and treatment carts and cold storage (refrigerators) and expired medications found in medication carts and treatment carts and items not stored per manufacturer guidelines.Observation and interview on 03/11/26 at 8:30 A.M. with Licensed Practical Nurse (LPN) #155 of the [NAME] medication room revealed one opened bottle of sodium chloride (mineral) one gram (gm) with an expiration date of 09/2025 and an open date of 02/2026, one unopened bottle of zinc (mineral) 50 milligrams (mg) with an expiration date of 01/2026, one opened bottle of aspirin 325 milligrams (mg) with an expiration date of 12/2025, one unopened bottle of vitamin B12 500 micrograms (mcg) with an expiration date of 12/2025, one opened bottle of vitamin B6 50 mg with an expiration date of 01/2026 and an open date of 06/18/25, one opened bottle of vitamin B1 100 mg with an expiration date of 11/2025 and an open date of 07/14/24, one HypoPen glucagon injection one mg per 0.2 milliliter (ml) with an expiration date of 08/2025, and three intravenous (IV) medicine balls of Meropenum (antibiotic) one gm/100 ml with expiration dates of 02/09/26. LPN #155 verified the expired medications.Observation and interview on 03/11/26 at 8:45 A.M. with LPN #120 of medication cart for Central Avenue revealed one opened bottle of acidophilus (probiotic) with an expiration date of 10/2025 and an open date of 02/03/26 and one opened bottle of aspirin 325 mg with an expiration date of 12/2025 and an open date of 03/23/25. LPN #120 verified the expired medications.Interview on 03/11/26 at 9:40 A.M. with the Director of Nursing (DON) revealed the expectation was for the floor nurses to check the medication rooms routinely for expired medications. Review of the facility policy titled Medication Storage, dated 01/02/2024, revealed the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.

Based on observations and interview, the facility failed to ensure expired food items were not kept in the kitchen. The had the potential residents who utilized cream for their beverages. The facility census was 70.Findings include:Observation on 03/09/26 at 8:19 A.M. revealed the dry storage area of the kitchen contained four large containers of expired coffee creamer. Two expired on 12/24/19 and two expired in 03/2020.Interview on 03/09/26 at 8:20 A.M. with Dietary Manager #107 confirmed there were expired coffee creamers in the dry storage area. She stated they were not used by the kitchen, but were used by activity staff.

Based on record review, policy review, and staff interview, the facility failed to ensure residents were educated on and had the opportunity to receive the updated annual COVID-19 vaccine, if they desired to do so. This affected four (Residents #2, #5, #7, and #68) of five residents reviewed for immunizations.Findings include:1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), adult onset diabetes mellitus, heart failure, chronic ischemic heart disease, and personal history of COVID-19. Review of Resident #2's informed consents for immunizations revealed it was absent for any evidence of the resident having been educated on the COVID-19 vaccine for the 2025- 2026 respiratory illness season (October thru March) or that the updated COVID-19 vaccine was even offered to the resident. Her immunization record revealed the last time a COVID-19 vaccine had been given to the resident was on 10/09/24. On 03/16/26 at 10:50 A.M., an interview with Registered Nurse (RN) #110 confirmed there was no documented evidence of Resident #2 had been educated on the COVID-19 vaccine or given the opportunity to receive that vaccine during the 2025- 2026 respiratory illness season. The facility's prior Infection Preventionist no longer worked in the facility and they did not have access to any consents for immunizations other than what had already been provided. 2. Review of Resident #5's medical record revealed the resident was originally admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), adult inset diabetes mellitus, dementia, and a personal history of COVID-19. Review of Resident #5's informed consents revealed there was no evidence of the resident having been provided education in the COVID-19 vaccine or that he was afforded the opportunity to receive the COVID-19 vaccine for the 2025- 2026 respiratory illness season, if he chose to receive it. The last documented COVID-19 vaccine given to the resident was on 10/09/24. On 03/16/26 at 10:50 A.M., an interview with Registered Nurse (RN) #110 confirmed there was no documented evidence of Resident #5 had been educated on the COVID-19 vaccine or given the opportunity to receive that vaccine during the 2025- 2026 respiratory illness season. The facility's prior Infection Preventionist no longer worked in the facility and they did not have access to any consents for immunizations other than what had already been provided. 3. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included dementia, personal history of traumatic brain injury, adult onset diabetes mellitus, and morbid obesity. Review of Resident #7's informed consents revealed there was no documented evidence of the resident having received education on the COVID-19 vaccine or that she had been offered to receive the updated COVID-19 vaccine for the 2025- 2026 respiratory illness season, if she chose to do so. On 03/16/26 at 10:50 A.M., an interview with Registered Nurse (RN) #110 confirmed there was no documented evidence of Resident #7 had been educated on the COVID-19 vaccine or given the opportunity to receive that vaccine during the 2025- 2026 respiratory illness season. The facility's prior Infection Preventionist no longer worked in the facility and they did not have access to any consents for immunizations other than what had already been provided. 4. Review of Resident #68's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, personal history of a traumatic brain injury, and personal history of COVID-19. Review of Resident #68's informed consents revealed there was no evidence of the resident having been given education on the COVID-19 vaccine or that she had been offered the updated annual COVID-19 vaccine, if she wanted it. On 03/16/26 at 10:50 A.M., an interview with Registered Nurse (RN) #110 confirmed there was no documented evidence of Resident #68 had been educated on the COVID-19 vaccine or given the opportunity to receive that vaccine during the 2025- 2026 respiratory illness season. The facility's prior Infection Preventionist no longer worked in the facility and they did not have access to any consents for immunizations other than what had already been provided. Review of the facility's policy on Infection Prevention and Control Program revised 07/17/25 revealed it was the purpose of the facility to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Under the section for COVID-19 immunizations, the policy indicated residents would be offered the COVID-19 vaccine when vaccine supplies were available to the facility. Education about the vaccine, risks, benefits, and potential side effects would be given to residents or their representatives prior to offering the vaccine. Documentation would reflect the education provided and details regarding whether or not the resident received the vaccine.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident receiving psychotropic medications signed consent for the use of those medications, after the risks and benefits associated to their use were explained to the resident. This affected one (Resident #5) of five residents reviewed for unnecessary medications.Findings include:Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Schizo-affective disorder, dementia, Bipolar disorder, major depressive disorder, and anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was able to make himself understood and was able to understand others and cognitively intact. Resident #5 had verbal behaviors directed at others and other behaviors not directed at others. Resident #5 received anti-psychotic medications, anti-anxiety medications, and anti-depressants during the review period. Review of Resident #5's physician's orders revealed on 05/13/25, an order to administer Duloxetine HCL (Cymbalta) 60 milligrams (mg) by mouth (po) twice a day for major depressive disorder. On 05/06/25, an order for Remeron 7.5 mg po at bedtime for the targeted behaviors of angry outbursts. On 02/24/26, an order to receive Clonazepam 0.25 mg po three times a day for anxiety, and had previous order for that medication at a different dose prior to the most recent order. Review of the Informed Consents for Medications revealed Resident #5 had been provided education on the risks and benefits for the use of his antipsychotic medications to include Invega, Olanzapine (Zyprexa), and Aripiprazole (Abilify) on 10/29/24 and signed consent for the use of those psychotropic medications. There was an Informed Consent for Medication form filled out for the resident's use of Duloxetine and Remeron, but it was not signed by Resident #5 to provide documented evidence that the risks and benefits of those medications were explained to the resident and he gave consent for their use. A Psychoactive Medication Consent and Management Agreement was provided for the Clonazepam upon request that had an effective date of 03/11/26 at 11:33 A.M. (date the consent form was requested by the facility). That form indicated the date the consent was given for the use of that medication was 02/24/26 (date of the latest order). It was signed by Resident #5 by him adding his initials to the form. The progress note dated 02/24/26 revealed the nurse practitioner was in to visit and decreased Resident #5's Clonazepam to 0.25 mg three times a day. The resident and his family were made aware of the new order. On 03/11/26 at 9:15 A.M., an interview with Registered Nurse (RN) #110 confirmed Resident #5's Informed Consent for Medications for the resident's use of Duloxetine and Remeron was not signed by Resident #5. RN #110 acknowledged without the resident signing receipt, there was no documented evidence to support he had been informed of the risks and benefits associated with those medications and gave an informed consent for their use. On 03/11/26 at 1:25 P.M., an interview with the Director of Nursing (DON) revealed she was not able to find a signed consent for Resident #5's use of Remeron and Duloxetine providing documented evidence he had been educated on the risks and benefits of those medications and provided signed consent to receive those medications. The DON further indicated the Psychoactive Medication Consent and Management Agreement that the facility provided on the Clonazepam was dated for 03/11/26 and was not signed by Resident #5 until that same morning. The DON indicated the progress note by the nurse that documented the nurse practitioner's visit and changed to the dose of the Clonazepam was all they had that showed the resident and family was aware of the order for the Clonazepam. The DON acknowledged they did not provide evidence of the resident having been educated on the risks and benefits of that psychotropic medications use, prior to 03/11/26. Review of the facility's policy on Psychotropic Medication Use revised 07/02/25 revealed an resident receiving a psychotropic medication or a medication used for a mood or behavior indication was required to have an informed consent prior to initiation or with an increase in dosage. All medication-related activities must be documented or recorded in the resident's medical record, including but not limited to informed consents, reviews, gradual dose reductions (GDRs), and changes.

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure the rooms were kept in good repair. This affected one (#8) of one resident reviewed for environmental concerns. The facility census was 70.Findings include: Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebrovascular accident and anxiety disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8's cognition was intact.Interview and observation on 03/10/26 at 9:00 A.M. with Resident #8 revealed his room had large white patches on the wall next to his window, black scuffs on the bottom of the walls in the entry way of the room, a missing wheel to the left upper side of his bed, the lower bathroom door had a plastic cover to it which had cracked and was loose with sharp edges, in the bathroom the paper towel holder had been moved and paint had peeled away and not repaired, two holes in the bottom of the bathroom wall under the toilet paper holder and behind the toilet, and the toilet paper holder was moved to a different part of the wall leaving a patch of paint which did not match the rest of the room. Resident #8 stated he did not like the condition of his room and wished they would fix it up but it had been this way for a while. Resident #8 stated he would not let his home be in disrepair. Interview on 03/12/26 at 11:30 A.M. with Certified Nursing Assistant (CNA) #138 confirmed multiple white patches of plaster on the wall near the window, black scuffs on the walls in the entry way, the bathroom door cover was cracked and broken, two holes were in the bottom of the bathroom walls, and confirmed the toilet paper and paper towel holders had been moved but the areas were not repaired.Review of the policy titled Resident Rights dated 01/02/24 revealed residents have the right to a safe, clean, comfortable and homelike environment.

Based on record review, policy review, and interview, the facility failed to ensure a resident was comprehensively assessed and provided medical necessity for a resident to reside in the memory care unit. This affected one (#24) of one resident reviewed for restraints. The facility census was 70.Findings include:Record review revealed Resident #24 admitted to the facility on [DATE] with diagnoses including schizophrenia and dementia.Review of an elopement risk assessment dated [DATE] revealed Resident #24 was not at risk of elopement.Review of a late entry interdisciplinary team (IDT) note dated 07/28/25 at 8:39 A.M. by Assistant Director of Nursing (ADON) #500 revealed the IDT reviewed a situation with Resident #24 and due to increased falls and attempting to drink hand sanitizer throughout the facility, the resident and family were agreeable to move to the locked memory care unit to increase activity time and monitor closely.Review of an order dated 09/06/25 revealed Resident #24 resided on the secure unit to meet his physical, mental, spiritual, emotional well-being and safety needs.There was no additional documentation to support Resident #24 residing in the memory care unit. Interview on 03/16/26 at 3:45 P.M. with the Administrator verified there was no assessment and no other medical necessity for Resident #24 prior to admitting the resident to the locked unit. The Administrator stated it was based of needs of the resident.Review of a policy titled Restraint Free Environment dated 01/02/24 revealed physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Based on staff interviews and medical record review, the facility failed to monitor potential side effects of psychotropic medications for Resident #64. This affected one (#64) of five residents reviewed for unnecessary medications. The facility census was 70.Findings include:Review of Resident #64's medical record revealed the resident was admitted on [DATE] and diagnoses included depression and anxiety disorder.Review of the current physician's order list for March 2026 revealed the following active orders: Duloxetine HCl Capsule Delayed Release Particles 20 milligrams (mg) one one capsule by mouth two times a day for depression with a start date of 11/20/25 and Lorazepam oral tablet one mg, give one tablet by mouth two times a day for restlessness; anxiety and give one tablet by mouth every one hour as needed for restlessness, anxiety with a start date of 12/20/25. There were no physician orders to monitor for side effects of the antidepressant or antianxiety medications.Review of Resident #64's care plan initiated on 10/03/25 revealed Resident #64 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects.Review of Medication Administration Records dated December 2025, January 2026 and February 2026 revealed no documentation of the assessment for adverse side effects of psychotropic medications.Interview on 03/12/26 at 8:10 A.M. with Licensed Practical Nurse (LPN) #143 confirmed that when any resident is ordered a psychotropic medication, the nursing staff was expected to monitor for behaviors and medication side effects. LPN #143 stated an order to monitor for side effects of psychotropic medication should be present on the physician's order list and the nursing staff documents the assessment of side effects in the medication administration record. LPN #143 confirmed Resident #64 was ordered an antianxiety and antidepressant medication and staff were not monitoring side effects of psychotropic medications.Interview on 03/12/26 at 1:19 P.M. with the Director of Nursing (DON) confirmed the facility should monitor side effects of psychotropic medications for all residents with current psychotropic medication orders. The DON stated the facility monitors these side effects using the medication side effect monitoring tool, which is reflected in the medical chart as a monitoring order on the clinical physician's order list. The DON stated that ideally, the order to monitor side effects of psychotropic medications would be placed simultaneously with the order for psychotropic medication.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident, who was transferred out of the facility to the hospital, received a transfer notice and a bed hold notice, at or around the time of the transfer. This affected one (Resident #74) of three closed records reviewed for transfer/ discharges. Findings include:Review of Resident #74's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, kidney transplant status, retention of urine, and anxiety disorder. The progress note dated 12/29/25 at 6:30 A.M. revealed Resident #74 had a change in condition and was sent to the emergency room for an evaluation. He was admitted to the hospital and did not return to the facility. There was no evidence of a transfer notice or a bed hold notice was provided too the resident and/ or his family at/ or around the time of his transfer in Resident #74's medical record. On 03/11/26 at 8:55 A.M., an interview with the Administrator verified the facility did not have a transfer notice or a bed hold notice for Resident #74's transfer to the hospital on [DATE]. The Administrator stated she checked with social services, and since the resident was covered under an advantage plan, he did not require those notices. The Administrator reported the resident would have been treated as a discharge from the facility on that date. On 03/12/26 at 10:42 A.M., an interview with Social Service Assistant (SSA) #175 revealed he had been the facility's social worker up until three weeks ago. SSA #175 was now the facility's business office manager. SSA #175 was the facility's social worker at the time of Resident #74's transfer to the hospital on [DATE]. SSA #175 confirmed he did not issue a transfer notice or a bed hold notice to Resident #74, when the resident was transferred to the hospital on [DATE]. SSA #175 indicated it was his understanding that he did not have to provided the transfer notice to residents discharged from the facility and, due to the resident's payer source, he was considered a discharge from the facility when he was transferred to the hospital. He did not think he had to provide a bed hold notice either to residents whose payor status was other than Medicaid. SSA #175 acknowledged transfer notices were to be given to residents who were transferred from the facility to the hospital. He further acknowledged all residents should have the option to hold a bed at the facility, regardless of payor status, as they had the option to pay privately to do so. Review of the facility's policies on Bed Hold Notices revised 07/29/25 revealed the purpose of the policy was to ensure residents and their representatives were informed of their rights and the facility's procedures regarding bed holds during temporary absences, including hospitalizations or therapeutic leaves. Bed hold was defined as a means of holding or reserving a resident's bed while the resident was absent from the facility for therapeutic leave of hospitalization. At the time of the transfer for hospitalizations or therapeutic leaves, the facility would provide to the resident and/ or their representative written notice which specified the duration of the bed hold policy and address information explaining the return of the resident to the next available bed. In the event of an emergency transfer of a resident, a written notice of the facility's bed hold policy would be provided within 24 hours, as stipulated in the State's plan. The written bed hold notice information would be given to the resident and/ or their representative and a signed and dated copy of the written bed hold notice information would be kept by the facility in the resident's medical record.

Based on record review, policy review, and staff interview, the facility failed to ensure comprehensive resident-centered care plans were in place. This affected one (#12) of 23 residents reviewed for care plans.Findings include:Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, paranoid personality disorder, and suicide ideations.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12's cognition was severely impaired, she had behaviors including delusions, and other behaviors one to three days in the review period.Review of the care plan dated 02/03/26 revealed there was no care plan related to Resident #12 having a history of suicidal ideations.Interview on 03/11/26 at 12:43 P.M. with Director of Nursing (DON) confirmed Resident #12 did not have a care plan in place to address her history of suicidal ideations.Review of the policy titled Comprehensive Care Plan dated 11/01/24 revealed the facility should develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan should be developed within seven days after the completion of the comprehensive MDS. The care plan should reflect resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on record review, interview, and policy review, the facility failed to ensure protocol was followed after an incident of suicidal ideation. This affected one (#12) of one resident reviewed for suicidal ideation. The facility census was 70.Findings include:Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, paranoid personality disorder, and suicide ideations.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12's cognition was severely impaired, she had behaviors including delusions, other behaviors one to three days in the look back period, and wandered one to three days in the look back period.Review of the nursing note dated 11/10/25 at 2:01 A.M. by Registered Nurse (RN) #113 revealed Resident #12 was suicidal and stated she would kill herself. Resident #12 had been looking for her jackets and there was no jacket. RN #113 told her the jackets were dirty and sent to laundry which was closed at night. Resident #12 screamed and kept stating she was going to kill herself. RN #113 stayed with resident to calm her down, hugged her, told her she was loved, and gave her some comfort food. Resident #12 was resting in bed with eyes closed and would continue to be monitored. There was no evidence a provider was notified of the incident, no new orders, and no evidence a room search was completed.Review of the behavioral health note dated 11/20/25 revealed staff reported Resident #12's behaviors have been at baseline, no reports of increased anxiety, insomnia, or troubles with appetite. Provider reviewed nursing notes in the clinical record and found Resident #12 had an episode where suicidal comments were made, staff were able to redirect resident and no further incidents. Review of an interdisciplinary team (IDT) note dated 11/24/25 at 2:34 P.M. by previous Director of Nursing (DON) revealed the IDT and behavioral health nurse practitioner discussed Resident #12's previous suicidal statements, resident had no plan or means and was upset about clothing items. Resident #12 was admitted with a diagnosis of suicidal ideations and no other behaviors were noted. Provider was updated.Review of the care plan dated 02/03/26 revealed there was no care plan related to Resident #12 having a history of suicidal ideations.Interview on 03/11/26 at 8:53 A.M. with Licensed Practical Nurse (LPN) #155 revealed if a resident stated they want to harm themselves, you should ensure a safe environment by checking their room, have an aide sit with them, and go tell the nursing management and go from there.Interview on 03/11/26 at 10:51 A.M. with Life Story Program Director (LSPD) #179 revealed if someone stated they wanted to harm themselves, she would tell the nurse so they could complete an assessment and in her role as the social worker for the unit she would provide empathy and support then document it in a progress note.Interview on 03/11/26 at 12:43 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence of a care plan related to suicidal ideation, notification to the physician, and no social services follow up or support for Resident #12. The DON stated Resident #12 was seen by a provider but did acknowledge it was 10 days after the incident and staff did not report the incident to the provider, but they found out by reading nursing notes. The DON stated it was an isolated incident despite having a diagnosis of suicidal ideation upon admission to the facility.Interview on 03/12/26 at 2:15 P.M. with Social Services Assistant (SSA) #175 revealed if an incident of suicidal ideation was discovered, he would speak with nursing and make an immediate intervention to address the issue then reach out to behavioral health to assess the resident as soon as possible. SSA #175 stated he thought he was aware of the incident with Resident #12 the following morning and it was discussed but was unable to state his involvement in addressing the issue. SSA #175 stated anything he did would be documented in the computer.Review of an undated standard operating procedure titled Suicidal Thoughts and Ideation revealed the initial response should be to immediately report any suicidal thoughts or ideations to the DON and/or social services and the resident should be kept in a staff member's line of sight throughout the assessment, notification, and coordination of services. Interview the resident for any thoughts, plans, behaviors, and intent to harm self. Utilize assessment tools such as brief interview for mental status (BIMs) and patient health questionnaire (PHQ) -9, assess the resident's risk factors including but not limited to history of prior suicide attempts of self-injurious behaviors, current or past psychiatric disorder and/or recent changes in psychiatric treatment such as medication, treatment, provider, or recent discharge from in-patient psychiatric setting; mood or behavioral symptoms; family history of suicide; triggering events; access to objects used to harm self; consider protective factors; objectively and thoroughly document and care plan the resident's mood and behavioral symptoms as well as all actions or interventions taken by care team members in the medical record including but not limited to the initial response, risk assessment, orders, one-to-one care, assessment of the resident's environment, referrals made, accommodations, notifications, and psychosocial follow-ups; immediately notify the provider; notify responsible party; implement any new orders; organize mental health referrals; if imminent risk is identified, coordinate a possible hospitalization; mood and behavioral symptoms will be monitored daily and documented in the medical record; psychosocial follow-up will be completed; and all staff will be trained annually on risk factors and warning signs of suicide as well as how to respond to a resident with suicidal ideation.

Based on record review and staff interview, the facility failed to ensure a resident receiving an anti-hypertensive medication had his blood pressure obtained and recorded at the time of the anti-hypertensive medications administration, when the physician's orders included parameters to notify the physician if the resident's systolic blood pressure (SBP) was greater than 100 millimeters of mercury (mmHg). This affected one (Resident #5) of five residents reviewed for unnecessary medications.Findings include: Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included the diagnosis of hypertension (high blood pressure). Review of Resident #5's physician's orders revealed the resident had an order in place to receive Metoprolol Succinate (a beta blocker used in the treatment of hypertension) Extended Release (ER) 25 milligrams (mg) by mouth every night at bedtime for hypertension. The order included a parameter to call the physician, if the resident's SBP (top number of a blood pressure reading) was less than 100 mmHg. The order had been in place since 08/20/25. Review of Resident #5's medication administration record (MAR) for February and March 2026 revealed the resident was receiving his Metoprolol Succinate 25 mg by mouth every night at bedtime as ordered. The MAR included the parameter to call the physician if the resident's SBP was less than 100 mmHg. The MAR did not include a place for the nurse administering that medication to record the resident's blood pressure at the time of the administration. There was no documented evidence on the MAR for either month that the resident's blood pressure had been checked. Review of Resident #5's blood pressure readings recorded under the Weights and Vitals Summary in the electronic medical record (EMR) revealed the facility was only sporadically obtaining and recording the resident's blood pressure. There were no blood pressures recorded for the month of February 2026, and two blood pressures recorded for the month of March 2026. One of the blood pressure readings recorded for March 2026 (03/06/26 at 1:47 A.M.) was noted to have a SBP less than 100, when the nurse recorded a blood pressure of 90/48. It was unclear what the resident's blood pressure was when the Metoprolol Succinate was administered on 03/05/26 at bedtime, due to no blood pressure being obtained and recorded for that time of the administration. On 03/11/26 at 12:10 P.M., an interview with the Director of Nursing (DON) confirmed Resident #5's physician's order for the use of Metoprolol Succinate did include parameters to notify the physician, if the resident's SBP was less than 100 mmHg. The DON confirmed the MARs for February and March 2026 did not show evidence of Resident #5's blood pressure being monitored at the time the Metoprolol Succinate was being administered. The DON acknowledged, without documenting a blood pressure at the time of the medication's administration, the nurses would not be able to show evidence they were following the parameters included in the order on when to notify the physician of the resident having a SBP less than 100 mmHg.

Based on record review, interview, and policy review, the facility failed to complete lab work as physician ordered. This affected one (#68) of five residents reviewed for unnecessary medications. The facility census was 70.Findings include:Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including Parkinson's disease and edema.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68's cognition was intact.Review of the physician orders revealed on 07/30/24, Resident #68 would have the following laboratory (lab) blood draws every three months (August, November, February, and May): complete blood count (CBC), basic metabolic panel, vitamin D, B12, lipid panel, liver panel, and prealbumin.The care plan dated 03/28/25 revealed Resident #68 was at risk for fluid imbalance due to diuretic use related to edema. Interventions included lab work as ordered. Review of the laboratory results revealed Resident #68 last had lab work completed on 08/28/25. There were no lab results for November 2025 and February 2026 as physician ordered.Interview on 03/12/26 at 9:49 A.M. with the Administrator verified Resident #68 did not have labs drawn as physician ordered in November 2025 or February 2026. Administrator stated a stat order had been placed for a lab draw at this time.Review of the policy titled Physician Orders dated 01/02/24 revealed the facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. Documentation of diagnostic tests, results and date/time of physician notification will be maintained in the resident's clinical record.

Based on record review, staff interview and policy review, the facility failed to ensure a resident received timely dental services. This affected one (#25) of one resident reviewed for dental care. The facility census was 70.Findings include:Review of the medical record for Resident #25 revealed an admission date of 11/30/23 with diagnoses including dementia with behavioral disturbance, depression, dysphagia, and anxiety disorder.Review of the dental consult dated 09/11/25 revealed Resident #25 had a referral to an oral surgeon to extract of all symptomatic teeth.The progress note dated 09/16/25 authored by Transportation Aide (TA) #176 revealed they a faxed referral to Dental Clinic #1. On 10/15/25 a progress note authored by TA #176 indicating a referral was faxed to referral to Oral Surgery and Dental Implants #2. On 10/22/25, a telephone call placed to Oral Surgery and Dental Implants #2 asking if they take Medicaid. On 11/07/25, an email was sent to Family Dental #3 by TA #176. The dental consult dated 01/13/26 revealed Resident #25 had a referral to an oral surgeon to extract of all symptomatic teeth. There was no further documentation attempting to get Resident #25 seen by an oral surgeon for dental extractions until 03/12/26.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had severe cognitive impairment, no obvious or likely cavity or broken natural teeth, no facial pain and no difficulty chewing.The progress note dated 03/08/26 authored by Registered Nurse (RN) #165 revealed Resident #25 was having tooth pain and assessed to have a right upper tooth missing and cold sensitivity.Interview on 03/12/26 at 11:33 A.M. with TA #176 verified no appointment was made for oral surgeon consult for extractions for Resident #25. TA #176 stated she attempted to call others but did not document and verified she did not contact insurance to find a provider.Review of the facility policy titled Dental Services dated 12/16/25 revealed to ensure residents/patients receive timely, appropriate, and safe dental care to maintain oral health, prevent complications and support overall well-being. Care team members will assist the resident/patient, if necessary or requested, with making dental appointments and arranging transportation to and from the dental services location.

Based on record review and staff interview, the facility failed to ensure the resident's medical record had accurate documentation for care related to a resident's Jackson Pratt (JP) drain. This affected one (Resident #60) of 23 residents reviewed for medical record accuracy.Findings include:Review of Resident #60's closed medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of her rectum and status post colostomy placement. She remained in the facility until 03/04/26, when she was discharged home. Review of Resident #60's initial skin evaluation completed on 01/28/26 revealed one JP drain (a closed-suction medical device used after surgery to remove excess fluid from the body, preventing infection and promoting healing; it consisted of a silicone tube connected to a bulb that, when squeezed, created a gentle vacuum to pull fluid into a collection chamber) was present to her lower abdominal area. The other two JP drains were indicated to be in the right lower extremity. She also had three small post-surgical incisions to her abdomen, with one to the umbilical area, one above her umbilical area, and a third one to the left lower quadrant of her abdomen. Review of Resident #60's physician's orders revealed the resident had orders in place to drain her abdominal JP drain and record the output every shift (day and night shift). Her orders also included the need to drain JP drain #2 (site not specified) and JP drain #3 (site not specified) and to record the outputs from those drains every shift, as well. The orders regarding the JP drains had been in place since 01/28/26. Review of Resident #60's treatment administration records (TAR) for February 2026 revealed there were two separate times when the nurses failed to document the amount of drainage that was emptied from the resident's JP drains to the abdomen and for JP drain #3 that month. There were no amount of drainage that had been emptied and recorded from those to drain sites on 02/11/26 night shift or 02/26/26 day shift. JP drain #2 did not have an amount of drainage that was emptied and recorded for night shift on 02/11/26. Review of Resident #60's TAR for March 2026 revealed the nurse failed to record the amount of drainage that was emptied from the JP drain to the resident's abdomen and JP drain #3 on 03/02/26 for the night shift. The resident was discharged on 03/04/26. Review of Resident #60's progress notes revealed there was nothing documented in the progress notes to show evidence of the resident's drainage amounts being emptied and recorded or evidence that the treatments to the surgical wounds on the resident's left and right lower abdomen were completed as ordered. No refusals of any treatments were noted in the progress notes to support the lack of documentation for the above dates of concern. On 03/12/26 at 8:30 A.M., an interview with the Director of Nursing (DON) verified the resident did not have the outputs recorded from her JP drains for days and/ or nights identified above. The DON stated the only other place the drainage amounts from those JP drains may have been recorded would be in the progress notes. If they could not be found there, then they would not have documented evidence they were emptied and the amount of drainage was recorded for those dated. The DON acknowledged the progress notes were checked with no drainage amounts from the JP drains being recorded for any of the dates previously mentioned.

Based on closed record review, interview, and policy review, the facility failed to provide care and services to prevent pressure ulcers from developing or worsening. This affected two residents (#39 and #65) of six residents reviewed for skin breakdown. The facility census was 63.Actual Harm occurred on 09/08/25 when Resident #65, who was assessed to be high risk for skin breakdown developed two unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to her right and left heels. On 09/10/25 Resident #65 developed a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to her coccyx. The facility failed to identify the ulcers to the heels prior to them being unstageable and failed to ensure comprehensive, individualized and effective interventions were in place to prevent the development of the pressure ulcers. Findings include: 1.Review of Resident #65's closed medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including psychosis, traumatic brain injury, and schizophreniform.Review of an order dated 06/28/25 revealed Resident #65 had a full code status in place.Review of a care plan dated 06/29/25 revealed Resident #65 was at risk for skin breakdown and had dry callous areas to feet. The goal was for Resident #65 to be free of skin breakdown. Interventions included check for incontinence and provide incontinence care as needed and notify nurse of any redness or irritation (06/29/25), preventative skin care as ordered/indicated (06/29/25), and skin inspection weekly and as needed- document and notify physician of abnormal findings (06/29/25).Review of a skin risk evaluation dated 07/01/25 revealed Resident #65 was at high risk for skin breakdown related to age greater than [AGE] years old, dementia, and encephalopathy.Review of a nursing note dated 07/01/25 at 10:12 A.M. by Licensed Practical Nurse (LPN) #203 revealed Resident #65's age was identified as a high risk for pressure ulcer development and should immediately proceed to integrated care plan interventions to preserve the resident's skin integrity. Resident #65 was a new admission with progressive cognitive disease and care team would provide an escalated level of care to ensure resident's safety and skin preservation. Review of Resident #65's care plan and physician orders revealed no evidence the facility provided an integrated care plan with interventions to preserve skin integrity following the evaluation and note dated 07/01/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65's cognition was intact, she was able to walk and complete transfers independently, was continent, did not have a condition or chronic disease that may result in a life expectancy of less than six months, she did not have skin issues, and had a pressure reducing device for chair and bed.Review of an order dated 07/05/25 revealed staff were to apply Remedy Prevent Silicone Cream (creates a breathable, water-resistant film, protecting fragile skin from moisture, dryness, irritation, redness, and cracking) to Resident #65's bilateral feet for callous and dry areas every day and night shift.Review of a nursing note dated 08/20/25 at 4:14 P.M. revealed Resident #65's son approached the nurse and reported the resident was on the floor in her bathroom doorway. Upon entering the room, the resident was lying on her left side with feet in the bathroom and trunk in the room, the resident was unable to verbalize what happened, she did have her pants at hip level but not quite over buttocks. Resident #65 was incontinent of bowel. Resident #65 was known to have poor balance with a walker and was receiving therapy. Resident #65 reported she was trying to get away from the man. Range of motion and assessments were completed with no injuries identified. Resident #65's fall on 08/20/25 reflected a decline for the resident and thereby placed the resident at an increased risk of skin integrity issues including the development of pressure ulcers. This decline was not recognized by the facility and the facility failed to provide an integrated/escalated plan of care to ensure the resident's safety and skin preservation.Review of a weight note dated 08/25/25 revealed Resident #65 weighed 125.8 pounds. Prior weights included: On 08/18/25 the resident weighed 122 pounds, on 08/11/25 the resident weighed 122.4 pounds, on 08/04/25 the resident weighed 121 pounds, and on 07/28/25 the resident weighed 128 pounds.The decrease/fluctuation in the resident's weight reflected a decline for the resident and thereby placed the resident at an increased risk of skin integrity issues including the development of pressure ulcers. These weight changes were not recognized by the facility and the facility failed to provide an integrated/escalated level of care to ensure the resident's safety and skin preservation.Review of a provider note dated 08/26/25 by Certified Nurse Practitioner (CNP) #305 revealed staff were concerned of Resident #65's increased confusion. The note revealed the resident did have an MRI on 06/13/25 with no acute abnormalities. Resident #65 had muscle weakness and debility. Resident #65 was feeling tired, continued with a moist, non-productive cough, and all labs, records, medication, and nursing notes were reviewed. The note did not include information related to skin integrity and/or skin prevention interventions. Review of an order dated 08/28/25 revealed Resident #65 was placed on contact isolation precautions for presumptive shingles every shift. Review of a skin evaluation assessment dated [DATE] revealed Resident #65 did not have any new skin issues. (Please note that the surveyor view of this assessment did not include the name of the staff person completing the assessment.)Record review revealed on 09/04/25 Resident #65 weighed 117 pounds (this represented an 8.8 pound weight loss over ten days (from 08/25/25)). Review of a nursing note dated 09/04/25 at 2:24 P.M. by Registered Nurse (RN) #324 revealed Resident #65 was set for a significant change MDS due to a decline in ADLs noted; however, since the resident had a urinary tract infection, urinary retention, and shingles the note revealed RN #324 would re-assess need for significant change assessment once acute illnesses had resolved.Review of Resident #65's medical record including turn and reposition documentation revealed no documented evidence Resident #65 was turned or repositioned on 09/04/25. Additionally, there was no documentation for dayshift for turning and repositioning Resident #65 on 09/06/25. Review of a skin evaluation assessment dated [DATE] revealed Resident #65 did not have any new skin areas. Review of a skin evaluation assessment dated [DATE] revealed Resident #65 had new skin areas. The assessment noted to the right heel an area measuring 8.5 centimeters in length by 8.5 cm width with deep purple center that gradually lightens to purple/deep red and extends to yellowish red; to the left heel a 5.5 cm by 7.5 cm area with deep purple center that gradually lightens to purple/deep red and extends to yellowish red. The assessment documentation noted a treatment was applied. However, this skin assessment did not identify a stage of the pressure wounds.Review of an order dated 09/08/25 revealed Resident #65 was to be encouraged to be up in chair during wake hours for wound healing every shift.Review of an order dated 09/08/25 (following the identification of the pressure ulcers) revealed Resident #65 should offload bilateral heels while in bed every shift.Review of an order dated 09/08/25 revealed skin prep left heel, place Optifoam heel non-adhesive foam and wrap with kerlix twice daily and as needed.Review of an order dated 09/08/25 revealed skin prep right heel, place Optifoam heel non-adhesive foam and wrap with kerlix twice daily and as needed.Review of a nursing note dated 09/08/25 at 11:32 A.M. by LPN #203 revealed she was notified Resident #65 had discoloration to her bilateral heels. Right heel area was measuring at 8.5 by 8.5 by unknown depth closed without drainage, soft to touch, non-blanchable without drainage, non-blanchable with deep purple center that gradually extends to lighter purple/deep red surrounded by yellowish-red tissue. Left heel area measuring 5.5 by 5.7 by unknown depth closed without drainage, soft to touch, non-blanchable with deep purple center that gradually extends to light purple/deep red surrounded by yellowish red tissue. Resident (#65) did voice areas to be tender to touch but no complaints of pain when not touched. Resident was unable to rate the pain but grimaced when heels were touched. Resident (#65) with previous decline due to UTI, urinary retention and suspected shingles, provider was notified. New orders were received at this time to discontinue compression stockings, start liquid protein 30 mL, offload heels while in bed, encourage to be up in chair while awake, skin prep with Optifoam twice daily and as needed, and a referral to dietician. Family was aware of new orders.Record review revealed on 09/09/25 Resident #65 weighed 116 pounds (a additional one pound weight loss in five days). Review of a provider note dated 09/10/25 at 1:40 P.M. authored by Physician #300 revealed Resident #65 now had a developing pressure injury to her sacrum and an unstageable (pressure ulcer) to each heel.Review of a nursing note dated 09/10/25 at 5:40 P.M. revealed Resident #65 had new areas to coccyx (pressure injury) and right inner thigh (discoloration), Depends (urinary incontinence brief) elastic in leg pinched resident causing discoloration. Treatment orders were put in place, air mattress intervention for pressure injury. Staff were educated on proper alignment of Depends to prevent pinching of skin. Provider and family notified.Review of a nursing note dated 09/10/25 at 6:29 P.M. by LPN #203 revealed Resident #65's pressure injury to sacrum measured 3.5 (cm) by 3.5 (cm) by 0.1 (cm) at a Stage 2 (II) with light serous drainage noted, discomfort to site with cleansing no signs/symptoms of infection noted. Provider and family were aware and orders were in place at this time to promote wound healing. Review of an E-interact change in condition form dated 09/10/25 revealed Resident #65 had a steady decline in health status. Family was considering hospice but requested the resident be sent to the emergency room for evaluation to see if there were any treatable conditions prior to making (hospice) decision. The form included Resident #65 had no changes observed but needed more assistance with activities of daily living (ADLs), general weakness, and decreased mobility. Resident #65 was transferred to the emergency room per family request.Review of a nursing note dated 09/10/25 at 11:27 P.M. revealed Resident #65 was admitted to the hospital for failure to thrive. The resident returned to the facility on [DATE]. The resident returned to the facility on [DATE] and passed away on 10/28/25.Interview on 01/06/26 at 3:52 P.M. with the Director of Nursing (DON) confirmed Resident #65 did not have a comprehensive (integrated/escalated) plan of care in place with preventative interventions for skin breakdown prior to the skin breakdown occurring. In addition, the DON confirmed prior to the skin breakdown the resident experienced an overall decline that included more limited mobility, decline in cognition, a UTI, potential shingles, urinary retention, and edema. The DON confirmed Resident #65 developed two unstageable pressure areas on 09/08/25 to her heels and one Stage II area on 09/10/25 to her sacrum. The DON also confirmed Resident #65 had been losing weight during that time. The DON confirmed overall decline could lead to wound (pressure ulcer) development. Interview on 01/07/26 at 10:03 A.M. with Regional Nurse #307 revealed the areas on Resident #65's heels did not ever open up meaning they were deep tissue injuries and not unstageable areas because they were closed areas. Regional Nurse #307 stated Resident #65 had severe cognitive concerns so wounds would have happened regardless. However, no additional information was provided to support the wounds were avoidable due to the resident's cognitive loss. Identification of the cognitive loss, decline in overall status and increased dependence on staff should have prompted the facility (in July 2025) to implement comprehensive integrated/escalated interventions to decrease the risk of pressure ulcer development which had not been done. Interview on 01/07/26 at 10:20 A.M. with Physician #300 revealed he thought Resident #65's skin breakdown was largely due to nutrition issues, sepsis and immobility. During the interview, Physician #300 revealed he felt the wound on the resident's sacrum could be a Kennedy ulcer. However, there was no information in the resident's medical record to support this. Physician #300 confirmed he did not document suspicions of a Kennedy ulcer and confirmed he did not look at the resident's skin every time he saw her. Review of National Pressure Ulcer Advisory Panel Pressure Injury Stages (dated 2018) revealed an unstageable pressure injury was a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure injury would be revealed. Stable eschar (in example dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.Review of a policy titled Wound Management Policy, dated 05/30/24, revealed it was the policy of the facility to ensure residents who do not have skin integrity impairments do not develop a new condition affecting the skin and that those residents with impaired skin integrity are recognized by our care team, treated timely, and interventions to heal were not exhausted until the skin was healed. The three constructs of the wound program were prevention of skin conditions, optimization of healing solutions, and prevention of impaired skin sequela. The skin was the largest organ of the body and impairment could result in additional medical complexities for the resident known as sequela. The facility would have a system in place to prevent the condition of skin impairment from evolving and eroding the health of the resident affected. The RCT would act to prevent and/or treat the following complexities associated with skin impairments: infection, pain, mental anguish, and failure to thrive. 2. Review of Resident #39's medical record revealed he was admitted to the facility on [DATE] with diagnoses including urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, pressure ulcer unstageable and diabetes. Review of Resident #39's admission MDS assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #39 had an indwelling catheter and was frequently incontinent of bowel. Review of the physician's orders revealed an order dated 12/03/25 for cleaning of a sacrococcygeal pressure ulcer. The order identified to cleanse with soap and water; pat dry; apply Triad hydrophilic dressing in a dime thick layer over wound and wound edges; leave open to air. When cleansing, remove top layer of ointment only then reapply. Do not scrub ointment off skin every day and night shift for wound care instructions. Review of physician orders revealed an order dated 12/15/25 that changed the cleaning of the sacrococcygeal pressure ulcer. The new order identified to cleanse with soap and water; pat dry; apply alginate dressing to wound bed and picture frame application of zinc barrier to peri-wound, cover with ABD every day shift and as needed. Review of the treatment record for December 2025 revealed no documented evidence Resident #39's sacrococcygeal pressure ulcer treatment was completed on dayshift on 12/07/25, 12/10/25, 12/11/25, 12/12/25 and 12/15/25, 12/16/25, 12/23/25 and 12/29/25 and on night shift on 12/10/25 and 12/24/25.On 01/06/26 at 11:49 A.M. interview with the Director of Nursing verified there was no evidence treatments were completed as ordered for Resident #39's sacrococcygeal wound.This deficiency represents non-compliance investigated under Complaint Number 2702525.

Based on medical record review and staff interview, the facility failed to provide ordered treatment of a thoracic abscess, daily weights and monitoring intake and outputs for a resident on fluid restrictions. This affected two residents (#39, #66) of eight resident records reviewed. The census was 63. Findings include:1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including methicillin susceptible staphylococcus aureus (MSSA) infection, endocarditis, and altered mental status. Resident #66 discharged from the facility on 12/26/25. Review of an email sent to the facility on [DATE] revealed Resident #66 would need a wound vac and orders were attached. Review of an order dated 12/04/25 revealed Resident #66's wound needed a wound vac for a wound to left chest at pressure setting 125 (standard) with no wound vac cover, the wound vac dressing would need changed three times a week and as needed, cover with white foam and wound cleanser would be normal saline. The suction was to be continuous. Review of a hospital Discharge summary dated [DATE] revealed Resident #66 would continue with cefazolin with end date of 01/18/26 and needed weekly labs while on antibiotics. Resident #66 was seen by the physician for discharge and the wound vac was in place. There was no order for the wound vac to be discontinued. Review of an order dated 12/12/25 revealed on 12/13/25, Resident #66 would start receiving cefazolin (antibiotic) sodium injection solution reconstituted 2 grams use 2000 milligrams (mg) intravenously every eight hours for infection for 40 days. The end date would be 01/22/26. Review of an order dated 12/13/25 revealed Resident #66 would receive the following wound treatment to his left chest: sodium hypochlorite external solution 0.125% apply to left chest surgical incision wound topically every day shift for infection of the wound, pack with Dakins moistened 4 by 4s, and cover with dry dressing or Tegaderm. Change daily and as needed. Review of a medication administration record for December 2025 revealed the administration of IV antibiotic cefazolin was marked as completed for 6:00 A.M. dose on 12/13/25, but medication was not available for 2:00 P.M. and 10:00 P.M. doses on 12/13/25 or for the 6:00 A.M. and 2:00 P.M. doses on 12/14/25. Review of a nursing note dated 12/14/25 at 1:08 P.M. revealed a call was made to the pharmacy due to receiving none of Resident #66's medications from them. Pharmacy reported Resident #66's medications left the pharmacy on 12/13/25 and were still enroute. There was no evidence of resident/representative notification or of physician notification/new orders to hold medication or use a substitute medication from back up until Resident #66's medications arrived. Review of a care plan dated 12/15/25 revealed Resident #66 had a diagnosis of bacterial endocarditis, the goal was for symptoms of the infection to be resolved and interventions included but were not limited to administer medications as ordered, document abnormal findings and notify physician, and encourage activity as tolerated. Review of a treatment record for December 2025 revealed Resident #66 did not receive wound care on 12/15/25, 12/17/25, 12/24/25, or 12/26/25 which was the date of discharge. There were no corresponding nursing notes to document why treatment was not completed. Review of an MDS dated [DATE] revealed Resident #66's cognition was mildly impaired, he had no behaviors, and received intravenous (IV) medications. Interview on 01/06/25 at 1:53 P.M. with the Director of Nursing (DON) confirmed there was no evidence in the medical record for Resident #66's wound vac was ordered, was to be discontinued, or that he refused the wound vac. Additional interview on 01/06/25 at 3:52 P.M. with the DON confirmed Resident #66 did not receive his IV medications as ordered due to not arriving from pharmacy, the providers were not notified, and new orders were not received to either hold medications or use medications in stock in medication storage pod. Additionally, the DON confirmed Resident #66 did not receive wound care as ordered on 12/15/25, 12/17/25, 12/24/25, or 12/26/25. 2. Review of Resident #39's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, pressure ulcer unstageable and diabetes. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #39 has an indwelling catheter and is frequently incontinent of bowel. a. Review of the medical record revealed on 12/04/25 a physicians order to obtain daily weight and notify the physician if there was a weight gain greater than three (3) pounds in a day or five (5) pounds in a week was obtained. Further review revealed no documented evidence of weights for December 2025 for 12/04/25, 12/05/25, 12/06/25, 12/07/25,12/08/25, 12/09/25, 12/10/25, 12/11/25, 12/12/25, 12/14/25, 12/17/25, 12/18/25, 12/19/25, 12/23/25, 12/25/25 and 12/30/25. This was verified during interview on 01/06/26 at 3:02 P.M. with the Director of Nursing. b. Review of the medical record revealed on 12/03/25 a physician's order for Meropenem intravenous solution one gram intravenously every eight hours for a thoracic epidural abscess until 01/13/26. Further review revealed no documented evidence it was administered on 12/04/25, 12/26/25 and 12/20/25. This was verified during interview on 01/06/26 at 3:02 P.M. with the Director of Nursing. c. Review of the medical record revealed on 12/03/25 a physicians order to monitor intake and output every shift for fluid restriction and congestive heart failure. Further review revealed no documentation of the intake and output on day shift 12/04/25, 12/07/25, 12/10/25, 12/11/25, 12/12/25, 12/23/25, and 12/29/25 and for night shift 12/09/25, 12/11/25, 1215/25, 12/16/25, 12/17/25, 12/21/25, and 12/29/25. This was verified during interview on 01/06/26 at 11:49 A.M. with the Director of Nursing. This deficiency represents non-compliance investigated under Complaint Number 2702525.

Based on medical record review and staff interview, the facility failed to obtain laboratory services as ordered. This affected one resident (#39) of eight resident records reviewed. The census was 63. Findings included:Review of Resident #39's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, pressure ulcer unstageable and diabetes.Review of the admission minimum data set (MDS) dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #39 had an indwelling catheter and was frequently incontinent of bowel. Further review revealed a physician's order on 12/04/25 for a complete blood count (CBC), e-diff (electronic differential), platelets, basic metabolic profile (BMP) without glucose, hepatic function panel weekly in the morning every Thursday for Meropenem (antibiotic) therapy and send the results to the physician. Review of the medical record revealed there was no evidence of laboratory results on 12/11/25 and 12/25/25. On 01/06/26 at 8:49 A.M. interview with the Director of Nursing verified there was no evidence the labs were completed as ordered.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702525.

Based on interviews, observations and facility policy, the facility failed to maintain a safe and homelike environment for four residents ( #11, #20, #30, and #40) of four residents reviewed. The facility census was 56. Findings include: Observation on 03/31/25 at 12:35 P.M. of private room [ROOM NUMBER] revealed in the bathroom, a small quarter size rusted hole through the sink. Interview on 03/31/25 at 12:59 P.M. with the Director of Nursing revealed the facility did an audit for the entire facility on resident's bathroom conditions on 03/06/25 and found two sinks that had rusted holes found in room [ROOM NUMBER] as well as the shared bathroom for rooms #106 and #108. Verified room [ROOM NUMBER] is now unoccupied, but did have Resident #11 when she was at the facility. room [ROOM NUMBER] has Resident #30 and #40 currently and room [ROOM NUMBER] has Resident #20 currently. Observed on 03/31/25 at 1:21 P.M. of the shared bathroom for rooms #106 and #108 revealed a baseball sized hole that was rusted through the sink. Interview on 04/01/25 at 8:38 A.M. with the Maintenance Director verified the bathrooms for room [ROOM NUMBER] and for the shared bathroom for rooms #106 and #108 had holes rusted through the sinks. He also revealed he ordered sinks about a month ago to replace them and was picking them up today to start the repairs. Review of the facility policy titled Safe & Homelike Environment last reviewed on 12/12/2023 revealed the facility will provide a safe, clean, comfortable homelike environment that includes ensuring that the residents can receive care and services safely and the physical layout of the facility maximizes residents' independence and does not pose a safety risk. The word environment includes but is not limited to the resident's bathroom. This deficinecy represents non-compliance investigated under Master Complaint Number OH00163982 and Complaint Number OH00162700.

Based on interviews, record reviews, and facility validation accessing implanted vascular access port guidelines the facility failed to ensure an antibiotic was ordered correctly and an implanted vascular access port (port a cath) was accessed with a physician's order. This affected one resident (#11) of two residents reviewed for indwelling devices and antibiotics. The facility census was 56. Findings include: Review of the medical record for Resident #11, revealed an admitted [DATE] and a was sent to the hospital when at Fairfield Healthcare Professional Hematology and Oncology infusion appointment on 03/07/25. Diagnoses included but were not limited to partial intestinal obstruction, malignant neoplasm of colon, moderate protein-calorie malnutrition, osteoarthritis, iron deficient anemia, essential hypertension and personal history of venous thrombosis and embolism. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to require setup or clean-up assistance with eating, oral hygiene, toilet hygiene, shower/bathe self, and supervision or touching assistance with bed mobility and transfers. This resident was also assessed to be occasionally incontinent or bladder and bowel elimination. Review of the hospital discharge paperwork dated 02/12/25 revealed Resident #11 had an implanted vascular access port to her left upper chest. Review of the facility admission assessment dated [DATE] revealed Resident #11's implanted vascular access port was not accessed. Review of the plan of care for Resident #11 revealed no focus, goal and interventions for the un accessed implanted vascular access port. Review of the physician's order dated 03/06/25 at 5:22 P.M. entered by Registered Nurse (RN) #323 revealed Cefepime Hydrochloric Acid (HCL) intravenous solution reconstituted 2 grams, use 2 grams intravenously two times a day for bacteremia until 03/18/25 telephone order from Physician #222. Review of the progress note dated 03/07/25 at 6:10 A.M. authored by RN #420 revealed a Huber needle 20 gauge by 1 inch accessed to left upper chest per sterile procedure. Port a cath flushed with blood return from cath. Resident tolerated procedure well. Intravenous (IV) antibiotics started. Review of the Medication Administration Record dated 03/07/25 at 7:00 A.M. revealed Resident #11 received the Cefepime HCL IV 2 grams. Review of Resident #11's medical record did not reveal any provider documentation and no laboratory tests to support the new diagnosis of bacteremia for antibiotic medication order of the Cefepime HCL. Further review also revealed no physician's order to access the implanted vascular access port. Interview on 03/31/25 at 1:58 P.M. with Physician #222 via telephone revealed he did not order the Cefepime HCL antibiotic medication via telephone on 03/06/25 for Resident #11 for bacteremia. Also verified he did not give the facility an order and permission to access her implanted vascular access port and does not allow them to be accessed for medications and labs at all unless it is urgent. Interview on 03/31/25 at 2:10 P.M. with Certified Nurse Practioner (CNP) #520, who works under Physician #222, via telephone revealed she did not order the Cefepime HCL antibiotic medication via telephone on 03/06/25 for Resident #11. Also verified she did not give the facility an order and permission to access her implanted vascular access port. Interview on 03/31/25 at 3:02 P.M. with RN #323 revealed she took the telephone order for the Cefepime HCL antibiotic medication for Resident #11 from a woman and could not remember who it was. Verified she placed the order under Physician #222's name and stated I entered the order under him because that is her doctor. Interview on 03/31/25 at 3:29 P.M. with the Director of Nursing (DON) revealed she is unable to confirm what provider ordered the Cefepime HCL antibiotic medication for Resident #11 as well as find any provider notes supporting the new diagnosis of bacteremia for it. Interview on 03/31/25 at 3:43 P.M. with the Assistant Director of Nursing revealed to access an implanted vascular access port an order is usually required, and the facility has a guideline to follow. Interview on 03/31/25 at 3:58 P.M. with Medical Assistant #1000 at Fairfield Healthcare Professionals General Surgery office of Physician #777 via telephone revealed Resident #11 was seen in their office on 03/05/25 and Physician #777 did not order the Cefepime HCL antibiotic medication and did not give an order to access the implanted vascular access port. Interview on 04/01/25 at 9:00 A.M. with CNP #111 via telephone revealed Resident #11 was at their infusion clinic for fluids and iron on 03/07/25. An infusion nurse noted Resident #11 to have her implanted vascular access port to be improperly accessed was concerned for her decline in overall condition. CNP #111 assessed Resident #11 and decided to send her to the emergency room due to a decline in her overall condition. No adverse effects to Resident #11 were assessed by CNP #111 due to the improper access of her implanted vascular access port and she sent a communication to the facility to not access it. She also verified she never ordered the Cefepime HCL antibiotic medication and to have the facility access her implanted vascular access port. Interview on 04/01/25 at 9:35 A.M. with the DON revealed she was unable to provide documentation and an order for the Cefepime HCL antibiotic medication as well as an order and permission for the facility to access the implanted vascular access port for Resident #11. Attempted to interview RN #420 via telephone with no successful attempts. Review of the facility validation checklist for accessing implanted vascular access ports with no date revealed the purpose of the checklist is to determine if the individual performs vascular access port care in accordance with professional standards of practice. The first step is to review the physician's orders. This deficinecy represents non-compliance investigated under Master Complaint Number OH00163982.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident, who was dependent on staff for personal care, received the assistance needed with routine incontinence care and repositioning as needed when up in her wheelchair. This affected one (Resident #39) of three residents reviewed. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (MS), cognitive communication deficit, abnormal posture, scoliosis, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, and chronic pain syndrome. Review of Resident #39's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired, she was not known to display any behaviors nor was she known to reject care. She had a functional limitation in range of motion (ROM) of her bilateral upper and lower extremities and a wheelchair was listed as the only mobility device used. The resident was dependent on staff for bed mobility, transfers, and toileting hygiene. She was known to be always incontinent of her bowel and bladder and was not on a toileting program for either. She was identified as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers. Review of Resident #39's Braden Scale for Predicting Pressure Ulcer Risk dated 10/02/24 revealed the resident was assessed to be a high risk for pressure ulcers. Risk factors included a slightly limited sensory perception, her skin being very moist (degree to which skin was exposed to moisture), being chairfast, being completely immobile, and she had a problem with friction and shearing. Review of Resident #39's Bowel and Bladder assessment dated [DATE] revealed the resident had a history of bowel and bladder incontinence. She was always incontinent of her bowel and bladder, was dependent on staff for toileting, and did not request toileting when needing to go. She was not able to tell when her urine flow started or stopped. The plan was for the resident to be checked and changed. Review of Resident #39's active care plans revealed she had a care plan in place for the potential for impairment to skin integrity related to decreased activity, incontinence, limited mobility, shear/friction risks, and history of a chaffed area. She was at risk for skin breakdown to her posterior thighs secondary to incontinence. The goal was for the resident to maintain intact skin with no breakdown. The interventions included keeping body parts from excessive moisture and encourage the resident to turn and reposition on routine care rounds and as needed. She also had a care plan for being incontinent of her bowel and bladder related to MS, impaired mobility, and recurrent urinary tract infections (UTI). The goal was for the resident to be clean, dry, and odor free through the review date. The interventions included providing skin care after each incontinent episode and to apply a moisture barrier. On 12/17/24 at 9:00 A.M., an observation of Resident #39 noted her to be sitting up in her wheelchair in her room. She was in a tilt space wheelchair and was leaning to the right. A neck pillow and bolsters were noted on her bilateral armrests. On 12/17/24 at 9:59 A.M., ongoing observations of Resident #39 noted her out of her room and in the dining room for a music activity. The resident was sitting in her tilt space wheelchair leaning over to the right side and not actively engaged in the activity. On 12/17/24 at 10:46 A.M., Resident #39 was observed to be wheeled out of the dining room by another female resident that was also in a wheelchair and pushing Resident #39 from behind. The other resident assisted Resident #39 to leave the dining room after the activity had been completed, and left her in the front lobby area. On 12/17/24 at 11:37 A.M., Resident #39 was still up in her tilt space wheelchair in the front lobby area sitting there with her eyes closed and leaning to the right. No staff members were noted to come and check on her or offer to change her. No staff members were noted to reposition the resident or assist her with shifting her weight while she sat in her wheelchair. On 12/17/24 at 11:47 A.M., Resident #39 was observed to be taken to the dining room for lunch. She was assisted by an activity aide that was in the dining room preparing for the upcoming meal. She remained sitting in her tilt space wheelchair leaning to the right until she was served her meal tray at 12:17 P.M. On 12/17/24 at 12:35 P.M., Resident #39 was removed from the dining room and assisted back to her hallway by an aide. She was left sitting in the middle of her hallway in her tilt space wheelchair and continued to lean to the right, while staff members collected meal trays from the residents that ate their lunch in their rooms. The area that she was placed in the hall was not outside of her room. She remained there as the aides on that hall began doing rounds at the opposite end of the hall from where the resident's room was. It was not until 1:05 P.M. that Certified Nursing Assistant (CNA) #100 was noted to take the resident into her room and close the door. On 12/17/24 at 1:12 P.M., an interview with Licensed Practical Nurse (LPN) #155 revealed Resident #39 was totally dependent on staff for care and was a mechanical lift for transfers. The resident was completely incontinent of her bowel and bladder. The nurse reported the resident had no idea when she needed to go to the bathroom and did not alert the staff when she was incontinent. The staff were to turn and reposition her, as she couldn't move herself. She indicated the resident was flaccid on the left side. The resident was to be checked and changed every two hours and turning and repositioning should be done with every two hour rounds. She stated the CNA's knew what each residents' care needs were based on the care plans and the Kardex they had access to in the computer. The nurses were responsible for ensuring the CNA's were doing their jobs. She revealed she had been in and out of the resident's room a few times that day, when passing meds or answering call lights. She further revealed she no longer considered the resident to be at risk for falls as the resident did not move enough on her own to be a fall risk. On 12/17/24 at 1:28 P.M., an interview with CNA #100 revealed Resident #39 was totally dependent on staff for care. They helped the resident with changing her as needed. She indicated the resident was incontinent of her bowel and bladder at all times and she required the staff to assist with turning and repositioning/chair mobility, and was a mechanical lift for transfers. The CNA revealed the resident had the use of only one arm. She revealed the staff did rounds to check and change residents every two to three hours. She stated sometimes Resident #39 had been known to have irritation between her legs, but she described the resident as being compliant with her care. The resident's normal routine was to get up before 7:00 A.M. The night shift aides would have her up before they got there in the morning. The night shift aides usually left her in her room with her television on, then at breakfast time, they took her down to the dining room to eat. She went to the dining room for breakfast that morning and after breakfast she usually came back to her room and staff would check her. If she needed changed, they would put her in bed to change her. They had a music activity after breakfast that morning, so the resident did not go back to her room until after the activity was over. CNA #100 was not sure what time that was. She stated the music activity started at 10:00 AM and usually lasted between 30 minutes to an hour. The resident would have went back to her room sometime after that. She confirmed they placed the resident back in bed to change her around 1:05 P.M. She stated the resident was found to be incontinent of her bladder at that time. She acknowledged, with the observations made and her interview, it was able to be determined that the resident had not been changed between the hours of 7:00 A.M. and 1:05 P.M. She further acknowledged the resident had not been observed to be out of the chair or repositioned or have her body weight shifted from the time she was observed on 12/17/24 at 9:00 A.M. until they placed her in bed at 1:05 P.M. On 12/17/24 at 2:55 P.M., an interview was conducted with the facility's Director of Nursing (DON) and she confirmed there had been concerns raised from the resident's family regarding the facility staff not going in the room to change her on a regular basis. They had a care conference where that was discussed. The DON was informed observations of Resident #39 made during the complaint investigation and interviews with facility staff confirmed the resident had been up in her chair since before 7:00 A.M. and was not observed to be provided any incontinence care or repositioning in her wheelchair until 1:05 P.M., when the day shift aides put her back in bed and changed her. She confirmed it was the expectation of the staff to complete rounds every two hours and assist residents with incontinence care and repositioning. Review of the facility's policy on Activities of Daily Living (ADL), revised January 2022, revealed it was the policy of the facility that each resident would have their ADL needs determined within seven days of their admission, then would have an individualized plan of care to guide the staff in delivering the necessary ADL support and care. The facility's ADL goal was that a resident's abilities in ADL did not diminish unless circumstances of the individual's clinical condition demonstrated that decline was unavoidable. That included the resident's ability to toilet, transfer, and ambulate. ADL care plans would be implemented in the following categories that included toileting and mobility. Staff were to carry out the ADL care tasks by following the resident's ADL care plan and document the assistance provided. Residents that had the decreased ability to reposition themselves would be repositioned throughout the course of the day during routine ADL's when in bed or in their wheelchair. Incontinence care would be delivered timely as necessary while attempting to anticipate the resident's needs. Frequent rounding on the unit (recommended at least every hour) was to be done to observe residents, needs, and unit atmosphere. This deficiency represents non-compliance investigated under Complaint Number OH00159738.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent residents from falling. This affected two residents (#62, #82) of three residents reviewed for accidents. The facility census was 59. Actual Harm occurred on 02/02/24 when Resident #62 was being prepared for a transfer from her wheelchair to her bed by one staff member who then left her alone unsupervised. Resident #62 fell from her wheelchair and sustained a fracture to her right wrist. Actual Harm occurred on 02/10/24 when Resident #82, who required a dependent assist from staff for transfers, fell in the bathroom when left unsupervised and sustained a right hip fracture resulting in hospitalization . Findings included: 1. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, stiffness of left elbow, chronic pain syndrome, hyperlipidemia, scoliosis, osteoarthritis, and mild cognitive impairment. Review of a minimum data set (MDS) assessment completed on 11/14/23 revealed Resident #62 had a brief interview for mental status of two (severe cognitive impairment), had impairments to bilateral upper and lower extremities, used a wheelchair, and required a dependent assist of two staff for chair to bed transfers. Review of orders revealed Resident #62 had an order starting on 10/22/23 for a full body lift for all transfers (mechanical hoyer transfer). Review of a care plan with a review date of 02/07/23 revealed Resident #62 was at risk for falls related to multiple sclerosis, chronic pain, pain and psychotropic medication use, and incontinence of bladder with a goal to remain injury free through the next review date. Fall interventions included call light within reach, non-skid footwear, attending activities, grab bars as enablers, have commonly used items within easy reach, perimeter mattress to bed, place glasses within reach and encourage use, provide assistance as needed for mobility tasks and assure utilization of appropriate devices, and to ensure wheelchair brakes are fully engaged prior to transferring resident to her chair. Review of a nursing note from 02/02/24 at 11:50 A.M. by Licensed Practical Nurse (LPN) #170 revealed Resident #62 returned to the facility from the hospital with a splint to right limb due to a broken wrist. Review of a nursing note from 02/02/24 at 8:00 P.M. by LPN #170 revealed Resident #62 was sent out via ambulance to the emergency department due to possible right wrist fracture from a previous fall. All responsible parties were made aware. Review of a fall investigation from 02/02/24 revealed the nurse was called to Resident #62's room and found resident lying on the floor in front of her bed with no injuries noted at this time, and the immediate action taken was to get help from the other side of the facility to pick resident up with the hoyer lift and put her in bed. Other information obtained for the investigation revealed Resident #62 was leaning in her chair and a State tested Nursing Assistant (STNA) (later identified as STNA #145) was attempting to move resident from her chair to the bed when Resident #62 leaned and came out of the chair and onto the floor. Review of a statement from 02/02/24 by STNA #175 revealed while in another resident's room, STNA #145 informed her Resident #62 had fallen out of her chair and she needed help. Additional STNAs were walking by and stated they would help as well. STNA #175 stated when she entered the room, Resident #62 was face down on the floor at the bottom of the bed with her head facing the window and her feet pointed towards the door of her room. Review of a statement from 02/02/24 by STNA #110 revealed she was coming from the kitchen when she saw STNA #145 and STNA #175 coming from the top of hallway one. STNA #110 overheard other STNAs say someone was on the ground and she volunteered to help get the resident up. When STNA #110 entered Resident #62's room, resident was lying face down at the foot of the bed on the floor with her feet and legs towards the door and her face was laying on the wheels of the bed. STNA #110 stated a pillow had been placed under Resident #62's head. Resident #62 had a bruise to her forehead. Review of a statement from 02/02/24 by STNA #190 revealed she was taking trays to the kitchen when she saw aides coming down the hall. When she heard a resident was on the floor, she offered to help. Upon entering the room, Resident #62 was face down with her head on the bottom bed lock and her feet were facing the door. Review of a statement from 02/02/24 by STNA #145 revealed she was in Resident #62's room to return her to bed and Resident #62's face was down on her bedside table. STNA #145 moved the tray table and Resident #62 started to lean forward in the chair grabbing her ankle. STNA #145 stated she told Resident #62 she was going to fall and stop, while attempting to hold one of Resident #62's shoulders back and using the other hand to try to tilt the wheelchair back but the chair would not tilt back. STNA #145 stated when she turned to open the door for help, because no one came to assist when she had turned the call light on, she heard Resident #62 fall to the floor. Review of X-ray collected on 02/02/24 at 9:36 P.M. revealed Resident #62 had a minimally displaced mild impaction fracture of the distal ulnar metadiaphysis. There was apex dorsal angulation. Interview on 02/13/24 at 1:28 P.M. with the Director of Nursing (DON) revealed STNA #145 was adjusting the resident in her chair, not necessarily transferring her. The DON revealed the incident report was filled out by a nurse who wasn't even there. Interview on 02/13/24 at 1:33 P.M. with STNA #145 revealed Resident #62 was leaning forward in her chair and grabbing her ankles with her good (right) hand. STNA #145 stated she thought Resident #62 was going to fall, so she turned on the call light for assistance. STNA #145 stated she tried to hold the resident up by her shoulder, with one hand, while using the other hand to attempt to tilt her wheelchair back, but it would not tilt and no one came to answer the call light. STNA #145 stated Resident #62 was too close to the edge of her seat. STNA #145 stated she went to go get help and as she was walking towards the door, she heard Resident #62 fall. STNA #145 stated Resident #62 was not immediately sent out for a checkup because the nurse determined she did not need to go to the hospital. Observation on 02/13/24 at 1:57 P.M. revealed Resident #62 was seated in her bed with a light yellow, fading bruise to her left eye, a cast to her right arm, no glasses, and dry lips. A tilting wheelchair was noted at bedside, a perimeter mattress was in place, and a soft touch call light was in reach. Interview on 02/14/24 at 9:33 A.M. with Family Member (FM) #216 revealed Resident #62 had told her and an STNA that she was dropped. Interview on 02/14/24 at 9:47 A.M. with Resident #62 revealed the girls were trying to move her when she was dropped. Resident #62 did have a hard time communicating but was able to answer yes or no questions regarding the incident. Interview on 02/14/24 at 10:30 A.M. with STNA #133 revealed when she asked Resident #62 what happened to her wrist and face, Resident #62 told STNA #133 she was dropped by STNA #145. STNA #133 stated she reported this to an LPN (#139) but did not write a statement due to leaving work for an emergency. Interview on 02/14/24 at 3:34 P.M. with Registered Nurse (RN) #155 revealed she was down the hall from Resident #62's room when STNA #145 went in to take care of Resident #62. RN #155 stated she believed the call light came on but there were multiple lights on, so it was difficult to tell. RN #155 stated STNA #145 was going in to transfer Resident #62 and would usually prepare the resident for a transfer, then come to the doorway to call for help when the resident was ready. When RN #155 entered the room, the hoyer lift was not near Resident #62 and the left side of Resident #62's face was on the floor and her left arm was under her. RN #155 stated she assessed Resident #62 and did not notice any injuries. Observation on 02/15/24 at 02/15/24 revealed Resident #62 resting in bed, perimeter mattress in place. Interview on 02/15/24 at 2:03 P.M. with Regional Support Administrator confirmed Resident #62 fell and sustained a fractured wrist due to being left unsupervised in a compromising position. 2. Closed record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-ST elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set (MDS) assessment completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Review of a care plan from 11/29/23 revealed Resident #82 was at risk for falls related to dementia, poor safety awareness, psychoactive medications, forgetting to use walker, periods of agitation, and history of falls with a goal of remaining free from injury through next review date. Interventions included administer medications as ordered, be sure call light is within reach, educate resident and family about safety reminders and what to do if a fall occurs, ensure the resident is wearing appropriate footwear when ambulating/in wheelchair, non-skid footwear, follow fall protocol. Review of the care plan for activities of daily living revealed no instructions for the level of assistance Resident #82 required for transfers. Review of Point of Care (POC) documentation from 01/23/24 to 02/12/24 for walking in room, transfer and toilet use revealed no documentation. Review of POC documentation from 01/23/24 to 02/12/24 for urinary continence revealed Resident #82 was intermittently incontinent. Review of POC documentation from 01/23/24 to 02/12/24 for sitting in bed revealed Resident #82's ability fluctuated from independent to maximum assistance. Review of POC documentation from 01/23/24 to 02/12/24 for lying down to sitting on the side of the bed revealed Resident #82's ability fluctuated between minimum to maximum assistance. Review of POC documentation from 01/23/24 to 02/12/24 for sit to stand revealed Resident #82 required moderate to maximum assistance. Review of POC documentation from 02/13/24 to 02/12/24 for toilet transfers revealed Resident #82 required minimum to maximum assistance. Review of POC responses from 01/23/24 to 02/12/24 for walking 10 feet revealed Resident #82 required minimum assistance. Review of Hospice documentation from 01/22/24 revealed Resident #82 was no longer able to walk, unable to stand and pivot transfer independently, required a one to two person assist for transfers at all times due to increased weakness, would often yell I'm going to fall while being transferred, and was unable to scoot herself up in the bed anymore and became very short of breath when she tried. Review of a Fall Risk Assessment completed on 01/23/24 revealed Resident #82 was unable to independently come to a standing position and exhibited loss of balance while standing. Resident #82's fall risk score was 19, indicating the resident was at a high risk for falls. Review of a Kardex revealed no direction to staff of Resident #82's needs for transferring. Review of a nursing note from 02/10/24 at 7:19 P.M. by LPN #165 revealed the nurse was called to Resident #82's room, wheelchair was noted in the bathroom doorway, and resident was sitting on her buttocks, legs straight out in front of her, facing the toilet with her hands at her sides, holding her up. Resident #82 stated I unlocked my wheelchair so I could get in it but it moved and I fell . LPN #165 assessed the resident for injuries and found slight redness to her upper back, and determined range of motion was within normal limits. All responsible parties were notified. Review of a nursing note from 02/10/24 at 8:16 P.M. by LPN #165 revealed the nurse offered to send Resident #82 to the hospital for evaluation due to complaint of right thigh pain and family declined. Review of a nursing note from 02/10/24 at 9:15 P.M. by RN #195 revealed Resident #82 was sent to the hospital via ambulance per family request due to increased pain in her right lower extremity after a fall. Resident #82 was admitted to the hospital for a right greater trochanter break. Review of a Head-to-Toe Assessment completed on 02/10/24 at 7:11 P.M. revealed Resident #82 had slight redness to her upper back. Review of a fall investigation from 02/10/24 revealed no injuries were noted to Resident #82 after she fell , then listed injury as right thigh with a pain of five. The mobility section of the investigation revealed Resident #82 was wheelchair bound. Review of a statement from 02/10/24 by STNA #105 revealed she was in the dining room when she heard Resident #82 yell for help, and she ran to her room. STNA #105 reported this to a nurse. Review of additional statement from STNA #105 dated 02/10/24 revealed STNA #105 was the only staff member on the unit at the time of the fall. Interview on 02/21/24 at 11:25 P.M. with the DON revealed Resident #82 was able to walk and transfer by herself but staff should provide total assistance for safety reasons. Interview on 02/21/24 at 12:01 P.M. with Anonymous Source (AS) #268 revealed Resident #82 had approximately 11 to 12 falls within the last year with multiple injuries including a broken arm and hot coffee scalding her. AS #268 stated Resident #82 was a high fall risk and was told she was left unattended in the bathroom (from the fall on 02/10/24). AS #268 stated Resident #82 was screaming in pain and screaming she wanted to die. AS #268 stated Resident #82's hip was broken in four places and required the placement of a rod. AS #268 stated she did not decline to have Resident #82 sent to the hospital at any time and begged the staff to send her to the hospital. AS #268 stated Resident #82 was dependent on staff to transfer her from her chair to the toilet, and Resident #82 was still wearing a sling on her broken arm. Resident #82 was non-ambulatory. AS #268 stated after the fall, Resident #82's right foot was rotated and laying on its side. Interview on 02/21/24 at 1:15 P.M. with STNA #145 revealed Resident #82 required a one-person minimum assist for transfers. The STNA stated staff know how much assistance to provide to residents based on their Kardex. Interview on 02/21/24 at 1:19 P.M. with STNA #150 revealed Resident #82's ability to transfer fluctuated; sometimes she was a minimum assist and other times staff had to use some muscles. STNA #150 reported Resident #82 had been non-ambulatory for a while. Interview on 02/21/24 at 1:29 P.M. with LPN #165 revealed she was called to the memory care unit and saw Resident #82 on the floor in the bathroom with her legs facing the toilet and her back towards the sink. LPN #165 stated Resident #82 was non-ambulatory but was able to transfer herself. LPN #165 stated Resident #82 had no injuries at the time, but later began to complain of pain. Multiple attempts were made to interview STNA #105 and were unsuccessful. The follow up interview on 02/21/24 at 3:07 P.M. with the DON confirmed Resident #82's care plan was not up to date and the Kardex did not list the level of assist Resident #82 required for mobility. The DON also confirmed hospice documentation stated Resident #82 was dependent on staff for transfers and therefore would not have been able to wheel herself into the bathroom and transfer herself independently onto the toilet. This deficiency represents non-compliance investigated under Complaint Number OH00151293, Complaint Number OH00150942, Complaint Number OH00150797.

Based on observation, record review and interviews, the facility failed to provide adequate hydration to a resident, who depended on staff for assistance with drinking fluids, to meet the resident's hydration needs. This affected one resident (#62) of one resident reviewed for dehydration. The facility census was 59. Actual Harm occurred to Resident #62 on [DATE] when the facility failed to provide the resident with adequate fluid intake and the resident was admitted to the hospital for treatment of acute kidney injury and dehydration. Findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, stiffness of left elbow, chronic pain syndrome, hyperlipidemia, scoliosis, osteoarthritis, and mild cognitive impairment. Review of a minimum data set (MDS) assessment completed on [DATE] revealed Resident #62 had a brief interview for mental status score of two (severe cognitive impairment), had no behaviors, had impairment to bilateral upper extremities, required dependent assistance of two staff members for activities of daily living, set-up help for meals, and was always incontinent of bowel and bladder. Review of orders revealed Resident #62 had an order on [DATE] for a regular diet with pureed texture and thin liquids and for dietician to evaluate for optimal nutritional values. Review of an annual Nutrition Assessment completed on [DATE] revealed Resident #62's estimated daily nutritional needs included 1,894 to 2,152 milliliters (ml) of fluids, to monitor intakes and elimination. Review of a quarterly Nutrition Assessment completed on [DATE] revealed Resident #62 had adequate hydration. Review of a care plan from [DATE] revealed Resident #62 had dehydration or potential fluid deficit related to diuretic use with a goal of remaining free of symptoms of dehydration and maintain moist mucus membranes, good skin turgor, and interventions including monitor and report decreased/no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset of confusion, increased pulse, headache, fatigue/weakness, fever, thirst, and dry/sunken eyes. An activities of daily living care plan revealed Resident #62 should be provided set-up help and a dietary care plan to offer/encourage fluids of choice. Review of Point of Care (POC) response for frequent check and change for Resident #62, with a timeframe of [DATE] through [DATE], revealed no documentation indicating check and changes were completed. Review of POC response for urinary incontinence revealed Resident #62 was incontinent twice on [DATE], once on [DATE], no documentation for [DATE], twice on [DATE], twice on [DATE], three times on [DATE], twice on [DATE], once on [DATE] then was out of the facility from [DATE] through [DATE], was incontinent once on [DATE], twice on [DATE], and once on [DATE]. Review of POC response for fluid intakes revealed Resident #62 consumed 600 ml on [DATE], 1,080 ml on [DATE], 1,200 ml on [DATE], 720 ml on [DATE], 360 ml on [DATE], 960 ml on [DATE], 360 ml on [DATE], 480 ml on [DATE], 360 ml on [DATE], 960 ml on [DATE], 1,080 ml on [DATE], 960 ml on [DATE], 480 ml on [DATE], 720 ml on [DATE], 720 ml on [DATE], 840 ml on [DATE], 960 ml on [DATE], was not available on [DATE], 960 ml on [DATE], 1,080 ml on [DATE], 480 ml on [DATE], 760 ml on [DATE], 720 ml on [DATE], was out of the facility from [DATE] through [DATE], and had 480 ml on [DATE]. Resident #62's fluid intake was significantly below her daily needs of 1894 ml to 2152 ml as indicated on her nutritional assessment completed [DATE]. Review of a therapy note from [DATE] at 8:48 A.M. by Director of Rehab (DOR) #119 revealed Resident #62 was screened for therapy services due to having a right wrist fracture from a fall on [DATE]. The resident was not able to use her right arm and hand due to the fracture. Review of a general note on [DATE] at 2:55 P.M. by Registered Nurse (RN) #155 revealed Resident #62's right arm was wrapped with splint and wrap, medicated as needed for pain and discomfort, and is a feed and must be offered liquids frequently. Review of a therapy note from [DATE] at 9:37 A.M. by Certified Occupational Therapy Assistant (COTA) #160 revealed Resident #62 is unable to use left upper extremity and with recent fracture, is unable to use right upper extremity and is a total feed due to this. Review of nursing note from [DATE] at 6:15 P.M. by RN #155 revealed Resident #62 had a moist cough with mucus, family was at bedside and requested resident to be sent to the emergency department for evaluation. Physician and Assistant Director of Nursing notified. Review of nursing note from [DATE] at 11:08 P.M. by Licensed Practical Nurse (LPN) #170 revealed Resident #62 was admitted to the hospital for acute kidney injury and dehydration. Review of labs from [DATE] revealed Resident #62 tested positive for a urinary tract infection with Klebsiella pneumoniae. The resident's sodium level was high with a level of 153.3 mmol/L (normal ,d+[DATE]), blood urea nitrogen (BUN was high at 40 mg/dL (normal ,d+[DATE]), creatine was high at 1.29 mg/dL (normal 0XXX,d+[DATE].04), and a chronic kidney disease epidemiology collaboration score of 41.5 (normal above or = 60 mL/min) indicating moderate to severe decrease in function. Review of an After Visit Summary (from the hospital) from [DATE] revealed Resident #62 should discontinue torsemide (a diuretic medication) 100mg tablet and torsemide 20mg tablet. Observation on [DATE] at 1:57 P.M. of Resident #62 revealed the resident sitting next to her bed in her wheelchair, her lips were dry and pale. A State tested Nursing Assistant (STNA) was walking by, the surveyor requested assistance for Resident #62 to receive a drink of water. Resident #62 took two long swigs of the water. Interview on [DATE] at 9:33 A.M. with Family Member (FM) #216 revealed Resident #62 is not able to use her hands. Family Member #216 revealed when the resident was admitted to the hospital with dehydration she was severely ill, almost died and required IV hydration. Observation on [DATE] at 3:10 P.M. and [DATE] at 1:03 P.M. revealed Resident #62 had dry and pale lips. Interview on [DATE] at 3:34 P.M. with RN #155 revealed acute kidney injuries can be caused by not having enough to drink but could have also been caused by multiple sclerosis. Interview on [DATE] at 1:03 P.M. with Resident #62 revealed resident's mouth was dry, her lips were dry and peeling. When asked if staff are offering fluids, Resident #62 stated no and when asked if she would like surveyor to have a staff member come help her get a drink, Resident #62 stated yes. Interview on [DATE] at 12:36 P.M. with Dietitian #100 revealed that when she documented on the quarterly nutritional assessment dated [DATE] adequate hydration she based it off of staff reports and things like that. Dietitian #100 stated Resident #62's annual review dated [DATE] unfortunately was not done by her. Dietitian #100 stated it's all very general. The fluid recommendations are vague, and it depends. Interview on [DATE] at 2:03 P.M. with Regional Support Administrator confirmed documentation in the POC, care plan, and notes regarding Resident #62's hydration status. Review of a policy titled Hydration Policy dated ,d+[DATE] revealed each resident shall be provided with sufficient fluids to maintain acceptable parameters of electrolyte balance and should be considered upon admission, significant change, annually and at a minimum quarterly by the Dietary Professional. Additionally, fluids based on resident preferences should be provided at each meal. This deficiency represents non-compliance investigated under Complaint Number OH00150757.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of guidelines from the Centers for Disease Control (CDC), review of the facility's [CONDITION(S)]-CoV-2 (Covid-19) timeline supported by information on the facility's long term care (LTC) Respiratory Surveillance Line List and the facility's Covid-19 Positive Resident Testing Line List, observations, record reviews, review of the facility's COVID-19 policies and procedures, review of the facility's policy on personal protective Equipment (PPE) use, review of cleaning product information, family interview, and staff interview, the facility failed to implement effective and recommended infection control practices, including the appropriate use, donning and doffing of PPE, proper disinfection of PPE, and adequate screening procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on 03/07/22 when the facility was experiencing an outbreak of Covid-19 infections among residents and staff and concerns were identified with appropriate infection control practices not being followed to help prevent the spread of Covid-19 throughout the facility. Additionally, the facility's screening process for employees and visitors failed to have adequate oversight to limit the risk of Covid-19 being introduced into the facility. The facility has had 19 residents (Resident #7, #10, #12, #19, #20, #26, #31, #35, #37, #43, #45, #46, #47, #48, #49, #50, #53, #56, and #58) contract Covid-19 infection since 01/07/22 and 10 staff members (State tested Nurse Aide (STNA) #14, STNA #22, STNA #29, STNA #31, Therapist #61, Housekeeper #63, STNA #67, Licensed Practical Nurse (LPN) #69, STNA #74 and Registered Nurse (RN) #84) contract Covid-19 since 02/07/22. The lack of effective infection control practices and prevalence of continued positive cases in the facility placed all residents at risk for harm, complications and/or death related to the facility's failure to control the COVID-19 outbreak. This had the potential to affect all 59 residents residing in the facility and specifically affected Resident #41. On 03/08/22 at 3:14 P.M., the Administrator, Regional Director of Clinical Operations, Regional Clinical Support Nurse, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/07/22 when the facility was experiencing an outbreak of Covid-19 and concerns were identified with appropriate infection control practices not being followed to help prevent/ limit the spread of Covid-19 throughout the facility. Additionally, the facility's screening process for employees and visitors failed to have adequate oversight to limit the risk of Covid-19 being introduced into the facility. Nineteen of the facility's 59 residents have or have had Covid-19 infections since the outbreak began on 01/07/22. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 03/07/22 at 4:45 P.M., the Director of Nursing completed an initial audit on PPE including: all appropriate PPE supplies stocked and available outside of isolation rooms, and observation of staff donning/doffing PPE appropriately, changes N95 mask when exiting droplet isolation room, disinfecting eye wear when exiting droplet isolation room, all appropriate PPE, and disinfecting supplies available. · On 03/08/22 at 4:00 P.M., the Regional Director of Clinical Operations completed re-education with the Director of Nursing, Assistant Director of Nursing, and Receptionist regarding Covid-19 symptom screening process. All visitors, vendors, and staff members will be screened by a staff member. If any question of the screening tool is answered yes, they will not be permitted to enter the facility. All questions on the screening tool must be asked to the person wanting to enter the building by the screener. · On 03/08/22 at 5:55 P.M., the Director of Nursing completed re-education regarding infection control topics including appropriate PPE donning/doffing, handwashing, mask/N95 usage, disinfecting eyewear upon exiting droplet isolation rooms. All staff were re-educated 03/08/22 by 5:55 P.M., that included 28 STNA's, 12 LPN's, 6 RN's, 12 Therapy, 4 Laundry, 8 Housekeeping, 10 Dietary, 2 Social Services, 5 Activities, 1 Admission Director, 1 Maintenance Supervisor, 1 Business Office Manager, 1 Human Resources Manager, 1 Administrator. · Starting 03/09/22 (no time identified), the Director of Nursing or designee will complete this audit three times a week for two weeks, then two times a week for two weeks, then weekly for two weeks then as determined necessary. The findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. · Starting 03/09/22 (no time identified), the Director of Nursing or designee will complete an audit on observation of the screening process. Audit will be completed three times a week for two weeks then twice a week for two weeks, then weekly for two weeks then as determined necessary. Findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. · On 03/09/22 at 1:30 P.M., the Regional Clinical Support Nurse, Administrator and Director of Nursing reviewed the facility's current Covid/Infection Control Guidance Policy. The policy was found to be adequate. · On 03/09/22 from 4:40 P.M. to 5:00 P.M., interviews with two STNA's, one nurse and one housekeeper confirmed they received education on infection control topics that included appropriate PPE use, donning/ doffing, N95 use, and disinfecting eyewear upon exiting droplet isolation rooms. All were able to show an understanding of the education they were provided. Although the Immediate Jeopardy was removed on 03/09/22 at 3:30 P.M., the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: 1 a. On 03/07/22 at 8:07 A.M., a visit to the facility noted they had a sign posted at the front entrance that indicated they have positive Covid-19 cases in the facility. An observation made upon entering the facility noted Housekeeper #10 to be walking across the lobby area at the front entrance in the direction from Unit 1 to Unit 2. She was pushing her housekeeping cart across the lobby and was wearing a N95 respirator mask but was not noted to be wearing any eye protection. On 03/07/22 at 9:57 A.M., an interview with Housekeeper #10 revealed the facility did have positive Covid-19 cases in the building with both residents and staff being infected. She was asked what PPE staff should wear and replied they should be wearing a N95 mask and safety glasses when working. Housekeeper #10 stated staff were to wear those PPE items everywhere in the facility, apart from the breakroom or when outside. Staff have been wearing that PPE for about a month now. Housekeeper #10 confirmed she was observed upon entrance walking across the front lobby area without her eye protection on. She stated her eye goggles were on her housekeeping cart and she did not like to wear them as they fogged up on her when wearing her N95 mask. Housekeeper #10 was noted to be adjusting her N95 mask frequently during the interview. Housekeeper #10 was asked if she tried to press on the aluminum strip that was across the top of the N95 mask to see if she could get it to fit and seal better. Housekeeper #10 stated her N95 mask did not have that aluminum strip as it had fallen off. She acknowledged she would not have a proper seal or fit with that strip missing and not being able to form it across the bridge of her nose. Housekeeper #10 denied she considered discarding that N95 and replacing it with a new one. Further interview questions were asked regarding the doffing process of PPE. Housekeeper #10 reported she would remove her PPE when leaving an isolation room of a resident on droplet precautions following an exposure to Covid-19 or when leaving the Covid-19 unit. Per Housekeeper #10 part of her doffing process would include the cleaning of her eye goggles. Housekeeper #10 was asked what she used to disinfect her eye goggles and reported she used Windex cleaner. Per Housekeeper #10, Windex cleaner was used as it was readily available on her housekeeping cart, and she did not have any alcohol wipes to clean them with instead. Housekeeper #10 was asked why she did not use the disinfectant wipes that were in the PPE carts outside of those isolation rooms. Housekeeper #10 replied, she never thought about that. On 03/07/22 at 12:30 P.M., an interview with Resident #5's family, who was noted to be at the facility visiting, revealed she had not seen the staff wear eye goggles or face shields prior to that day. Resident #5's family stated she had seen them wear masks but denied they had eye goggles or face shields on when she was there. Resident #5's family reported she visited often. A review of the facility's Covid-19 policy on Infection Control Guidance (dated February 2022) revealed the policies included guidelines from CDC's Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes (updated 02/02/22) and the Interim Infection Control Recommendations for Healthcare Personnel During Covid-19 Pandemic (updated 01/21/22) revealed under the facility's infection control guidance, it indicated older adults living in congregate settings were at high risk of being affected by respiratory and other pathogens, such as Covid-19. The facility strived to develop a strong infection prevention and control program to protect both residents and staff. They were to educate and train the staff about recommended practices to prevent the spread of Covid-19. Guidance on masks included the use of an N95 mask could be part of source control and worn for an entire shift unless they became soiled, damaged, or hard to breathe through. All staff should wear source control when they were in areas of the facility where they could encounter residents (e.g., dining rooms, common halls/ corridor). Under use of PPE for staff, staff working in facilities located in counties with substantial or high transmission should also use PPE that included a N95 mask and eye protection during all resident care encounters. Protective eyewear was required for resident care areas in counties with substantial (orange) or red community transmission. A review of CDC guidance on Eye Protection (updated 09/13/21) revealed in areas of substantial to high transmission in which healthcare personnel (HCP) are using eye protection for all resident encounters, extended use of eye protection may be considered as a conventional capacity strategy (PPE supply adequate). Reusable eye protection should be cleaned and disinfected after each resident encounter. They were to ensure appropriate cleaning and disinfection after each use of reusable face shields or goggles were used. Under Selecting Options for Reprocessing Eye Protection, they were to adhere to recommended manufacturer instructions for cleaning and disinfection. When manufacturer instructions for cleaning and disinfection were unavailable, they were advised to wipe the inside followed by the outside of the goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. They were then to carefully wipe the outside of the goggles using a wipe or clean cloth saturated with an EPA- registered hospital disinfectant solution. A review of the product information for Windex Antibacterial Glass and Surface Cleaner revealed it was a limited disinfectant effective against gram negative bacteria such as Salmonella and Escherichia coli (E. coli). It's active ingredients only included 3.5% Isopropanol (alcohol). It was not indicated to be an effective disinfectant for Covid-19. It was not one of the listed approved disinfectants effective against Covid-19 on the EPA website when entering the EPA registration number. 1 b. A review of Resident #41's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was given on 03/02/22. A review of Resident #41's nurses' progress notes revealed a nurse's note by LPN #240 dated 03/02/22 at 11:57 A.M. that indicated the resident was placed in droplet isolation precautions secondary to being exposed to Covid-19. The nurse's note indicated the resident was not fully vaccinated. On 03/07/22 at 9:31 A.M., an observation during a tour of the facility noted Physical Therapy Assistant (PTA) #7 to enter the room of Resident #41, who was in droplet/ contact isolation precautions for being exposed to someone with Covid-19. She had a respirator mask and goggles on at the time she approached the room. She was then noted to don additional PPE to include a gown and gloves. She entered the room and closed the door while in with the resident. Upon leaving the room, she was observed to come out of the room without a gown and her gloves on. They had been doffed upon leaving the room. She stopped at the PPE cart that was in the hall outside the resident's room. She performed hand hygiene and was noted to start walking down the hall. On 03/07/22 at 9:40 A.M., an interview with PTA #7 confirmed she did not doff her respirator mask or clean her eye goggles when leaving Resident #41's room. She confirmed the resident was in isolation precautions following her exposure to someone with Covid-19. Observations at the time of the interview noted PTA #7 to be wearing a KN95 mask. It was clearly printed on the outside of her mask. She stated she should have disposed of her mask when leaving the isolation room and donned a new one. She also stated she should have disinfected her eye goggles as part of the doffing process before going on to other areas of the facility. If going onto the Covid-19 unit, she would have donned a surgical mask over her respirator mask as part of the PPE she put on. When leaving the unit, she would have discarded the surgical mask and continued to wear the respirator mask she already was wearing. She denied knowledge of the facility having any shortages in PPE supply to include the N95 (respirator) mask. A review of the facility's Infection Control Guidance Policy (dated February 2022) revealed the policy was following the guidelines from the CDC with source information from Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes (updated 02/02/22) and Interim Infection Control Recommendations for HCP During the Covid-19 Pandemic updated (01/21/22). The guidance under Source Control- Masks revealed if masks were used during the care of residents for which a NIOSH approved respirator or facemask was indicated for PPE (e.g., NIOSH approved N95 during the care of a resident with Covid-19 infection), they should be removed and discarded after the resident care encounter and a new one should be donned. Under Managing Residents with Suspected or Confirmed Covid-19 Infections, staff caring for residents with suspected or confirmed Covid-19 infections should use full PPE that included gowns, gloves, eye protection and a NIOSH approved N95 or equivalent or higher- level respirator. A review of the facility's PPE policy (dated April 2018) revealed it included doffing procedures. The doffing procedures instructed the staff to remove their gloves, remove goggles and place in a receptacle for reprocessing or discard in a waste container, remove gown and then remove the mask and discard in a waste container. A review of CDC guidance on Eye Protection (updated 09/13/21) revealed in areas of substantial to high transmission in which healthcare personnel (HCP) are using eye protection for all resident encounters, extended use of eye protection may be considered as a conventional capacity strategy (PPE supply adequate). Reusable eye protection should be cleaned and disinfected after each resident encounter. They were to ensure appropriate cleaning and disinfection after each use of reusable face shields or goggles were used. Under Selecting Options for Reprocessing Eye Protection, they were to adhere to recommended manufacturer instructions for cleaning and disinfection. When manufacturer instructions for cleaning and disinfection were unavailable, they were advised to wipe the inside followed by the outside of the goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. They were then to carefully wipe the outside of the goggles using a wipe or clean cloth saturated with an EPA- registered hospital disinfectant solution. A review of the CDC's guidance on Types of Masks and Respirators (updated 01/28/22) revealed masking was a critical public health tool for preventing the spread of Covid-19. To protect yourself and others from Covid-19, CDC continued to recommend that you wear the most protective mask you can that fit well. Some masks and respirators offer higher levels of protection than others. Masks and respirators can provide varying degrees of protection, with well-fitting National Institute for Occupational Safety and Health (NIOSH) - approved respirators offering the most protection. Some respirators (KN95) were designed and tested to meet international standards. They were designed to standards that do not often have a quality requirement. They filter varying levels of particles in the air depending on the standard they were designed to meet. Do not wear international respirators as a replacement for NIOSH approved respiratory protection when required by your job. NIOSH does not approve KN95 products certified to international standards. 1 c. On 03/07/22 at 8:55 A.M., an observation during a walkthrough of the facility with the Assistant Director of Nursing (ADON) revealed there was a designated Covid-19 unit. Ten residents resided on that unit. The ADON reported the PPE required when entering that unit as well as when entering the rooms of any resident in isolation precautions following an exposure to Covid-19, was to don a gown, gloves, and a paper mask over top of an N95 mask the staff member would already have on. She reported all staff throughout the facility were wearing an N95 mask and eye goggles. When leaving those areas, the staff were to remove and discard the surgical mask they had over top of their N95 mask as part of the doffing process. The N95 mask would continue to be worn. On 03/07/22 at 10:23 A.M., an observation of the facility's Covid-19 unit, which was Unit1 (back hall), noted several staff members to be on the unit behind the closed double doors. A PPE cart was on the other side of that door before going onto the unit. LPN #100 was noted on the unit at the medication administration cart pulling medications out of the cart to be administered. She was noted to have a gown, N95 mask, and eye goggles on. She was not noted to be wearing any gloves while on the Covid-19 unit. Housekeeper #112 was noted to also be on the Covid-19 unit. She was in the hall with her mop and was noted to be wearing a gown and a N95 mask with a surgical mask over top of it. She was not noted to be wearing any gloves either while on the Covid-19 unit. On 03/07/22 at 10:34 A.M., an interview with LPN #100 revealed she was the nurse assigned to the Covid-19 unit and was also responsible for the care of the residents on Unit 1 front hall. She confirmed she was not wearing gloves when pulling medications from the medication administration cart. She stated she did not like to wear gloves when popping the medications out of the blister packs they came in, as they got in the way, and it made it difficult. LPN #100 was asked what PPE was required in the facility. LPN #100 stated they wore N95 masks and goggles throughout the facility and when going on the Covid-19 unit they added a gown, gloves, and a mask over top of the N95 mask. She reported, when leaving the unit, they would doff their PPE to include removing the gown and the outer mask she put on over her N95 mask. She verified she did not have a surgical mask over her N95 mask when she was observed on the Covid-19 unit. She reported she had a second N95 mask over top her other N95 mask and only removed the outer mask when she left the unit. LPN #100 confirmed she would then be on other non-Covid-19 unit she was assigned to (Unit 1, front hall) for the care of other residents that did not have Covid-19. She denied the facility had any shortages of PPE to include the availability on N95 masks. On 03/07/22 at 10:55 A.M., the facility's PPE supply was checked in the central supply room and the conference room where additional PPE was being stored. Observation revealed a full case of N95 masks (240 count) in the central supply room with three loose boxes on top of that, which included 60 additional N95 masks. The conference room was noted to have another opened case of N95 masks with 180 masks present. On 03/07/22 at 10:57 A.M., an interview with Central Supply Clerk #25 revealed they had additional N95 masks on the Covid-19 unit and in the PPE carts on the halls. She denied the facility had any type of shortages of PPE to include N95 masks. She stated she placed an order weekly and did not have any problems getting the PPE they needed. She denied there was any type of backlogs with her suppliers, and they had loads of PPE. Central Supply Clerk #25 denied they were running under a crisis capacity strategy for PPE. A review of the facility's policy on Infection Control Guidance that was comprised of guidelines from the CDC in the Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes (updated 02/02/22) and the Interim Infection Control Recommendations for HCP During the Covid-19 Pandemic (updated 01/21/22) revealed the facility staff should be educated and trained about recommended practices to prevent the spread of Covid-19. Under Source Control- Masks, if the mask was being used during the care of residents for which a NIOSH- approved respirator or facemask was indicated for PPE (e.g., NIOSH- approved N95 during the care of a resident with Covid-19 infection), they should be removed and discarded after the resident care encounter and a new one should be donned. Under Managing Residents with Suspected or Confirmed Covid-19 Infection, staff caring for residents with suspected or confirmed Covid-19 infections should use full PPE to include gowns, gloves, eye protection and a NIOSH- approved N95 or equivalent or higher- level respirator. 1 d. On 03/07/22 at 8:07 A.M., an observation upon entrance of the facility revealed the front door at the main entrance was unlocked. Upon entering the facility, a table was set up inside the entryway beside the reception desk. There was no one stationed at the desk. The table had two different binders on it, one for the visitors and one for the staff. After several minutes after entering the facility and standing by the table to be screened in, the ADON came walking by the reception desk and asked if the Surveyor signed in. She directed the Surveyor to the visitor screening log and the screening process involved the visitor to answer a series of questions regarding the presence of any Covid-19 symptoms and exposure. The visitor then had to check their temperature and record it on the log. There was a reminder at the bottom of the form to ask the visitor to please wash their hands or use alcohol-based hand rub (ABHR). There were also reminders to social distance and avoid any direct contact with others during the visit. An attestation form was in a separate folder and needed to be filled out as well. The attestation form had the visitor check a box that indicated they were not having symptoms, did not have any known exposure, had not been diagnosed with Covid-19 and was not yet cleared as non-contagious by state or local public health authorities, and was following all CDC recommended guidelines as much as possible and limiting their exposure to Covid-19. The form was then placed in another folder for the storage of those completed forms. On 03/07/22 at 9:57 A.M., an interview with Housekeeper #10 revealed the facility staff screened themselves in when coming to work. Housekeeper #10 stated you had to check your temperature and fill out the log to show if you had Covid-19 symptoms. She denied another staff member screened them in. On 03/10/22 at 10:19 A.M., an observation noted two visitors come into the facility and went directly to the screening table. They checked their own temperatures using a thermal, non-contact thermometer and then screened themselves for signs and symptoms of Covid-19 and any known exposures. A receptionist was sitting at the desk but was not engaged or an active participant of the visitors screening process. On 03/07/22 at 10:34 A.M., an interview with LPN #100 revealed she screened herself in when reporting to work on her assigned days. LPN #100 confirmed all staff screened themselves in and they did not have anyone else to do it with them. She stated they did have a receptionist, but they were there to answer the phones. Per LPN #100, the receptionists were not there to be a part of the screening process. On 03/07/22 at 12:30 P.M., an interview with Resident #5's visiting family member revealed she screened herself in when she visited the facility. She had been in the facility several times to visit. She knew to check her temperature and to fill out the screening log to indicate whether or not she had any symptoms of Covid-19 or known exposure. Resident #5's family denied she would visit if symptoms were noted. She denied there was always someone at the front desk when she comes to include on the weekends. Resident #5's family did not recall ever receiving any extra instructions on Covid-19 prevention or things to do to reduce the risk of transmission. She had not been instructed to perform hand hygiene, but they had hand sanitizer there, so she always used it. On 03/08/22 at 8:25 A.M., a return visit to the facility noted the front doors to be locked. A doorbell had to be pressed to get staff to answer. Facility staff (unidentified) came over the intercom and allowed the Surveyor entrance after the Surveyor announced who they were. At this time, assistance from staff was provided to the Surveyor during the screening process. On 03/08/22 at 8:33 A.M., an interview with the DON revealed the facility used to have a participant in the staff and visitors screening process. She stated they felt it was best if they went back to that practice. Per the DON, they had a receptionist there Monday through Friday from 8:00 A.M. to 4:30 P.M. A weekend manager would help cover over the weekends or when the receptionist was not there. If no one was at the front desk, they locked the door, and the staff would have to respond to let a visitor in. The DON stated she suspected the door was unlocked yesterday, when the receptionist was not there, and a housekeeper unlocked it to allow the day shift staff to enter. A review of the facility's policy on Infection Control Guidance dated February 2022 revealed it referenced CDC guidelines from the Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes updated 02/02/22. Under Recommended Practices- Screening, the policy indicated a process was in place to identify anyone entering the center, regardless of their vaccination status, who had any of the following so they could be properly managed: a positive [CONDITION(S)] test for Covid-19, symptoms of Covid-19, and who meets criteria for quarantine or exclusion from work. Visitors meeting any of the three criteria would be restricted from entering the center until they met the criteria to end isolation or quarantine respectively. 1 e. A review of the facility's LTC Respiratory Surveillance Line List revealed STNA #22 tested positive for Covid-19 on 02/07/22. She was indicated to have a symptom onset of 02/07/22 that included a cough. A rapid Covid-19 test was indicated to have been completed and she was found to be positive for Covid-19. A review of a Covid-19 Contact Tracing Questionnaire Tool for STNA #22 dated 02/08/22 revealed her symptom onset date was 02/06/22. She was indicated to have been tested that day (02/08/22) and was positive for Covid-19. A review of STNA #22's time report revealed she was in the facility on 02/08/22 with a clock in and out time of 7:00 A.M. She was not noted to clock back in at the facility until 02/28/22. A review of STNA #22's rapid Covid-19 test report revealed the test was collected on 02/08/22 at 6:55 A.M. Her results were recorded as being positive for Covid-19 at 7:15 A.M. A review of a Start of Shift Daily Employee Screening Log dated 02/08/22 revealed STNA #22 had been screened in on that date and did not report having any symptoms of Covid-19. On 03/08/22 at 8:52 A.M., an interview with STNA #22 confirmed she started having Covid-19 symptoms beginning on 02/06/22. She stated she had a low-grade temperature, body chills, headache, and a cough. She reported she was feeling better but still had a cough on 02/08/22 when she came to work on her next assigned day. She screened herself in and then went to the Unit 1 nurses' station towards the back of the building to be tested . She wore a N95 mask and goggles when she entered the facility and waited at the nurses' station until her results came back. She confirmed her test was positive and she was sent home. She was asked if she notified the facility of having symptoms of Covid-19 when they developed on 02/06/22 or on her employee screening log. She denied she notified anyone at the facility about her symptoms and thought she marked her symptoms on the screening log. She denied anyone was there at the front desk to screen her in and it was typical for them to screen themselves in when they report for work. She denied being vaccinated for Covid-19 and was one of the employees that had a non-medical exemption. 1 f. A review of the facility's LTC Respiratory Surveillance Line List revealed STNA #14 became symptomatic of Covid-19 on 02/04/22. He had a rapid Covid-19 test done on 02/08/22 and was found to be positive for Covid-19. A review of a Covid-19 Contact Tracing Questionnaire Tool for STNA #14 dated 02/08/22 revealed STNA #14's symptoms started on 02/03/22. His symptoms included a fever, headache, shortness of breath and chest pain. A review of STNA #14's time report revealed he clocked in at the facility on 02/07/22 at 7:00 P.M. He clocked out at 8:00 P.M. He was not noted to return to the facility until he clocked in again on 02/18/22. A review of STNA #14's rapid Covid-19 test revealed he was tested for Covid-19 on 02/07/22. The test showed he was positive for Covid-19. On 03/08/22 at 3:35 P.M., an interview with the facility's DON revealed she had contacted STNA #14 regarding him having symptoms of Covid-19 on 02/03/22 and why he came in to work on 02/07/22 to be tested . She stated that was his next scheduled day to work. It was not clear if he was still having symptoms at that time but she stated any employee with symptoms of Covid-19 should be notifying the facility's administrative staff so they could have the employee come in to be tested . She stated if she knew STNA #14 or STNA #22 had Covid-19 symptoms she would have tested them with a rapid Covid-19 test in the parking lot. She denied any employee should be reporting to work if having symptoms that could be from Covid-19. She was not concerned with the employees screening themselves in as they should be informing a nurse if symptoms were present. She acknowledged STNA #2 [TRUNCATED]

Based on review of QSO Memo 22-09-ALL Attachment A for Long Term Care (LTC) Facilities issued 01/14/22, review of the facility's Covid-19 Staff Vaccination records, Covid-19 timeline/ LTC Respiratory Surveillance Line List, staff interview, and policy review, the facility failed to ensure 100% of their staff had received at least one dose of the Covid-19 vaccine or had a pending request for, or had been granted a qualifying exemption, or were identified as having had a temporary delay as recommended by the Centers for Disease Control (CDC). The facility had 87 of their 91 employees that had received at least one dose of the Covid-19 vaccine or had a pending or granted medical/ non-medical exemption for a vaccination rate of 95.6%. This resulted in Immediate Jeopardy on 03/07/22, when four of the facility's 91 employees refused to be vaccinated for Covid-19 and had failed to submit their medical/ non-medical exemption forms for approval. The facility was experiencing an outbreak of Covid-19, with 17 residents testing positive for Covid-19 since 02/07/22, failed to implement appropriate infection control practices to help prevent/ limit the spread of Covid-19 throughout the facility and failed to implement their Vaccination policy. The facility has had 19 residents (Resident #7, #10, #12, #19, #20, #26, #31, #35, #37, #43, #45, #46, #47, #48, #49, #50, #53, #56, and #58) contract Covid-19 since 01/07/22 and 10 staff members (State tested Nurse Aide (STNA) #14, STNA #22, STNA #29, STNA #31, Therapist #61, Housekeeper #63, STNA #67, Licensed Practical Nurse (LPN) #69, STNA #74 and Registered Nurse (RN) #84) contract Covid-19 since 02/07/22. The lack of effective infection control practices, implementation of the Vaccination policy, and prevalence of continued positive cases in the facility placed all residents at risk for harm, complications and/or death related to the facility's failure to control the COVID-19 outbreak. On 03/08/22 at 3:14 P.M., the Administrator, Regional Director of Clinical Operations, Regional Clinical Support Nurse, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/07/22 when the facility was experiencing an outbreak of Covid-19, the facility failed to ensure appropriate infection control practices were being followed to help prevent/ limit the spread of Covid-19 throughout the facility, and failed to ensure the facility vaccination policy was implemented resulting in four staff members (STNA #310, STNA #315, Laundry Aide #320, and the DON) to be non-vaccinated and without a pending/ granted medical or non-medical exemption while continuing to provide care and services to the residents in the facility. Nineteen of the facility's 59 residents have or have had Covid-19 infections since their outbreak began on 01/07/22 and 10 staff members have had Covid-19 since 02/07/22. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 3/8/22 at 4:14 P.M. the Regional Director of Clinical Operations completed re-education with the Administrator and Human Resources Manager regarding staff vaccination/exemption expectations, facility to ensure 100% of staff are Covid-19 vaccinated or have approved medical/religious exemption. · On 03/08/22 at 5:10 P.M. the Facility reached 100% compliance of all staff being vaccinated for Covid-19 or granted a medical/religious exemption. · On 03/08/22 at 5:55 P.M., Director of Nursing completed re-education regarding infection control topics including appropriate PPE donning/doffing, handwashing, mask/N95 usage, disinfecting eyewear upon exiting droplet isolation rooms. All staff were re-educated 03/08/22 by 5:55 P.M., that included 28 STNA's, 12 LPN's, 6 RN's, 12 Therapy staff, 4 Laundry staff, 8 Housekeeping staff, 10 Dietary staff, 2 Social Services staff, 5 Activities staff, 1 Admission Director, 1 Maintenance Supervisor, 1 Business Office Manager, 1 Human Resources Manager, 1 Administrator. · Starting 03/09/22 (time not identified), the Administrator or designee will complete an audit on employee Covid vaccination/exemption status to ensure 100% compliance. Audit will be completed weekly for four weeks then as determined necessary. Findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. · On 03/09/22 at 3:30 P.M., the Director of Nursing completed education with all unvaccinated/exempted employees on current Vaccination Policy regarding accommodations for unvaccinated/exempted staff to help prevent the spread of Covid-19. Ongoing education has been provided to all staff regarding Vaccination Policy/mandate for Covid-19 vaccination or the need for medical/religious exemption by the Director of Nursing. Education was provided to those seeking exemption on the exemption process. Evidence of education is facility reaching 100% vaccination or granted a medical/religious exemption status. · On 03/09/22 (time not identified), the Regional Clinical Support Nurse, Administrator, Director of Nursing and Director of Human Resources reviewed the facility's Covid Vaccination Policy. The policy was found to be adequate. · On 03/09/22 from 4:40 P.M. to 5:00 P.M., interviews with two STNA's, one nurse and one housekeeper confirmed they received education on infection control topics that included appropriate PPE use, donning/ doffing, N95 use, and disinfecting eyewear upon exiting droplet isolation rooms. All were able to show an understanding of the education they were provided. Although the Immediate Jeopardy was removed on 03/09/22 at 3:30 P.M., the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1a. A review of the facility's Covid-19 vaccination records revealed 50 of the facility 91 employees had been fully vaccinated for Covid-19. None of the 91 employees were partially vaccinated. Thirty-four (34) employees had a granted medical or non-medical exemption. Three employees had pending medical or non-medical exemptions. Four employees were indicated not to have been vaccinated and were without an exemption or a temporary delay. Out of the 91 employees, 87 of them had been vaccinated or had granted/ pending medical or non-medical exemptions. That was equivalent to 95.6% of their current staff being vaccinated or with a pending/ granted exemption, which did not meet the 100% requirement. The four employees, who were not vaccinated for Covid-19 and did not provide an exemption form for a medical or non-medical exemption, were STNA #310, STNA #315, Laundry Aide #320 and the facility's Director of Nursing (DON). On 03/07/22 at 3:30 P.M., an interview with the facility's Administrator revealed they have had four employees who refused to receive the Covid-19 vaccine and had not submitted their exemption forms to be considered for a medical or non-medical exemption. The Administrator stated they have been getting after them but have not been able to get them (the four employees) to turn those forms in. The Administrator denied any of the four employees who had not submitted their exemption forms were recent hires, with the most recent being hired in 2020. The Administrator acknowledged they only had 95.6% of the current staff vaccinated or with a pending/ granted non-medical/ medical exemptions and did not meet the 100% threshold requirement. The Administrator stated he had thought there was a grace period in effect where they only needed to be above 80% but could have been wrong about that. The Administrator stated the four employees that had not submitted their exemption forms were for religious exemptions. The Administrator confirmed all four employees continued to work in the facility without being vaccinated for Covid-19 and had not submitted their exemption forms to be considered a pending exemption. The Administrator stated that once he received the exemption forms, they would be sent to the corporate office to be reviewed by the human resources department. The Administrator indicated that once the exemption forms were submitted, they get a response back quickly either granting approval or requesting additional information. 1 b. A review of the facility's Covid-19 timeline and LTC Respiratory Surveillance Line List revealed they have had 17 residents test positive for Covid-19 in the past four weeks. In all, they have had 19 residents test positive for Covid-19 since 01/07/22 and 10 staff members test positive for Covid-19 since 02/07/22. One of the four non-vaccinated employees (DON), that had not submitted the exemption form for consideration of a medical or non-medical exemption, had tested positive for Covid-19 on 02/09/22. On 03/08/22 at 9:30 A.M., these findings were verified by the DON on the number of Covid-19 cases they have had in the facility among residents and staff since their latest Covid-19 outbreak began. 1 c. On 03/07/22 from 8:07 A.M. to 4:33 P.M., observations during the on-site visit for the complaint investigation revealed several concerns with appropriate infection control practices not being followed to help prevent/ limit the spread of Covid-19 though out the facility. Concerns noted included: · The facility's screening process not providing an appropriate level of oversight to ensure all staff and visitors were screened in upon entering the facility. Visitors and staff were permitted to screen themselves in without a staff member participating in that screening process. · Two staff members were found to have entered the facility when having symptoms consistent with Covid-19. One of the two staff members did not record her symptoms on the screening log when she screened herself in. Neither staff members reported their symptoms to anyone in management prior to returning to work on their next scheduled day. Both staff members entered the facility and reported to the Unit 1 nurses' station (back of the building) to be tested for Covid-19 upon their arrival, and both were found to be positive for Covid-19. · Concerns were noted with some of the staff not wearing appropriate eye protection and concerns were also identified with eye protection not being properly disinfected. · Observations also identified concerns with appropriate PPE not being worn, or not being donned/ doffed appropriately when in an isolation room for someone who had been exposed to Covid-19. Staff were inappropriately donning a surgical mask over top of an N95 mask or a N95 mask over top of another N95 mask when entering those rooms. They doffed the outer layer mask off when leaving isolation rooms or the Covid-19 unit but left the underlying N95 mask still in place when going to non-Covid-19 areas of the building. The facility was following conventional capacity strategies as PPE supply were adequate and they were not in crisis capacity strategies at that time. · Concerns were also noted with two of the unvaccinated staff reporting (through interviews) they were not restricted from using the employee breakroom and did so with their masks off when other vaccinated employees were present. They were not aware their Vaccination Policy directed them to only pull their mask down when eating a bite of food or drinking and then return the mask, so it properly covered their nose and mouth. A review of QSO Memo 22-09-ALL Attachment A issued on 01/14/22 revealed, within 30 days after the issuance of the memorandum, policies and procedures were to be developed and implemented for ensuring all facility staff, regardless of clinical responsibility or resident contact were vaccinated for Covid-19, including all required components of the policies and procedures (e.g., related to tracking staff vaccinations, documenting medical and religious exemptions etc.). The facility was also to demonstrate 100% of staff have received at least one dose of Covid-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or were identified as having a temporary delay as recommended by the Center for Disease Control (CDC). Less than 100% of all staff have received at least one dose of Covid-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or were identified as having a temporary delay as recommended by the CDC, the facility was non-compliant under the rule. A review of the facility's Vaccination Policy (revised February 2022) revealed the intent of the policy was to outline the facility's plan to follow the Omnibus Covid-19 Health Care Staff Vaccination Interim Final Rule. Under exemptions and accommodations, the policy indicated current staff that were eligible to receive the vaccination could complete a Covid-19 Vaccination Medical Exemption form and submit it to the Administrator or Human Resources no later than 11/24/21. The facility would also allow staff to submit a religious exemption based on their sincere religious beliefs, observances, and practices. Current staff that were eligible to receive the vaccination could complete a Covid-19 Vaccination Religious Exemption form and submit it to the Administrator or Human Resources no later than 11/24/21. The Administrator, Medical Director, Director of Human Resources, or the Infection Preventionist would review submitted Covid-19 vaccination Religious Exemption forms and decide if the exemption request was approved or denied within seven calendar days of submission. New staff would have the opportunity to request an exemption form during the new hire onboarding process. The staff member would not be allowed to work until exemption determination had been made and the next steps discussed. The facility was to record and track exemption status on the CDC Covid-19 Staff Vaccination Log or similar tracking process. It was the responsibility of the Administrator to ensure the staff vaccination status was tracked and maintained on the CDC Covid-19 Staff Vaccination Log or similar tracking process. The CDC Covid-19 Staff Vaccination Log or similar tracking process would be reviewed regularly for action items. The Administrator was responsible for the validation of vaccination status.

Based on record review, interview, and policy review the facility failed to ensure fall safety interventions were in place for Resident #56 to prevent a fall. Actual harm occurred when Resident #56, who required staff assistance for dressing sustained a fall on 12/09/19 as a result of her pants being too long covering her non-skid footwear resulting in a humerus (arm) fracture. This affected one resident (#56) of five residents reviewed for accidents. Findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident required extensive, physical assistance from one person for dressing and personal hygiene and limited assistance from one person for toileting and walking in her room. Review of the plan of care, dated 11/12/19 revealed the resident was at risk for decreased ability to perform activities of daily living (ADLs) in dressing related to dementia, fatigue and activity intolerance. Review of Resident #56's fall risk assessment, dated 11/19/19 revealed the resident was high risk for falls. Review of an x-ray report, dated [DATE] revealed an acute [MEDICAL CONDITION] neck and greater tuberosity (of the resident's humerus). Review of a nursing progress note, dated 12/11/19, revealed the resident was resting in bed complaining of pain in the left arm and was scheduled to visit the orthopedic specialist later in the day. Review of Resident #56's Fall Investigation, dated 12/11/19 revealed a fall occurred on 12/09/19 at 9:54 A.M. The Fall Investigation Report revealed the resident yelled out for help and was found lying on her stomach, on the floor. The investigation revealed the resident's pants were noted to be too long and covered a large portion of her non-skid footwear. The immediate action taken was for the pants to be rolled up to prevent further falls. The Fall investigation report identified the cause of the fall to be the result of Resident #56's pants being too long and a request was made to the resident's responsible party to provide pants of appropriate length or to have the resident's pants hemmed. Review of a physician progress notes [REDACTED].#56 sustained a [MEDICAL CONDITION] (arm bone). During interview on 01/14/20 at 2:16 P.M., the Director of Nursing (DON) reviewed the Fall Investigation and confirmed the resident's pants were too long, partially covered the anti-skid footwear, which resulted in a fall and subsequent fractured left humorous. Review of the facility policy titled Fall Prevention, dated 07/11/18 revealed the purpose of the Fall Prevention Program was to ensure consistency in the implementation of preventative measures to assist with the reduction of falls.

Based on observation, medical record review, self- reported incident review, death certificate review, policy review and physician and staff interviews, the facility failed to meet the psychiatric needs of a resident with known suicide attempts. Staff found Resident #79's dead body hanging from the clothes rod in the closet of his room. Resident #79 had attempted suicide at the facility five months earlier, was hospitalized , was readmitted and the facility failed to refer the resident to psychiatric services, failed to follow the Suicide Precaution policy and procedure, and failed to notify the physician of Resident #79's refusal of counseling services. This resulted in Immediate Jeopardy for one (Resident #79) of three residents (Residents #50, #60 and #79) reviewed for depression. The facility identified 48 residents with documented signs and symptoms of depression, and 16 residents with documented psychiatric diagnosis (excluding dementia and depression). On [DATE] at 3:59 P.M., the Vice President of Operations, Manager of Clinical Operations, Registered Nurse (RN) #1, and the Director of Nursing (DON), were notified that Immediate Jeopardy began on [DATE], when Resident #79 refused counseling services with no physician notification. Resident #79 had a history of [REDACTED]. Resident #79 was readmitted to the facility on [DATE] after a psychiatric hospitalization with [DIAGNOSES REDACTED]. The discharge documentation included a plan for the resident to be followed by a psychiatrist at the facility. There was no evidence Resident #79 was seen by a psychiatrist after he was readmitted to the facility on [DATE], no physician notification of the resident's refusal of counseling services on [DATE] or [DATE], and no evidence of suicidal ideation monitoring. On [DATE] Resident #79 was found dead in his closet of an apparent hanging. Resident #79 cut the electrical cord off his radio, looped it through two shoe strings that he had tied together making a noose, then sat down in his closet causing strangulation. The death certificate identified the immediate cause of Resident #79's death was strangulation by hanging. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] (no time indicated), in-service training was conducted by Nurse Practice Educator (NPE) #19 for all staff, including all disciplines in all areas, on suicide prevention and identifying signs and symptoms, monitoring and removing hazardous items from resident rooms, the facility abuse policy and procedure, and supervision of resident's independent with activities of daily living. · On [DATE], environmental rounds were conducted by State tested Nurse Aides (STNA) #22, STNA #23, STNA #24, STNA #25 and STNA #26 to monitor for hazardous items in all resident rooms. There were no hazardous items located. · On [DATE], multiple nursing staff including the DON, RN #20 and RN #21 completed chart audits of all 92 residents in the facility to identify residents with [DIAGNOSES REDACTED]. The DON, RN #20 and RN#21 identified 60 residents with [DIAGNOSES REDACTED]. These residents were assessed using the Minimum Data Set 3.0 resident mood assessment (PHQ-9) to identify any risk for suicide. The facility identified no residents at risk for suicide at the time of the assessments. · On [DATE] (no time indicated), in-service training was conducted by NPE #19 for all Licensed Nurses and Social Service Designee (SSD) #16 on follow-up psychiatric services after an inpatient stay (hospitalization ). · On [DATE], the Administrator mailed reminder letters to all the responsible parties or resident contacts regarding the process for tracking items brought into the facility for residents. · On [DATE] (no time indicated), a quality assurance (QA) committee meeting was held. · On [DATE], Psychiatrist #15 evaluated 25 residents identified with depression and/or psychiatric [DIAGNOSES REDACTED]. · On [DATE], Physician Assistant #27 evaluated 24 residents identified with depression and/or psychiatric [DIAGNOSES REDACTED]. · On [DATE], NPE #19 identified six STNA's, one dietary staff, and one housekeeping staff were on leave/vacation and unable to be educated as of [DATE]. NPE #19 stated the above employees were going to be educated prior to returning to work. · On [DATE], review of Resident Room audits dated [DATE], [DATE], [DATE] and [DATE] revealed resident rooms were free of hazardous items or safety concerns. · On [DATE], review of Signs and Symptoms of Depression and Suicidal Ideation revealed audits were complete for [DATE] and [DATE] and identified staff was able to identify three signs of depression and indication of suicidal ideation and what to do if a resident has increased depression or stated harm to self. · On [DATE], review of the Psych Services audit dated [DATE] revealed Resident #50 and #60 returned after inpatient psychiatric stays, were ordered psychiatric services and referrals for psychiatric services were completed. · On [DATE] between 9:17 A.M. and 9:57 A.M., interviews with RNs #40, #41, and #42, Licensed Practical Nurse (LPN) #43, #44, and #45, STNAs #46, #47, #48, #49, #50, #51, and #52, Housekeeping Aide #53 and #54, Activity Aide #55 and #56, Laundry Aide #57 and Therapy Assistant #58 confirmed they were able to articulate the policy for Abuse, Signs of Depression and Suicidal Ideation, Discharge Summary review, and Environmental Monitoring. · On [DATE] interview with NPE #19 revealed all staff in service and education had been completed for staff with the exception of four (4) employees who are currently on medical leave (FMLA) Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more that minimal harm that is not Immediate Jeopardy) as the facility had not yet completed: 10 staff interviews regarding depression, identifying suicide ideations, and supervision of independent residents three times a week for two weeks. Also not completed, weekly for two weeks audits regarding appropriate follow-up for psychiatric services on all new admissions and readmissions each week for four weeks; complete environmental audits three times a week for two weeks, then weekly for two weeks to ensure continued understanding of the policy. Findings include: 1. Review of the Self-Reported Incident dated [DATE] revealed an allegation of neglect involving Resident #79 when the resident was found in his wardrobe closet hanging from a bar. The facility unsubstantiated the allegation of neglect. Closed medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] and [DATE] revealed Resident #79 was cognitively intact for daily decision-making, was independent with activities of daily living and had no symptoms of [MEDICAL CONDITION], mood or behaviors. Review of the Progress Notes revealed on [DATE] STNA #14 overheard someone say I've changed my mind. STNA #14 entered Resident #79's room and observed him in his closet with a trash bag and a cord tied around his neck. The cord was tied to the rod in the closet and the resident was sitting on the floor of the closet. STNA #14 removed the bag and the cord from his neck and informed the nurse. The resident was sent to the emergency room for a psychological evaluation. Resident #79 was admitted to a psychiatric hospital on [DATE] and was ordered an anti-depressant medication ([MEDICATION NAME]), provided a supportive, structured, non-threatening environment and instructed to participate in group activity. His estimated length of stay was approximately five days. The resident was discharged back to the facility on [DATE]. Review of Resident #79's hospital Discharge Instructions dated [DATE] revealed the resident was newly diagnosed with [REDACTED]. The resident was to see Psychiatrist #15 at the nursing home for follow-up treatment. Review of the Progress Notes dated [DATE] revealed Resident #79 returned to the facility with no signs or symptoms of depression. Resident #79 was started on one-on-one supervision for 24 hours and then 15 minute checks between [DATE] and [DATE]. Review of the record between [DATE] and [DATE] revealed no evidence the resident was evaluated for suicidal behavior or implementation of suicide precautions. Review of the Counseling Referral Sheet dated [DATE] revealed Resident #79's presenting problems included being depressed and problem behaviors. The licensed counseling professional attempted to meet with the resident on [DATE] and [DATE]; however, the resident refused mental health services. Review of the physician progress notes [REDACTED].#79's attending physician was notified at approximately 8:50 P.M. the resident was found dead in his closet of an apparent hanging. Another physician (Physician #28) was in the building, assessed the resident and confirmed the resident was deceased . The attending physician, Medical Director (MD) #18, also the county coroner, arrived at the building and investigated the scene. Resident #79 had cut the electrical cord off his radio, looped it through two shoestrings he had tied together making a noose, and sat down in his closet causing strangulation. The police were called and investigated the scene. Resident #79's daughter stated she brought the resident a side-cut style nail clippers per his request. This instrument matched the cut marks on the radio electrical cord that was used to commit the suicide. His lace-up shoes were without shoe strings which were found looped around his neck. Review of the Death Certificate dated [DATE] revealed the immediate cause of Resident #79's death was strangulation by hanging. The Coroner identified other significant conditions contributing to the resident ' s death were depression and advanced age. Review of the social service Interdisciplinary Progress Notes dated [DATE] through [DATE] revealed no documented evidence of Resident #79's suicide attempt on [DATE]. On [DATE], Resident #79 informed Social Service Director (SSD) #16 that he did not want to talk to those kinds of people (referring to counselors) stating he was not crazy. There was no documented evidence of Resident #79's refusal of counseling services on [DATE] or physician notification of the refusals. Review of the record revealed no documentation by SSD #16 after [DATE] for Resident #79. Review of the quarterly Social Services assessment dated [DATE] and [DATE] revealed questions to ask the resident during the assessment included if the resident was thinking about hurting themselves now, had they thought about how they would do it and did they have something with which to do it. There was no evidence SSD #16 completed this section of the assessments on [DATE] and [DATE]. Review of the Behavior Monitoring and Interventions assessment dated September, 2015 through January, 2016 revealed Resident #79 was only being monitored for symptoms of withdrawal and no episodes of withdrawal was documented. There was no evidence of behavior symptom monitoring for depression or [MEDICAL CONDITION]. Review of the medical record revealed no documented evidence Resident #79 was seen by Psychiatrist #15 between [DATE] and [DATE], and no evidence Psychiatrist #15 or Medical Director #18 were notified of Resident #79's refusal of counseling services. Review of the physician progress notes [REDACTED].#79 for [MEDICAL CONDITION]. Review of the care plan titled History of Suicidal Attempts initiated [DATE] and reviewed [DATE] revealed interventions included: one-on-one with resident, verbally encourage him to voice his feelings, encourage family visits, encourage involvement in life of facility, monitor for change in behaviors and psych consult as needed. Review of the care plan titled Exhibits Distressed Mood Symptoms as evidenced by sadness/depression and withdrawal initiated [DATE] revealed interventions included: allow the resident time to verbalize anger, frustration, express empathy and reassurance, elicit family friend support, participation in diversional activities, attend out of room activities, medication per order and monitor for side effects of medication including sedation, drowsiness, dry mouth, blurred vision [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity and excess weight gain. Review of the care plan titled At Risk for Complications related to the use of [MEDICAL CONDITION] drugs medication: Antidepressants initiated [DATE] revealed to complete behavior monitoring flow sheet, monitor for changes in mental status and functional level and monitor for symptoms of depression including withdrawal and tearfulness. On [DATE] at 9:50 A.M., interview with SSD #16 revealed Resident #79 had no signs of suicide ideation prior to his suicide attempts and SSD #16 stated the resident had been offered counseling services in August and September, 2015 but refused. SSD #16 stated the nursing department would determine if a resident needed to be seen by the psychiatrist. SSD #16 stated residents did not return to the facility until they were stable and the nursing department determined who was referred to psychological services. SSD #16 stated the licensed counselor was not a psychiatrist or physician but a licensed professional who came to the facility to talk to residents if they were sad or just wanted someone to talk to. On [DATE] at 10:29 A.M., interview with SSD #16 and the DON verified the facility did not offer any other psychological service to Resident #79 after he refused counselor services on [DATE] and [DATE]. SSD #16 and the DON verified Resident #79 committed suicide on [DATE]. On [DATE] at 11:35 A.M., interview with the DON verified Resident #79 had a suicide attempt at the facility on [DATE], was sent to the hospital and upon return to the facility was not put on suicide precautions. The DON stated if a resident voiced wanting to die or attempted suicide the facility initiated the Suicide Precaution policy until the resident could be transferred to the hospital. Once the resident was discharged from the hospital, the facility deemed the resident stable and no longer at risk to commit suicide, initiated one-on-one for up to 48 hours, then 15 minutes checks for up to 72 hours and then routine monitoring. The DON verified there was no written procedure for residents who return to the facility after a suicide attempt and what symptoms or behaviors staff was to monitor. The DON stated Resident #79's mental health was stable on [DATE] because the hospital discharged him back to the facility. On [DATE] at 1:25 P.M., interview with the DON verified no documented evidence Resident #79's physician was notified of the refusal of counselor sessions. The DON verified SSD #16 was responsible for completing all sections of the social service assessment and verified this was not completed on Resident #79's assessments dated [DATE] or [DATE]. On [DATE] at 1:30 P.M., interview with the DON verified Resident #79 was not seen by the psychiatrist at the facility due to the resident was not exhibiting any symptoms and there was no need. The DON verified the resident had a history of [REDACTED]. On [DATE] at 1:34 P.M., interview with the DON revealed monitoring of residents who had attempted suicide was to include observation for change in mood, withdrawn, voice intent to do harm to self and anything out of the normal for the resident. The DON stated Resident #79 did not have any symptoms or behaviors indicating he was going to commit suicide. On [DATE] at 1:54 P.M., interview with Psychiatrist #15 revealed when residents were discharged back to the nursing home after a psychiatric hospitalization it was the facility's responsibility to complete the referral form and notify him of residents that were in need of being seen. Psychiatrist #15 stated if a resident had two prior suicide attempts the facility should have been monitoring the resident for the mood and behavior indicators as defined on the MDS, maybe not daily, but more frequently. Psychiatrist #15 stated he was not referred to see Resident #15 or notified the resident refused counseling services. Psychiatrist #15 stated if a resident refused counseling services, further investigation into why they refused should be explored. Psychiatrist #15 stated with the resident's history something else should have been done. On [DATE] at 11:37 A.M., interview with SSD #16 verified she was responsible to complete all sections of the social service assessment and Resident #79's assessments dated [DATE] and [DATE] had no evidence if he wanted to harm himself or had a plan to harm himself. On [DATE] at 12:47 P.M., interview with the DON revealed discharge information was reviewed by the DON, unit manager or staff education nurse prior to readmission. The charge nurse reviewed orders upon readmission and then the unit manager double checked the orders the day after admission for accuracy. The focus of these reviews was the transfer orders only and not the entire discharge packet. The DON stated the counselor utilized was contracted by the facility, but if a resident wanted to have a different counselor the facility would try to find someone else. On [DATE] at 1:11 P.M., interview with SSD #16 verified she completed the referral for Resident #79's counseling referral; however, counseling referrals were made when nursing stated there was a need to be seen. SSD #16 would not reply when asked if the counseling service referral was made because of the resident ' s suicide attempt on [DATE]. On [DATE] at 1:14 P.M., interview with Licensed Professional Clinical Counselor (LPCC) #17 revealed she had seen Resident #79 in 2013 but during the session he refused to complete the evaluation and refused her services. LPCC #17 stated she attempted to evaluate him in August and September, 2015 but the resident refused to sign the consent and told her it was water under the bridge . On [DATE] at 1:35 P.M., interview with Medical Director (MD) #18 revealed upon Resident #79's return to the facility following the resident's psychiatric hospitalization for an attempted suicide on [DATE], the facility should have followed the recommendations made by the psychiatrist in the discharge instructions. The resident should have been seen by the psychiatrist and if the psychiatrist failed to follow-up with Resident #79, the facility should have informed the psychiatrist of Resident #79 ' s need to be seen. MD #18 stated Resident #79 should have remained on suicide precautions until the psychiatrist determined to discontinue the precautions. MD#18 stated it was his expectation that suicide precautions were to be implemented for any resident that voiced intent to harm themselves. Review of Suicide Precautions policy revised [DATE] revealed residents with actual/potential suicidal behavior or who expressed the wish to die were to be evaluated and the behavior immediately reported to the supervisor and attending physician. Patients who exhibited actual/potential suicidal behavior were to have suicide precautions initiated including the following: one-on-one 24 hour supervision by either family or nursing staff, limit/restrict mobility throughout the facility, notify maintenance to secure windows, search the resident ' s room and remove objects that may potentially be used for self-harm including sharp items such as nail clippers and other items such as electrical cords, straps, belts, plastic bags and clothing that could be used for self-destruction. Disposable dinnerware and utensils were to be used and the resident was to be closely supervised during all medication administration. an order for [REDACTED]. After discontinuation of the suicide precautions, staff was to continue close observation of the resident especially at shift changes, during a disturbance on the unit and following visits from the physician or family. Documentation was to include the initiation of suicide precautions, notification of the psychiatrist, continuation of suicide precautions every shift until discontinued or patient transfer, and discontinuation of suicide precautions or transfer. On [DATE] at 11:18 A.M., interview with the DON stated the facility only initiated the suicide precautions policy if a resident voiced they wanted to end their life. Once a resident stated they wanted to end their life, the facility immediately implemented one-on-one supervision until transfer out of the facility. Upon return to the facility, the resident was not placed on suicide precautions because they were discharged back to the facility by a physician. The DON verified the facility does not write orders for suicide precautions, one-on-one supervision or 15-minute checks. The DON verified there were no physician orders for Resident #50, #60 and #79 ' s suicide precautions. On [DATE] at 10:30 A.M., interview with RN #1 stated she believed additional residents might be stating they wanted to die because the facility had asked all residents if they wanted to die and if they had a plan. RN #1 verified Residents #50 and #60 remained at the hospital at this time after voicing they wanted to die. This deficiency substantiated Complaint OH 547.

Based on observation, record review, policy review and staff interview, the facility failed to provide services to restore bowel function. This affected one resident (Resident #107) of three residents reviewed for incontinence. The facility identified 31 residents occasionally or frequently incontinent of bowel and no residents had an individually written bowel training program. Findings include: 1. Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was severely impaired for daily decision-making, required extensive assist with toilet use and was always continent of bowel. Review of the 60-day MDS 3.0 assessment dated [DATE] revealed Resident #107 required extensive assist with toilet use and was always incontinent of bowel. Review of the 90-day MDS 3.0 assessment dated [DATE] revealed Resident #107 was dependent on staff for toilet use and was always incontinent of bowel. Review of the resident's 72-hour Voiding Diary dated 11/29/14 through 12/02/14 revealed no evaluation of the resident's bowel continence. Review of the Bowel and Bladder Continence Evaluation dated 12/04/14 revealed no assessment of the resident's bowel continence. Comments included the resident was continent, was to be changed during the night. Review of the resident's 72-hour Voiding Diary dated 03/26/15 through 03/28/15 revealed no assessment of the resident's bowel continence. Review of the quarterly Bowel and Bladder Continence Evaluation assessment dated [DATE] revealed no evidence bowel continence was evaluated. Resident #107 was assessed to be continent, was to be changed at bedtime and no interventions were implemented to restore bowel function. Review of the MDS Kardex dated 03/08/15 revealed the resident was always incontinent of bowel with no toileting program. Review of the Bedside Kardex Report undated revealed no toileting frequency. Review of the medical record revealed no interventions implemented to restore bowel function, no bowel training program and no bowel incontinence care plan. Review of the Continence Management policy revised 01/02/14 revealed the bowel and bladder continence evaluation was to be completed if the patient was incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. The purpose was to provide appropriate treatment and services to minimize urinary tract infections and restore as much normal elimination function as possible. Daily toileting activity was to be documented on the ADL Record If the patient was incontinent, a complete bowel and bladder continence evaluation including a 72-hour voiding diary was to be completed. Resident #107 was observed on 5/05/15 at 11:58 A.M. and on 05/06/16 at 8:46 A.M. being provided incontinence care by staff. On 05/06/15 at 2:38 P.M., interview with Registered Nurse (RN) #92 verified Resident #107 was continent of bowel upon admission, declined to always incontinent and was unaware when this occurred. RN #92 verified there was no evidence of a comprehensive bowel assessment and no interventions were implemented. RN #92 also verified Resident #107 had the capability to be continent and was able to tell staff at times when she needed to go to the bathroom. RN #92 stated currently staff were just changing the resident when incontinent every two hours. However, there was no documented evidence of this. RN #92 was unaware occupational therapy recommended a maintenance program to toilet the resident every three hours. On 05/06/15 at 10:18 A.M., interview with the Director of Nursing (DON) stated the State-tested Nurse Aides use the Bedside Kardex Report and the MDS Kardex to know what care was to be provided for a resident. On 05/06/15 at 3:50 P.M., interview with the DON and RN #92 verified the resident had declined in bowel continence since admission in November 2014, and no interventions were implemented to prevent the decline or restore/maintain bowel continence. On 05/06/15 at 4:00 P.M., interview with the DON verified there was no comprehensive bowel assessment and no bowel incontinence care plan. The DON verified the resident was continent of bowel upon admission and was now always incontinent of bowel without any interventions implemented and no toileting program initiated to restore or maintain bowel continence. The DON also verified the 72-hour bowel and bladder assessment did not address the resident's bowel function/status. On 05/07/15 at 10:44 A.M., interview with Occupational Therapist (OT) #401 revealed Resident #107 was discharged from occupational therapy with strategy recommendations for self-care including one step directions, verbal cueing and assist to bedside commode every three hours. OT #401 stated she provided nursing staff with both a verbal and written summary of the recommendations for a maintenance program and was unaware the resident had declined in these areas.

Based on observation, medical record review, policy review and staff interview, the facility failed to implement a comprehensive restorative nursing program for Resident #107 to prevent the decline in the resident's ability to transfer and ambulate. This affected one resident (Resident #107) of three residents reviewed for rehabilitation. Harm resulted to Resident #107 when therapy recommended restorative nursing services on 03/02/15 for transfer and ambulation programs, the restorative programs were not implemented and the resident declined from transferring with minimum-to-moderate assist of one staff and ambulating 50 feet with caregiver assist (CGA) when discharged from therapy to being dependent on staff for transferring on 03/06/15 and an inability to ambulate. Findings include: Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 required extensive assistance with transfers, walking in room and corridor did not occur, and she received 150 minutes of physical therapy. Review of the Interdisciplinary Progress Notes, dated 03/05/15 revealed a mechanical (Hoyer) lift for transfers related to resident's difficulty with transfers. Review of the physician orders, dated 03/05/15 revealed Hoyer lift for transfers every shift. Review of the ADL Records dated March 2015 through 05/06/15 revealed the resident was dependent on staff for transfers. Review of the Daily Therapy Note dated 03/11/15 revealed Resident #107 was discharged from physical therapy services as of 03/08/15 due to reaching maximum potential. Review of the Updated Plan of Progress for Outpatient Rehabilitation dated 03/08/15 revealed Resident #107 was able to complete transfers with minimum-to-moderate assist with one staff when provided increased time to complete the task and was able to ambulate 50 feet with contact guard assistance (CGA) with a narrow base of support and use of a walker. Staff education was completed and Resident #107 was noted to be inconsistent with her abilities, and required the use of a Hoyer lift for transfers with staff. The resident was discharged due to maximum potential was reached and due to inconsistencies across staff disciplines despite education. Review of the Rehab to Facility Communication dated 03/02/15 revealed a recommendation for Resident #107 to the nursing restorative program. The resident's current functional level was ambulating with a front wheeled walker and transfers with moderate assist of two staff. Precautions included to give the resident time to complete tasks and try to find a time when she was not having increased behaviors. Goals included to ambulate daily to maintain gains made in therapy and transfer with decreased assist from staff. Recommendations included two person assist for safety with transfers and gait, follow with wheelchair and cue the resident to step wider. Review of the therapy Self-Care recommendations dated 01/15/15 revealed occupational therapy recommended to provide the resident with one step commands, allow her time to process the information and the resident fluctuates from day-to-day with level of assistance. Resident #107 was to be placed on the bedside commode every three hours for toileting. Review of the medical record revealed no nursing restorative transfer/ambulation or Self-Care maintenance programs for Resident #107. Review of Resident #107's ADL Reports dated March 2015 through 05/06/15 revealed walking in room/corridor did not occur, and transfers required extensive to dependence on staff assist. Review of Resident #107's ADL Report dated March 2015 revealed the resident required extensive to total dependence with transfers, and from 05/01/15 through 05/06/15 the resident was dependent on staff for transfers. Review of the Demonstrates Capacity and Motivation to Improve Function but At risk for decline care plan revised 03/13/15 revealed improvement with therapy was expected. Interventions included mechanical lift for transfers and to provide assistance and cueing to maximize current level of function. Review of the Restorative Nursing policy revised 10/01/10 revealed restorative programs were coordinated by nursing or in collaboration with rehabilitation and were patient specific based on individual patient needs. The purpose of the program was to promote the patient's ability to adapt and adjust to living as independently and safely as possible, and to help attain and maintain optimal physical, mental and psychosocial functioning. On 05/05/15 at 12:05 P.M. and 1:43 P.M. Resident #107 was observed sitting in a wheelchair in the dining room. On 05/06/15 at 9:06 A.M. staff were observed pushing the resident in wheelchair to dining room. On 05/06/15 at 12:09 P.M., interview with Registered Nurse #70 stated Resident #107 was not on any restorative programs and did not ambulate. On 05/06/15 at 10:18 A.M., interview with the Director of Nursing (DON) verified the resident was not on a restorative program and the facility did not monitor maintenance programs recommended by therapy. The DON stated it was just part of the daily provision of care provided. The DON also stated Resident #107 was inconsistent with assistance of transfers and was ordered to be a Hoyer lift for safety. The DON verified there was no documented evidence in the medical record of the resident's inconsistencies during transfers to support this. On 05/05/15 at 3:40 P.M., interview with the DON verified Resident #107 was able to transfer with extensive assist but for the resident and staff safety, she was ordered to be a Hoyer lift for all transfers. The DON also verified the resident was dependent on staff for transfers at this time, there was no evidence of the self-care maintenance program in the record and the resident had declined in transfers and ambulation. On 05/07/15 at 10:30 A.M., interview with Physical Therapist (PT) #400 revealed the resident was discharged from therapy on 03/08/15 and was capable of transferring with minimum-to-moderate assist of one therapy staff. PT #400 stated the resident's functioning level did fluctuate due to cognition but was stable at the time of discharge and the resident was able to ambulate 25 to 50 feet with extensive assist during the last month of therapy prior to discharge. PT #400 stated from 02/26/15 to 03/08/15 therapy was training the nursing staff on how to transfer and ambulate Resident #107 but there was inconsistency with staff despite education and that was when it was recommended for the use of a mechanical lift. PT #400 stated she was not notified of the resident's decline in ambulation and was unaware the resident was not walking, PT #400 also stated she had made a referral to restorative nursing on 03/02/15 for ambulation and transfers for Resident #107 and was unaware the restorative programs were not implemented. PT #400 verified Resident #107 now required the use of a Hoyer lift for all transfers because of the inconsistency with staff performing safe transfers of the resident from bed to chair/bedside commode. On 05/07/15 at 10:44 A.M., interview with Occupational Therapist (OT) #401 revealed Resident #107 was discharged from occupational therapy with strategy recommendations for self-care including one step directions, verbal cueing and assist to bedside commode every three hours. OT #401 stated she provided nursing staff with both a verbal and written summary of the recommendations for a maintenance program and was unaware the resident had declined in these areas.

Based on observation, medical record review, policy review and staff interview, the facility failed to provide services to restore bladder function for Resident #107. This affected one resident (Resident #107) of two residents reviewed for urinary incontinence. Harm resulted when the facility failed to ensure they provided a comprehensive assessment of bladder function, failed to implement interventions to restore bladder function and failed to provide intervention after a decline in bladder function for Resident #107. Findings include: Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was severely impaired for daily decision-making, required extensive assist with toilet use and was frequently incontinent of bladder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #107 was dependent on staff for toilet use and was always incontinent of bladder. Review of the resident's 72-hour Voiding Diary dated 11/29/14 through 12/02/14 revealed the following: On 11/29/14, continent of bladder. On 11/30/14, continent of bladder. On 12/01/14, continent of urine except at 12:00 A.M., 2:00 A.M., and 5:00 A.M On 12/02/14, continent of urine except at 1:00 A.M. and 4:00 A.M Review of the Bowel and Bladder Continence Evaluation dated 12/04/14 revealed no type of evaluation documented, no evaluation of the resident's diagnoses, no reason for the evaluation and type of urinary incontinence was functional. No evaluation of the resident's bowel continence was assessed. Comments included the resident was continent and was to be changed during the night. No toileting program was initiated to restore bladder function. Review of the resident's 72-hour Voiding Diary dated 03/26/15 through 03/28/15 revealed the following: On 03/26/15, continent of bladder. On 03/27/15, continent of bladder except at 3:00 A.M. and 5:00 A.M On 03/28/15, continent of bladder except at 3:00 A.M., 5:00 A.M., 4:00 P.M. and 9:00 P.M Review of the quarterly Bowel and Bladder Continence Evaluation dated 03/29/15 revealed Resident #107 was assessed to be continent, was to be changed at bedtime and no interventions were implemented to restore bladder function. Review of the MDS Kardex dated 03/08/15 revealed Resident #107 was always incontinent of bladder with no toileting program. Review of the Bedside Kardex Report undated revealed no toileting frequency. Review of the Self-Care for Resident #107 dated 01/15/15 revealed occupational therapy recommended a maintenance program to provide the resident with one step commands, allow her time to process the information, fluctuates from day-to-day with level of assistance and staff was to place the resident on the bedside commode every three hours for toileting. Review of the medical record revealed no documented evidence the maintenance program was implemented. Review of the Demonstrates Capacity and Motivation to Improve Function care plan revised 03/13/15 included Resident #107 exhibited decreased ability to perform ADL's and was incontinent of bladder. Review of the care plan revealed no interventions to restore bladder function and no type of urinary incontinence was identified. Review of the Continence Management policy revised 01/02/14 revealed the bowel and bladder continence evaluation was to be completed if the patient was incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. The purpose was to provide appropriate treatment and services to minimize urinary tract infections and restore as much normal elimination function as possible. If the patient was incontinent, a complete bowel and bladder continence evaluation including a 72-hour voiding diary was to be completed. Resident #107 was observed on 5/05/15 at 11:58 A.M. and on 05/06/16 at 8:46 A.M. being provided incontinence care by staff. On 05/06/15 at 10:18 A.M., interview with the Director of Nursing (DON) stated the State-tested Nurse Aides use the Bedside Kardex Report and the MDS Kardex to know what care was to be provided for a resident. On 05/06/15, at 12:07 P.M., interview with the DON verified Resident #107 had no comprehensive bladder incontinence care plan, no type of incontinence identified on the ADL care plan, and no interventions to restore bladder function. On 05/06/15 at 2:38 P.M., interview with Registered Nurse (RN) #92 verified Resident #107's Bowel and Bladder Continence Evaluation assessment dated [DATE] was not comprehensive and did not identify the decline during the quarterly assessment on 03/29/15. RN #92 also verified Resident #107 had the capability to be continent and was able to tell staff when she needed to go to the bathroom when asked. RN #92 stated currently staff was just changing the resident when incontinent every two hours. However, there was no documented evidence of this. RN #92 was unaware occupational therapy recommended a maintenance program to toilet the resident every three hours. On 05/06/15 at 4:00 P.M., interview with the DON verified Resident #107 was continent of urine upon admission, the resident declined to occasionally incontinent to frequently incontinent to always incontinent of urine between December 2014 and March 2015 without intervention to restore or maintain bladder function. On 05/07/15 at 8:52 A.M., interview with the DON stated if a resident had a decline in ADL's or continence, the STNA was to inform the nurse, the nurse was to inform the unit manager and then the unit manager was to evaluate the resident for a possible program to restore function. On 05/07/15 at 10:44 A.M., interview with Occupational Therapist (OT) #401 revealed Resident #107 was discharged from occupational therapy with strategy recommendations for self-care including one step directions, verbal cueing and assist to bedside commode every three hours. OT #401 stated she provided nursing staff with both a verbal and written summary of the recommendations for a maintenance program and was unaware the resident had declined in these areas.